an overview of child survival programme

1. Child Survival
Zaeem ul haq – Health Advisor, PPQ
August 17, 2012

2. Every year almost 10 million children die before they reach their fifth
birthday. More than half of these deaths are caused by just five
preventable and treatable conditions: pneumonia, diarrhoea,
malaria, measles and malnutrition, and often by a combination of
these.
When the most important causes of death in newborns are added,
more than eight in ten of these deaths could be avoided if those
children received timely and appropriate care.

3. CHILD SURVIVAL – GLOBALly

4. CHILD SURVIVAL – GLOBALly

5. CHILD SURVIVAL – MDG PROGRESS
SOURCE Countdwon Report 2012

6. CHILD SURVIVAL – MDG PROGRESS
SOURCE Countdwon Report 2012

7. CHILD SURVIVAL – DISPARITIES
(Nigeria)
SOURCE Countdwon Report 2012

8. CHILD SURVIVAL – global bod
~ 48%
Childhood
Pathologies
~ 36%
Noenatal
Pathologies

9. SO WHAT ARE
WE DOING
ABOUT IT?

10. Jones G et al., Lancet 2003
Evidence-Based Child
Survival Interventions (30) Darmstadt GL et al., Lancet
2005.
Preventive (15) Curative (8)
• Breastfeeding • ORT
• Insecticide-treated bednets • Antibiotics for sepsis
• Complementary feeding • Antibiotics for pneumonia
• Zinc • Antimalarials
• Clean delivery • Zinc
• Hib vaccine • Newborn resuscitation
• Water, sanitation, hygiene • Antibiotics for dysentery
• Antenatal steroids • Vitamin A
• Newborn temp. management
• Vitamin A
• Tetanus toxoid
• Neverapine/replacement feeding Other Newborn (7)
• Antibiotics for PROM • Folic acid
• Measles vaccine • Interventions to control syphilis,
• Antenatal antimalarial IPTP eclampsia, asymptomatic bacteriuria,
and breech
• Labor surveillance
• Kangaroo mother care

11. chILD SURVIVAL –
Case Definitions
 Integrated Management of Newborn and Childhood Illnesses
(IMNCI) – skills of facility-based health workers
 Community IMCI (c-IMI) – health promotion on 16 key
behaviours and practices
 Community Case Management (CCM) – community-based
health workers delivering Rx for common childhood illnesses
 Routine Immunizations (RI, EPI) – WHO recommended basic 6
vaccines (OPV, BCG, DPT, HBV, HIB, M), plus 2 newer ones
where applicable (PCV & Rota; DPT3 > 50%)

12. IMNCI
 Integrated Management Childhood Illnesses (IMCI) developed by WHO and
UNICEF in early 1990s to reduce childhood mortality globally
 comprises three components that all have to be implemented (preferably
simultaneously) to ensure success;
 improving case management skills of health-care staff
 improving overall health systems
 improving family and community health practices
 IMCI standardized evidence-based guidelines for first-level health workers
(FLHWs) using effective and easy-to-use tools to tackle major causes of
childhood mortality and morbidity
 Newborn component was included later on

14. IMCI – programming matrix

15. Challenges with IMCI
Globally, over 100 countries have adopted IMCI strategy, and achieved
impressive results in reducing childhood mortality
However, despite significant progress, a number of challenges related to its
implementation remain;
• ensuring periodical updates of national and sub-national IMCI guidelines
to respond to local health needs
• training and maintaining the knowledge and skills of hundreds of
thousands of health workers in IMCI
• underserved communities’ lack of access to trained health staff
SOURCE: WHO 2009

16. IMCI – training coverage, global

17. IMCI – implementation coverage, AFRO/2009

18. Challenges with IMCI
 Low training coverage; high cost of 11 day residential training course ~
$1000 per health worker
 Unavailability of lower cost alternatives
 Limited on-job training
 Poor compliance to protocols
 Infrequent supervision & mentoring
 Referrals poorly adhered to
 Shortage of drugs and job aids
SOURCE: DFID commissioned Review of IMCI implementation in Kenya, Tanzania and Nigeria;
Consortium for Research on Equitable Health Systems/LSHTM; 2008-09

19. ICcm
 Integrated Community Case Management (ICCM) strategy uses simplified
IMCI protocols to treat common childhood illnesses in communities where
the distances between them and the nearest health facility are so great that
the treatment services are inaccessible
 Community Health Workers (CHWs) are trained, equipped and supervised
to deliver treatment for diarrhoea, malaria and pneumonia; and in some
contexts, treatment for dysentry, newborn sepsis and acute malnutrition

20. Task shifting framework

21. MYANMAR – Donut approach

22. ImMUNIZATIONS
 Immunizations as part of Child Survival Framework, with programming
across the theory of change, compliant with global strategies;
 Reaching Every District (RED) approach; WHO (2002)
 Global Immunization Vision and Strategy; WHO/UNICEF (2006-15)
 Global Vaccine Action Plan – Decade of Vaccines (2011-20)
 Building capacity at district, health facility and community levels;
 support district planning and resource management
 improving immunization skills of health-care staff
 improving overall health systems; cold chain & supply chain systems,
 supportive supervision, monitoring & surveillance systems
 improve acceptance and uptake of immunization services in
communities

23. STILL,
WHAT WILL
WE DO?

24. CHILD SURVIVAL – ACCESS
we will;
• strengthen local health systems; technical and operational support on roll
out/ scale-up of evidence-based child survival interventions at both
community and primary health facility levels (dist. planning/budgeting,
service delivery, HMIS, LMIS, cold chain management)
• support (T2S2*) first-level health workers (FLHWs) to effectively
manage and prevent common and complicated childhood illnesses and
conditions, at both primary facility and community levels
• partner with Ministries of Health and agencies (UNICEF, WHO) to
scale up access to essential child survival interventions in underserved
communities
*T2S2; training, tools, supplies, supervision

25. CHILD SURVIVAL – QUALITY
we will;
• support* FLHW supervisors and supervisors’ supervisors to assure
quality of service delivery at community & facility levels
• support development of minimum standards on child survival quality
of care with MoH & partners, and work with local authorities, CSO
partners and communities to ensure that quality standards are met
• strengthen systems to integrate supportive supervision – provide
technical and operational support, tools, equipment and supplies, and use
innovative approaches such as clinical simulation exercises for FLHWs and
community empowerment on use of QA checklists
*T2S2; training, tools, supplies, supervision

26. CHILD SURVIVAL – demand
we will;
• develop and disseminate culturally sensitive information, to increase
awareness and improve behaviours on prevention and control of common
childhood illnesses and conditions
• use evidence-based participatory approaches such as community
groups and village health committees to increase awareness and uptake of
child survival services and promote appropriate health-seeking behaviours
• introduce formal linkages between health facilities and communities they
serve (HFMC linked to CHC)
• mobilize communities on prevention and control of diarrhoea, malaria
and pneumonia, importance of exclusive breast-feeding and appropriate
child feeding practices

27. CHILD SURVIVAL – INNOVATION
we will;
• strengthen the global evidence and learning on use of innovative
approaches on promoting newborn and child survival
• potentially;
• DL approaches for FLHW training and CME – HEAT model from OU
and ICATT from WHO
• empowering community groups, through awareness raising (counter
asymmetry of information) & use of checklists for quality assurance
and accountability – UCL/ICH
• cost of coping with illness analysis, mutual health insurance schemes
and VHC as financial intermediaries – LSHTM/LATH/QMU
• PBI for FLHWs, incentivized compliance to Rx and referral
completion – LSHTM/LATH/QMU

28. CHILD SURVIVAL – POLICY/ADVOCACY
we will;
• promote formation of (global), national and local partnerships to realize
the poorest and most marginalized children’s right to access essential
health services
• strengthen country capacity to determine and set policies and priorities
on newborn and child survival, and support development of national
policies and strategies on child survival
• promote equity in national coverage of essential child survival services
and scale-up to underserved communities
• advocate for adequate and sustainable financing for effective delivery and
scale-up of quality services for promoting child survival in communities

29. IMMUNIZATIONS – ACCESS
we will;
• strengthen national/district health systems and primary health facilities
through provision of essential equipment and supplies for EPI services and
infrastructure rehabilitation, where needed (dist. planning/budgeting,
service delivery, HMIS, LMIS, cold chain management)
• support (T2S2*) human resources for EPI at primary facilities and
support health authorities on effective planning and implementation of
outreach activities to scale-up coverage for unvaccinated children
• provide technical and operational support to improve vaccine
management and cold chain systems to ensure a reliable supply of
vaccines of assured quality
*T2S2; training, tools, supplies, supervision

30. IMMNIZATIONS – QUALITY
we will;
• support* FLHW (e.g. vaccinators, midwives & nurses) on quality
provision of EPI services and injection safety at facility level
• support MoH to set minimum quality standards and operational
guidelines for routine immunization (RI) service delivery, and work with
CSO partners & communities to improve the quality of RI services
• strengthen supportive supervision for EPI facility & outreach staff and
support data collection & management systems at community, facility and
district levels
*T2S2; training, tools, supplies, supervision

31. IMMUNIZATIONS – demand
we will;
• develop and disseminate culturally sensitive and comprehensible
information with participation of religious and community leaders, teachers
and FLHWs, through use of modern information communication
technologies and innovative approaches
• use evidence-based participatory approaches such as community
groups and village health committees to increase awareness and uptake of
routine immunization services
• introduce formal linkages between health facilities and communities they
serve (HFMC linked to CHC)

32. IMMUNIZATIONS – INNOVATION
we will;
• work with MoH to assess and develop mechanisms to integrate routine
immunization services in PHC systems and MNCH or IMCI
programmes
• pilot innovative approaches to scale-up quality RI services in partnership
with local governments and CSOs – such as alternate vaccine delivery
mechanisms
• improvise solutions with local partners and authorities, to scale up an
essential package of child health services that includes RI, for
sustained benefits for newborns, children and mothers

33. IMMUNIZATIONS – POLICY/ADVOCACY
we will;
• promote formation of (global), national and local partnerships to realize
the poorest and most marginalized children’s right to access immunization
services
• support MoH to determine and set policies and priorities for immunization
services, to ensure that routine immunization services are integrated with
essential package of PHC/MNCH services, and scaled-up to excluded
communities in underserved districts
• campaign and advocate to promote equity in coverage of EPI services
for underserved communities and sustainable financing for
strengthened national and district immunization systems for effective
delivery and scale-up of quality RI services

36. POTENTIAL PARTNERSHIPS

37. CHILD DEATHS AVERTED

38. FURTHER READING
• NCS A2015, March 2012
• IMNCI Programming Framework
• SOW for Child Survival and
Immunizations programming
• Good Practice Guide on working
with CHWs for Child Survival in
Communities
• ICCM Toolkit, March 2011
• CCM Essentials – Guide for
Implementers, 2009

39. THANK YOU FOR LISTENING
Please send your feedback to;
z.haq@savethechildren.org.uk