I. Introduction
This describes the broad framework for a bilateral partnership program in health (hereinafter, the “Health Partnership Program” or “HPP”), which is intended to achieve the assistance objective of strengthening health systems to address health needs of vulnerable populations.
The framework includes five intermediate results that are expected to lead to achievement of the overall assistance objective. The annex also describes the Behavior Change Communication Project (hereinafter “BCC Project” or “BCC”), and the Health of the Urban Poor Project (hereinafter “HUP Project” or “HUP”), the first projects to be undertaken within the program framework with initial funds obligated under this Agreement.
This description sets forth objective criteria for selection of future projects and activities to be implemented, within the program framework, with funds to be obligated in future years under the Agreement. Additional design work will be completed, through a collaborative process, before funds are obligated for these future projects and activities.
II. Background
Despite India’s strong economy and emergence as a global leader, the proportion of families living in poverty and related poor health statistics, particularly in the north of India, prevent India’s population from taking full advantage of economic and development gains. While there have been unprecedented gains and laudable achievements for which India can take credit, many vulnerable communities and families continue to suffer disproportionately from serious diseases and conditions, despite proven public health interventions. In line with the Indo-U.S. Strategic Dialogue, the U.S. Global Health Initiative (GHI) and the World Health Organization’s (WHO) framework on strengthening health systems, there is broad recognition that if health systems are not adequate, progress on the health of vulnerable populations will lag. Drawing on their longstanding partnership in the health sector, the GOI and USAID therefore are shifting the focus of USAID’s support from a disease-specific to a health systems approach.
III. Assistance Objective, Intermediate Results (IRs), and Indicators
Assistance Objective: Under the assistance objective of strengthening health systems to address health needs of vulnerable populations, the GOI and USAID will work together to achieve a broad set of intermediate results which contribute to the GOI’s national health programs, including, but not limited to, the Reproductive and Child Health (RCH) program and the National AIDS Control Program. Progress towards the assistance objective will be indicated by improvements in the maternal mortality ratio and the percentage of deliveries taking place per national guidelines at institutions and health facilities. In addition, reduction in the HIV prevalence rate in selected states will be used to assess progress on that key component of the HPP.
To attain the assistance objective, the program will focus on achieving the following intermediate results, with progress measured by the stated indicators:
HPP IR No. 1. Increased access to quality services, as indicated by: a) the immunization rate, b)the percentage of priority districts with at least 90 percent of community health centers providing quality care, c) percentage of most-at-risk populations for HIV infection who received an HIV test in the last twelve months and who know the results, and d) percentage of NACP priority districts with at least 80% of pregnant women undergoing HIV test as part of routine antenatal care.
Access to health services will be increased by removing the physical, structural, and financial barriers constraining vulnerable populations from using the health system. The quality of health services will be ensured through provider adherence to standards; the availability of skilled staff, commodities and equipment; a strong health information system; and the adaptation of systems to respond to patient needs. This element includes the on-going HUP activity, referenced below.
HPP IR No. 2. Strengthened policy and regulatory environment, as indicated by: a) the amount of district level public expenditure for healthcare programming in priority districts, b) the percentage of vulnerable populations in priority districts falling below the poverty line due to catastrophic illnesses, and c) number of local organizations provided with technical assistance for HIV-related policy development.
Technical assistance will support a strengthened policy environment that promotes high quality service delivery, and incorporation of the most up-to-date, scientifically-approved technical guidelines. Greater equity and transparency in the health system will be enhanced through improved financing mechanisms, promoting both access and incentives, with a focus on the vulnerable and poor.
HPP IR No. 3. Increased healthy behaviors, as indicated by: a) the proportion of children aged newborn to five months who are breast-fed exclusively, b) the percent of women and men aged 15-49 at risk for HIV reporting condom use, and c) the percentage of new smear-positive pulmonary tuberculosis cases that were detected under the Directly Observed Therapy, Short Course (DOTS).
By creating and supporting positive health behaviors which may be practiced at home and in the community or may generate increased demand for health services, the demand side will balance and help ensure the supply or service delivery side of the health system, at both national, state, district, community and household levels. Gender will be an explicit focus of activities under this component. The element includes the new BCC Project, described in detail below.
HPP IR No. 4. Increased use of data for decision-making, as indicated by the number of strategic information initiatives used to inform GOI health policies and programs.
The ability to obtain, analyze and use data for decision-making, while utilizing the latest information technology resources, will advance the capacity of the entire health system. This element includes USAID’s support for Behavioral Surveillance Surveys, and other related studies, which provide key data on patterns and trends on HIV/AIDS.
HPP IR No. 5. Increased private sector engagement in quality health service, as indicated by the percentage of private sector providers offering affordable quality health services per national protocols (linked to HIV/AIDS or key components of reproductive and child health).
The public sector alone cannot respond to the health needs of any country’s population. The scope and magnitude of India’s health system makes this especially evident. Enhancing linkages, models and the involvement of the growing private sector will be incorporated into overall health system strengthening.
A separate HIV/AIDS activity, with a primary mandate to build capacity of national and state AIDS control programs and institutions, and provide technical assistance to improve the quality and performance of the NACP, will be established. It will contribute to all five of the above IRs. In addition, HIV/AIDS activities integrated into activities under the above IRs will coordinate closely with the separate HIV/AIDS activity, with overall guidance from NACO.
IV. Project Selection Criteria within the HPP Framework.
The following basic criteria will be applied to the selection of new projects funded under the Agreement or in support of the program, and are based in part upon guidance provided by the GOI.
- a. New designs will have an integrated, systems approach.
- b. All activities, including designs, will be coordinated with the respective departments of the MOHFW, for example, RCH-related activities with the Department of Health and Family Welfare, and HIV/AIDS activities with NACO.
- c. Interventions, including technical assistance and any demonstration activities, will be targeted, to the extent possible, to districts in Uttar Pradesh (UP) and Jharkhand states, with data and other criteria aiding in the selection of focus districts. For HIV/AIDS activities, geographical coverage is expected to include the states of Gujarat, Karnataka, Maharashtra, Orissa, Rajasthan and UP. Final decisions will reflect priorities identified with NACO.
- d. Any focus on districts that are in states other than UP and Jharkhand will be based on national priorities with strong emerging evidence; however, the overall emphasis on technical assistance to strengthen systems will be a consistent feature.
- e. Implementation in selected districts will be complemented by and, typically led by, national level efforts.
- f. New projects, and related implementing instruments, will align with the framework of the assistance objective and intermediate results set forth above.
- g. In addition, selection of new projects will be guided by the principles of the U.S. Global Health Initiative, which include:
* Adopt a Women and Girl-Centered Approach to Health and Gender Equity
* Increase Impact through Strategic Integration and Coordination
* Strengthen and Leverage Multilaterals
* Encourage Country Ownership and Invest in Country-Led Plans
* Build Sustainability through Health System Strengthening
* Improve Metrics, Monitoring and Evaluation
* Promote Research, Development and Innovation
Additional design work will be completed, through a collaborative process, before funds are obligated for future projects. Older, on-going projects in the health sector are expected to be phased-out over a two-to-three year period, as the relevant agreements reach their completion dates. These ongoing activities include three existing GOI-USAID bilateral agreements. As new projects are designed and agreed upon, this annex will be revised to include further details on their specifics.
V. Increased Healthy Behaviors: BCC Purpose, Intermediate Results (IRs), Indicators and Illustrative Activities.
The BCC Project falls under the HPP IR Increased Healthy Behaviors.
a.
Project Purpose : The BCC Project’s purpose is to increase healthy behaviors, by increasing knowledge and positive attitudes at the individual, provider and community level, creating a supportive environment within communities for positive health behaviors, and by empowering vulnerable communities to seek health services and products. The project will seek to build sustainable systems and platforms that will strengthen India’s response to poor health outcomes. Progress will be indicated by the percentage of children from newborn to age five months who are exclusively breast-fed, the percentage of most-at risk populations for HIV/AIDS (MARPs) using condoms consistently, and the percentage of registered new smear-positive pulmonary TB cases that were detected under DOTS. The project underscores priorities of the MOHFW for an integrated BCC strategy that addresses various technical themes and sectors across the Ministry. In this way, it will support the objectives of the GOI’s national health programs and priorities under the Ministry and as other government programs for women and children, such as the Integrated Child Development Scheme (ICDS) under the MOWCD.
b. BCC Intermediate Results, Illustrative Indicators and Illustrative Activities: To achieve its purpose, the BCC Project will focus on the following intermediate results, as measured by the stated indicators.
BCC IR 1. Strengthened capacity to design, deliver and evaluate strategic communication
Illustrative Indicators:
- a. Budgetary expenditures for BCC at the national and state levels,
- b. Number of evidence-based communication campaigns developed at the national level and rolled out to the state level, and
- c. Number of academic and technical institutions strengthened at the national and state levels to provide technical support in BCC.
Illustrative activities include:
* Develop functioning BCC/Information, Education and Communication (IEC) units at the national and state levels;
* Technical support for national, state and district level BCC/Information, Education and Communication (IEC) unit to develop and produce evidence-based BCC campaigns (mass-media, mid-media and interpersonal) on a range of issues in health, including priorities under GOI national programs;
* Technical support to BCC/IEC units to conduct formative research that informs development of strategic communication plan, campaigns and materials; and
* BCC –Technical Resource Centers (TRCs) established at the national and state level.
BCC IR 2. Increase in accurate and appropriate knowledge and attitudes at the individual, family, community, provider, state and national levels
Illustrative Indicators
- a. Number of women who receive their Janani SurakshaYojana payments,
- b. Percentage of health providers who provide information about family planning spacing methods,
- c. Number of most-at-risk populations for HIV/AIDS reached with individual and small group level interventions, and
- d. Percentage of caretakers/mothers who know how to treat a child who is sick with diarrhea.
Illustrative activities include:
* Interpersonal communication (IPC) materials produced for various target groups, including providers, key influencers, frontline health workers, and
* Capacity building on IPC and counseling skills carried out.
BCC IR 3. Increase in community platforms, organizations and key individuals (influencers) who support improved health behaviors
Illustrative Indicator
- a. Number of Panchayati Raj institutions that conduct health promotion activities with their communities,
- b. Number of Accredited Social Health Activists and local leaders who are sensitized and support TB program objectives by disseminating information on TB symptoms and availability of cure,
- c. Percentage of couples who talk to each other regarding family planning,
- d. Number of individuals trained in HIV-related stigma and discrimination reduction, and
- e. Number of NGOs that celebrate or promote health actions and behaviors.
Illustrative activities include:
* Develop and pre-test BCC materials to target key influencers (e.g., mother-in-law, spouse, Panchayat Raj members, teachers),
* Develop and implement pilot test models for working with community groups to become supporters of positive health seeking behavior,
* Support national and state IEC units to disseminate model materials and tools statewide or nationwide.
BCC IR 4. Empower vulnerable communities to seek health services and products
Illustrative Indicator
- a. Percentage of high-risk populations, such as those at risk for HIV/AIDS, who seek prevention and testing services, and
- b. Percentage of women who make decisions regarding health care alone or jointly with their husbands.
Illustrative activities include:
* Develop and pre-test module and pilot-test training for health care providers on reducing stigma and/or discrimination based on caste, gender, disability or health status
* Establish a model network or support group for vulnerable populations through which stigma/discrimination could be addressed
c. Alignment with Program Criteria: In line with the HPP framework, the BCC Project will be implemented at the national and state level. The project will seek to build sustainable systems and platforms that will strengthen India’s response to poor health outcomes.
Technical expertise in BCC will be sustained by strengthening BCC Technical Resource Centers, one each at the national and state levels that will continue to provide overall BCC technical expertise to the central and state governments once the project is completed. In consultation with the GOI, such an institution will be identified and strengthened as a core activity under this project.
A salient feature of this project is its focus on strengthening the institutional capacity of national, state and district levels to develop, design, implement and evaluate BCC campaigns. The project’s success will be measured by the health system’s improved capacity to plan and design evidence-based campaigns. It is expected that annual government planning documents would increase budgetary allocations and expenditures for BCC for health programming. To achieve this objective, ongoing and intensive engagement with government counterparts on BCC will be necessary.
To consolidate and focus activities, the BCC project will include an emphasis on the state of Uttar Pradesh. Technical assistance for roll-out of BCC models in other states, particularly for HIV/AIDS BCC, will be accomplished through an appropriate mechanism
VI. Increased Access to Quality Services: HUP Project
HUP is an on-going activity falling under the HPP IR Increased Access to Quality Services. For purposes of obligating funds and communicating with GOI, it is now being folded into the HPP Agreement.
a. Project Purpose: The HUP Project’s purpose is to support improved delivery of a comprehensive package of maternal and child health and nutrition interventions, including the promotion of improved access to quality water supply, sanitation and hygiene services, in urban poor communities, to improve the health of the urban poor in India. HUP will continue USAID’s ongoing efforts to support national, state, and local governments and the private sector and forge linkages with other partners and donors. In addition, HUP will establish linkages with HIV/AIDS programs to reach populations vulnerable to HIV/AIDS, such as migrants residing in urban slums.
b. HUP Intermediate Results include:
a. Provide quality technical assistance (TA) to the GOI, states and cities for implementation of the National Urban Health Mission (NUHM) or the urban health components of other GOI national programs
b. Expand Public-Private Partnerships (PPP) for urban health
c. Promote convergence of GOI urban health and development efforts
d. Strengthen evidence-based city-level demonstration |
