1 Intervention Delivery Approaches AKA How do we get the interventions delivered? Horizontal vs. Vertical Approaches Facility vs. community based approach Social marketing? Reduced cost? Give away? Disease Eradication/Elimination PHC approach? Integrated approach? Target universal population? Target the poor?

Session Learning Objectives 1.Define various strategies for implementing MCH interventions including intersectoral, vertical, comprehensive, primary health care, integrated, social marketing, community-based, facility- based, universal and targeted approaches 2.Describe trends / historical context of various MCH implementation strategies 3.Compare the advantages and disadvantages of the major strategies used in MCH programming 4.Explain the successes and weaknesses of the IMCI strategy as it has been executed

Session Structure 1.Why studies strategies for intervention delivery? 2.Historical basis of strategies 3.Review strategies in the context of VPDs, malaria, injuries 4.IMCI

4 Summary: Interventions to Reduce Child Mortality 2/3 of child deaths could be averted with interventions that are already available and recommended for universal coverage! however We need to make better progress in expanding coverage of interventions

Interventions (What) vs. Strategy/Approach (How)

6 Causes of Child Mortality Reproduced from UNICEF ChildInfo website: and based on Black R et al. Global, regional, and national causes of child mortality in Lancet. 2010;375:1969–1987.

Expanded Program on Immunizations (EPI) Established 1974 Individual countries create and implement their own vaccination program policies Universal immunization with standard vaccinations –Ensure full immunization of children under age one in every district –Eradicate polio, reduce measles and neonatal tetanus deaths 7

Expanded Program on Immunizations (EPI) Expand access to relevant new vaccines Expand target groups to older children, adolescents and adults as needed Work in synergy with other public health programs 8

9 Basic Vaccine Schedule BirthBCG 6weeksDPT1, OPV1, HepB1, Hib1 10 weeksDPT2, OPV2, HepB2, Hib2 14 weeksDPT3, OPV3, HepB3, Hib3 9 monthsMeasles (MCV1) BCG=Bacillus Calmette-Guerin (against TB) DPT=Diphtheria, Tetanus, Pertussis OPV=Oral Polio Vaccine HepB=Hepatitis B Hib=Hemophilus influenza b

What is the Global Vaccine Coverage Rate?

11 Vaccine Coverage DPT3 immunization coverage, 2010

Immunization Programs: Multifaceted and complex 12

The State of the World’s Vaccines and Immunization. WHO/UNICEF Cost profile of immunizations

14 Malaria Plasmodium parasites Anopheles mosquito--vector –Parasites enter bloodstream via mosquito saliva –Invade red blood cells (RBCs), multiply there, lyse RBCs

15 ~50% of the worlds’ population live in malaria endemic areas; 90% of deaths in SSA Source: UNICEF childinfo.org

16 Malaria: Treatment Intermittent Preventative Treatment of malaria in pregnancy (IPTp) Prompt treatment with appropriate antimalarials

17 Malaria: Treatment Resistance Artemisinin Combination Therapy (ACT)

18 ACT Coverage fo.org/malaria_pr ogress.html Among all children who received an antimalarial drug, the proportion of children receiving ACT, African countries, 2007–2010

19 Malaria: Prevention Vector control –Indoor Residual Spraying (IRS) –Environmental measures (e.g. reduction of standing water)  Insecticide Treated Nets (ITNs) High ITN use  17% reduction in childhood mortality

ITN use in sub-Saharan Africa Proportion of children sleeping under an ITN (among all African countries with 2 or more comparable points)

ITN use in sub-Saharan Africa Proportion of pregnant women sleeping under an ITN (among all African countries with 2 or more comparable points)

22

23 ITN Distribution in Ghana

Childhood Injuries Burns, pedestrian injuries, drowning, falls 250,000 deaths of children <5 years Most injuries are preventable Multi-sector approach to prevent injuries Simple protocols can reduce fatality and disability

Session Structure 1.Why studies strategies for intervention delivery? 2.Historical basis of strategies 3.Review strategies in the context of VPDs, malaria, injuries 4.Integrated care / IMCI

Problems with unintegrated care and selective programming: Example of HIV infected woman AIDS treatment center of excellence T&C, ARVs, PMTCT drugs, condoms ANC FP Clinic Birth controls, condoms TB clinic Health post— Malaria, other illness

27 Integrated Management of Childhood Illnesses (IMCI) integrated approach to reduce death, illness and disability, and to promote growth and development preventive and curative elements implemented by families, communities and health facilities

28 Three Components of IMCI Improves health worker skills Improves health systems Improves family and community practices

29 IMCI Component 1: Improve Health Worker Skills Targets first level health facilities Addresses causes of at least 70% of deaths Case management guidelines Training Supervision Monitoring

30 IMCI Addresses Most Causes of Death Pneumonia Diarrhea Measles Malaria Malnutrition Sepsis Meningitis Dehydration Anemia Ear infection HIV/AIDS Wheezing

31 IMCI Component 2: Improve Family and Community Practices Community participation Preventive care –Immunization –Breast-feeding and other nutritional counseling Home care of sick children Recognition of severe illness Care-seeking behavior

32 IMCI Component 3: Improves Health Systems Planning and Management Availability of drugs and supplies Organization of work Monitoring and supervision Referral pathways and systems Health information systems

33 IMCI Multicountry Evaluation Training health workers  improved performance Difficult to maintain & expand existing IMCI sites District and national health systems lack sufficient management structure, funding, coordination, supervision, and manpower Low utilization rates of health services  IMCI cannot impact child mortality

34 Improving Health Worker Skills, Community Care, and Health Systems Capacity, structure and functions of health system Knowledge, Beliefs and skills caretakers Clinical Assessment and treatment by health workers

35 Conclusion Most maternal and child deaths are due to a select number of causes Effective interventions exist that are cost effective, feasible and recommended for implementation and can eliminate 2/3 of childhood deaths Need effective strategies to deliver interventions, especially to the poorest populations Need involved communities and strong health systems