1. Integrated Management of Neonatal and Childhood Illness Vikash R. Keshri Moderator: Dr. D. G. Dambhare

2. IMNCI: Framework for Presentation Introduction & Genesis of IMCI: – Need for Integrated Approach. – Strategies & Components of IMCI. Indian Adaptation: IMNCI – IMCI vs. IMNCI – Components of IMNCI Management algorithm: IMNCI case M/M guidelines. Newer Terms: – F- IMNCI – C- IMNCI and Household IMNCI – IMNCI +

3. Integrated Management of Childhood Illness: World Health Organization (WHO), UNICEF & other International Partner came out with a new strategy Known as Integrated Management of Childhood Illness (IMCI) in 1995. An effort to bring health equity for child health. The strategy emphasises on integrated approach for treating the sick children. Emphasizes on improving the family and community practices as well as care provided by the health system for better care of child.

4. Why Integrated Approach?

5. More Than One Symptom: 15.3% 18.6% 20.5% 16.9% 13.7% 7.6% 4.1% 2.3% 0.7% 0.2% 12345678910 Number of symptoms Number of symptoms in previous two weeks reported among sick children under five in Matlab Thana, Bangladesh, 2000 (n = 1302). Source: Arifeen S, et al. MCE-Bangladesh baseline household health and morbidity survey, ICDDR,B, 2000.

6. Single Diagnosis is Inappropriate: Presenting Symptoms Possible cause or associated condition Cough / or Fast BreathingPneumonia Severe Anaemia Fast Breathing Lethargy or UnconsciousnessCerebral Malaria Meningitis Severe Dehydration Very Severe Pneumonia Measles RashPneumonia Diarrhoea Ear Infection Very Sick Young InfantPneumonia Meningitis Sepsis

7. Why Integrated Approach? Integrated approach is child centred. Five conditions : Pneumonia, Diarrhoea, Measles, Malaria and Malnutrition are major cause of Death. 3 out of 4 children seeking health care in developing countries suffers from one of these condition. Children likely to be suffering from more than one condition. Often combination of theses conditions leads to fatal result. Making a single diagnosis may be difficult. Such children often need combined therapy for successful treatment.

8. Advantages of Integrated Approach: Speeds up the urgent treatment and treatment seeking practices. Prompt recognition of serious condition, hence prompt referral. Involves parents in effective care of baby at home. Involves prevention of diseases by active immunization, Improved nutrition and Exclusive Breastfeeding practices. Highly cost effective. It avoids wastages of resources by using most appropriate medicines and treatment. It reduces duplication of effort. Partial Success of Individual disease control programme.

9. Inadequacies in Health system: Health worker skills: – Incomplete examinations and counselling. – Poor communication between health workers and parents. – Irrational use of drugs. Health system issues: - Access to health services and Scarce availability of Skilled Worker - Availability of appropriate drugs and vaccines - Supervision / organization of work Community and family practices: – Delayed care seeking – Poor knowledge of when to return to a health facility – Seeking assistance from unqualified providers – Poor adherence to health worker advice and treatment

10. Components of IMCI: The IMCI strategy includes three important components :  Integrated management of childhood illness.  Health system strengthening.  Community IMCI or promotion of key family and community practices IMCI strategy are most effective when all three component are implemented simultaneously.

11. IMCI Process: Source: IMCI; Student’s Handbook, WHO

12. IMCI case management at first level health facility, referral level, and home :

14. Difference between IMCI and IMNCI: Features:WHO – UNICEF IMCI IMNCI Coverage of 0 to 6 days (early newborn period) NoYes Basic Health Care ModuleNOYes Home visit by the provider for newborn and Young Infant NoYes Training Training Home based CareNoYes Training days for newborn and young infants 2 out of 11 days4 out of 11 days Sequence of trainingChild (2 months to 5 years of age) then Young infant ( 7 days to 2 months of age) Newborn and young infants (0 to 2 months).Then Child (from 2 months to 5 years of age.)

15. IMNCI Package: Care of Newborns and Young Infants (infants under 2 months): – Keeping the child warm. – Initiation of breastfeeding immediately after birth and counselling for exclusive breastfeeding and non-use of pre lacteal feeds. – Cord, skin and eye care. – Recognition of illness in newborn, management and/or referral. – Immunization. Home visits in the postnatal period: – Home visits by health workers (ANMs, AWWs, ASHAs ). – Three home visits are to be provided to every newborn: first visit on the day of birth (day 1). Next two visit on day 3 and day 7. – For low birth weight babies, 3 more visits: on Day 14, 21 and 28. – care of mothers during the post-partum period.

16. Care of Infants (2 months to 5 years) – Management of diarrhoea, acute respiratory infections (pneumonia), malaria, measles, acute ear infection, malnutrition and anaemia. – Recognition of illness / at risk conditions and management/referral. – Prevention and management of Iron and Vitamin A deficiency. – Feeding Counselling for all children below 2 years – Feeding Counselling for malnourished children between 2 to 5 years. – Immunization. Who will provide IMNCI Services ? – The health workers in the community (ANM, AWW, ASHA ) or – Providers at the facility (PHC/CHC/FRU).

17. Components of IMNCI : Training: - IMNCI is skill based training based on a participatory approach combining classroom sessions with hands-on clinical sessions in both facility and community setting. – Two categories of training are included: One for medical officers A second for front-line functionaries including ANM’s and Anganwadi Workers (AWW’s).

18. Improvements to the health system. The essential elements include: – Ensuring availability of health workers / providers at all levels. – Ensuring availability of the essential drugs. – Improve referral to identified referral facility. – Referral mechanism to ensure hassle free transfer to higher level of care when needed. – Awareness of Health worker for when and where to refer a sick child. – The staff at appropriate health facilities must identify and acknowledge the referral slips and give priority care to the sick children. – Functioning referral centres, especially where healthcare systems are weak need to be reinforced or private/public partnerships established – Ensuring supervision and monitoring through follow up visits by trained supervisors – On-the-job supportive supervision.

19. Improvement of Family and Community Practices: ( Community IMNCI) Counselling of families and creating awareness among Communities. This includes: – Promoting healthy behaviours such as breastfeeding, illness recognition, early care seeking etc. – IEC campaigns for awareness generation. – Counselling of care givers and families as part of management of the sick child when they are brought to the health worker/health facility. – During Home Visits - identification of sickness and focused BCC for improving newborn and child care practices. Collaboration/coordination with other Departments, PRIs, Self Help Groups etc: – Community ownerships and participation is of paramount importance.

20. Management Algorithm:

21. The IMNCI Process for Children < 2 Months of Age

23. Then proceed for ……… Diarrhoea. Feeding Problem or Malnutrition. Immunization Status. Other Problems.

24. The IMNCI case management Process: for children 2 months to 5 years of Age

26. Then proceed for…… Main Symptoms – Cough or Difficult Breathing – Diarrhoea – Fever – Ear Problems Malnutrition Anaemia Immunization Status Other Problems

27. F- IMNCI: (facility based IMNCI) What?  Facility Based Care for severely ill children is complementary to primary care for providing a continuum of care for severely ill children.  Integration of existing IMNCI package and the Facility Based Care package in to one package. WHY?  Majority of the health facilities (24x7 PHCs, FRUs, CHCs and District hospitals) do not have trained paediatricians.  F-IMNCI training will help in skill building of the medical officers and staff nurses posted in these health facilities to provide IMNCI care.

28. TRAININGS in F- IMNCI Focus on Skill Development 50% of training time is spent on building skills by “hands-on training” involving actual case management and counselling. Remaining 50% in classroom for building theoretical understanding of essential health intervention. Training at two levels: – In service training for the existing staff. – Pre-Service Training– For including F-IMNCI in the pre-service teaching of doctors and nurses. Personnel to be Trained: There are 2 types of trainings under F-IMNCI: PRE-TRAINING STATUSPACKAGE TO BE USEDDURATION IMNCI not trained F-IMNCI complete package 11 days IMNCI trainedFacility based care package of F-IMNCI 5 days

29. Training of Trainers: – Faculty from the departments of Paediatrics and community medicine of the medical colleges. – The trainers at district level include all the paediatricians in the district. – The TOT for State and District facilitators will be facilitated by National F-IMNCI facilitators. Facilitator to trainees ratio: – Participant to facilitator ratio of 1:4-6 (one trainer to 4 – 6 participants). Training Institutions: – The Departments of Pediatrics and Preventive & Social Medicine in each college. Pre-service Training: – Include training on F-IMNCI for the undergraduate students and intern. Also for Nursing students.

30. C - IMNCI: Community and Household IMNCI: Community IMCI is basically Component 3 of the IMCI Package. It aims at improving family and community practices by promoting those Practices with the greatest potential for improving child survival, growth and development. Evidence that 80% of deaths of children under five years of age occur at home with little or no contact with health providers. ( Kirk et al.) C-IMCI seeks to strengthen the linkage between health services and communities, to improve selected family and community practices and to support and strengthen community-based activities.

32. Key family practices: 16 key family practices identified Under Four Broad Heading: The promotion of growth and development of the child: – Exclusive Breastfeeding for six months. Good quality complementary foods after six months. Continue breastfeeding for two years or longer. – Ensure enough micronutrients – such as vitamin A, iron and zinc – in diet or through supplements. – Promote mental and social development by responding to a child’s needs for care and by playing, talking and providing a stimulating environment. Disease prevention: – Dispose of all faeces safely, wash hands after defecation, before preparing meals and before feeding children. – Protect children in malaria endemic areas, by ensuring that they sleep under Insecticide - treated bed nets. – Provide appropriate care for HIV/AIDS affected people, especially orphans, and Take action to prevent further HIV infections.

33. Appropriate care at home: – Continue to feed and offer more fluids, including breast milk to children when they are sick. – Appropriate home treatment for infections. – Protect children from injury and accident and provide treatment when necessary. – Prevent child abuse and neglect, and take action when it does occur. – Involve fathers in the care of their children and in the reproductive health of the family. Care-seeking outside the home: – Recognize when sick children need treatment outside the home and seek care from appropriate providers. – Complete a full course of immunization before first birthday. – Follow the health provider’s advice on treatment, follow-up and referral. – Ensure that every pregnant woman has adequate antenatal care, and seeks care at the time of delivery and afterwards.

34. C - IMNCI: Experience of the our Department Pilot Initiative on Implementation of Community Based IMNCI in Warora Block, Chandrapur. Objectives : 1) To study the effect of the household and community IMNCI (HH/C IMCI) on key behaviours of caregivers for children (0-5 years) in the selected block of Chandrapur. 2) To document and disseminate the lessons learned. Main Intervention: – Development of Training Module and IEC material: – Capacity Building Program. Orientation of District Level Health Care Providers. Training of Anganwadi Workers. Training of ASHA Volunteers.

35. Behaviour Change Communication: For Key Community IMNCI Family Practices : Application of BEHAVE framework. Determinants of each behaviour were identified through ‘doers and non-doers analysis’. Development of behaviour specific IEC material Community Intervention: Participation in Village Health & Nutrition Day. Participation in VHNSC meetings: Midterm Assessment Post midterm intervention: – Group Health Education : – Re-orientation of VHNSC members – Reinforcement of Knowledge of AWW; – Focus Group Discussion with the Mothers: Monitoring and Supervision

36. Main Findings: Quantitative Findings: The Socio demographic status remained same. Definite change in the knowledge level and positive practices. Health insurance cover raised. The shift in more institutional deliveries and less home deliveries. The consumption of 90 or more iron folic acid tablets increased by 12 to 20%. No change in immunization coverage of two tetanus toxoid injection which was around 75%. 90% increase in Practice of weighing the baby on the very 1 st day of life. Almost 90% babies received breast milk within an hour of birth. 80% within half an hour in all PHCs. The practice of pre-lacteal feeds significantly reduced to less than 15% at end line survey from more than 45% at baseline survey. The proportion of mothers washing hands before feeding the child has increased from less than 40 % at baseline to more than75 % at end line survey. More than 90 % mothers opined to continue breast feeding during illness to the child.

37. Qualitative Findings: ( FGDs and IDI) The pregnant mothers register themselves early. Majority of pregnant mothers consume IFA tablets. The pregnant mother take proper care during pregnancy. Majority of the mother prefer hospital delivery. The mothers follow the advice given by Doctor, ANM, AWW and ASHAs The practice of giving prelactal feeding (Bola) had been reduced. The breastfeeding practices had been improved. The mothers bring their children for weighing regularly, and take advice from AWW or ASHAs. The mothers bring their children for immunization on their own on Village Health and Nutrition Day. The mothers seek medical advice as early as possible. The demand for contraceptive had been increased.

38. IMNCI + The objectives of the newborn and child health strategy are: – Increase coverage of skilled care at birth for newborns in conjunction with maternal care. – Implement a newborn and child health package of preventive, promotive and curative interventions using a comprehensive IMNCI approach: At the level of all: – Sub-centres. – Primary health centers. – Community health centers. – First referral units At the household level in rural and poor peri urban settings in at least 125 districts (through AWWs / ASHAs) – Implement the medium-term strategic plan for the UIP (Universal Immunization Program). – Strengthen and augment existing services in areas where IMNCI is yet to be implemented.

39. Why IMNCI ‘Plus’ RCH 2 NEW BORN and CHILD HEALTH PACKAGE:

40. What “IMNCI +” Adds Inpatient care component for facilities to ensure effective care of sick neonates and children who require hospitalization. IMNCI package not cover the vital care of the neonates at birth in home and facility settings. IMNCI approach includes counselling for immunization, but the implementation of immunization in India cannot be adequately done by the IMNCI contacts alone. Therefore, a comprehensive immunization plan will be required.

41. IMNCI: Implementation Status in Maharashtra Started selected 9 districts. 11 more districts also being covered for training since July 2007. 9 districts – – 4 from RCH flexi pool funds - Thane, Nashik, Amravati and Gadchiroli. – 5 from UNICEF Assistance: Osmanabad, Latur, Chandrapur, Nanded & Nandurbar. IInd Phase: IMNCI introduced in 9 Districts Raigad, Beed, Ahemadnagar, Jalgaon, Dhule, Pune, Gondia, Yavatmal. Nagpur, Wardha. Buldhana has been added recently. 20 out of 33 districts training started.

42. Status of IMNCI training (MOs & Paramedical) Sr.No.DistrictTotal Trg. LoadTrained 1.Thane1392523 2.Pune1594264 3.Raigad16392 4.Nashik29091440 5.Nandurbar2984554 6.Dhule808340 7.Jalgaon522258 8.Ahmednagar620165 9.Yeotamal357689 10.Amaravati744522

43. Status of IMNCI training (MOs & Paramedical) 11. Buldhana365275 12.Gadchiroli5498506 13.Chandrapur3068636 14.Nagpur250957 15.Osmanabad20611865 16.Latur25882126 17.Nanded39971009 18.Beed480329 Total3587811050

44. References: Improving Child Health; IMCI, The Integrated Approach. WHO, 1997. Downloaded on 04/ 06/2011 from URL: http://www.who.int/imci- mce/publications.htmhttp://www.who.int/imci- mce/publications.htm Student’s handbook for IMCI. 2001., WHO, Geneva. Arifeen S, et al. MCE-Bangladesh baseline household health and morbidity survey, ICDDR,B, 2000. http://www.who.int/pmnch/media/publications/aonsectionIII_5.pdf World Health Statistics 2011. Downloaded from URL; http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf RCH 2 – National Programme Implementation Plan: MOHFW, GOI. Dowloaded From URL: http://mohfw.nic.in/nrhm/reproductivechild health/programme document.pdf / Operational Guidelines for Implementation of IMNCI. MOHFW,GOI. Downloaded from URL; http://mohfw.nic.in/dofw%20website/F%20IMNCI%20Operational%20Plan %2013%20june%202006.htm http://mohfw.nic.in/dofw%20website/F%20IMNCI%20Operational%20Plan %2013%20june%202006.htm Student’s handbook for IMNCI. MOHFW, GOI & WHO country Office for India. 2003.

45. Operational Guidelines for Facility Based IMNCI. MOHFW, GOI. Downloaded from URL: http://mohfw.nic.in/nrhm/ Reaching Communities for Child Health and Nutrition: A Proposed Implementation Framework for HH/C IMCI. Baltimore, Maryland, 2001. D Hill Z, Kirkwood B & Edmond K. Family and community practices that promote child survival, growth and development: A review of the evidence. Geneva, World Health Organization, 2004 Child Health in the Community: Community IMCI, Briefing Package for Facilitator. WHO.2004. Child Health in the Community; Community IMNCI, Briefing package for Facilitator. WHO. 2004. Child Health in the Community; Community IMNCI, Briefing package for Facilitator. WHO. 2004.

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