1. GIVS and UNICEF: Strategic Priorities For Immunization and Child Survival
Dr. Peter Salama,
Chief Child Survival and Immunization Unit
Health Section, Programme Division
UNICEF
GIM, March 28th 2006

2. Outline UNICEF context UNICEF and GIVS Progress in 60 countries
Programme models
CS indicators- some examples
Next steps

3. New UNICEF Context UN reform Paris Principles Child survival and MDG 4
New partnerships
GIVS and strategic frameworks
New Executive Director

4. Health and Nutrition Strategy: Conceptual implementation framework
All MDGs
MDG 4
MDGs 1, 4, 5 & 6
Policies, plans & budgets
Knowledge & Evidence
Large scale action
Impact
Translating policies, plans and budgets into large scale action
Leveraging policies, plans and budgets through enhanced
Knowledge & evidence
Learning by doing, and doing better by learning

5. Global Causes of Under 5 Mortality*
Malnutrition
Contributes to
about 50% of
this mortality
*Source: Lancet Child Survival Series, (measles data revised). Total 10.8 million deaths per year

6. Global Causes of Under 5 Mortality By Vaccine-Preventable Status*
*Source: WHO/UNICEF
Total 10.8 million deaths per year

7. GIVS and UNICEF 1) Reaching the unreached 2) New vaccines
Complete ADC agenda
Large countries, marginalized pops, complex emergencies
2) New vaccines
3) Linking child survival interventions
4) Global interdependence
Forecasting, supply and procurement
Financing

8. Child Survival Countdown - 60 priority countries
Criteria:
Either total number of under-five deaths ≥ 50,000
Or under-five mortality rate ≥ 90 per thousand

9. Where we are…. We know: ● How many children are dying
● What they are dying of
● Which interventions can prevent most child deaths
Need to know:
● What are current coverage levels of interventions
● Is progress being made
● Where do we need to focus programs

10. priority countries in <5 MR
Under 5 Mortality
Progress for
60 Countdown
priority countries in <5 MR

11. Immunization

12. Measles and DTP3 Major progress during the 1980s
Coverage stagnated since 1990
DPT3
Developing World
76%
Target
Measles
Developing World
74%

13. Measles and DTP3 60 Countdown priority countries
• 10 countries with 90% or more coverage • Most countries still below target and need intensified efforts
Measles
DPT3
CAR, Chad, Cote d’Ivoire, Eq. Guinea, Gabon, Haiti, Liberia, Nigeria, PNG, Somalia
CAR, Cote d’Ivoire, Liberia, Nigeria, PNG, Somalia
>90%
>90%
<50%
<50%

14. Prevention
Insecticide-treated Nets
Vitamin A Supplementation

15. Vitamin A Supplementation
Developing
World
61%
• 3-fold increase in % children fully protected by two doses
• Greatest gains in least developed countries
• Among the 60 priority countries, 26 have 70% or more coverage with at least one dose, and 7 have unacceptably low coverage

16. malaria endemic countries
ITNs
Sub-
Saharan
Africa 3%
Sub-Saharan Africa:
malaria endemic countries
Low rates of ITN use
Major investments in
recent years
Rapid increases expected soon; 10-fold increase in nets distributed in
Sub-Saharan Africa
( )
Abuja target 2005

17. Case Management
80%
(1 dose)

18. Pneumonia Case Management
• Pneumonia kills more children than any other illness, accounting for 19% of all under five deaths
Neonatal pneumonia/sepsis is estimated to cause 26% of all neonatal deaths.
• Only 1 in 5 caregivers know the ‘danger signs’ of pneumonia – cough and fast or difficult breathing
• 54% of children with
pneumonia are taken
to an appropriate health care provider
Neonatal causes 27%
Pneumonia %
80%
(1 dose)

19. Pneumonia Case Management
Roughly 20% of children with pneumonia received antibiotics
(based on limited data from the early 1990s)
● Current estimates
not available
● Questions on antibiotic
use for pneumonia
included in current round
of MICS and DHS
● Rapid progress is
possible
80%
(1 dose)

20. Nutrition

21. Exclusive Breastfeeding
Developing World
36%
Significant progress has been made since 1990
Sub-Saharan Africa, in particular, has made significant
gains during the 1990s
Rates continue to be low across the developing world
+41%
+9%
+21%
+450%

22. Exclusive Breastfeeding
Rapid progress is possible
Rapid progress Higher rates achieved
Rapid progress Rates still low

23. Exclusive Breastfeeding
60 Countdown priority countries 23 countries with unacceptably low rates

24. Newborn Health
80%
(1 dose)

25. Summary of Findings
● Coverage levels remain too low for most indicators
● Rapid progress is possible
● Analysis needed of why rapid progress occurs in some countries, and for some interventions, but not others

26. Coverage too low for most causes of child death
Summary of Findings
Coverage too low for most causes of child death
Cause of death
Intervention coverage
Malaria
Pneumonia
Diarrhea
Undernutrition
Neonatal
Measles
ITN use
ORT
Antibiotics
ORT/continued feeding
Exclusive breastfeeding
Vitamin A supplementation (> 1 dose)
Exclusive Breastfeeding
Skilled attendant at birth
Measles vaccine

27. national household survey activity 2005-2006
Surveys for
national household survey activity
MICS
DHS
Other surveys

28. GIVS Strategy 3
Integrating immunization, other linked interventions and surveillance in the health systems context
UNICEF Approach:
Using immunization to deliver evidence-based packages of child survival interventions at country level

29. Evidence-Based Selection will Lead to a Mix of Interventions and Operational Strategies

30. SELECTION OF EVIDENCE BASED HIGH IMPACT INTERVENTION PACKAGES
EPI+
Strengthening routine EPI
Vitamin A supplementation
ITNs*
Cotrimoxazole prophylaxis*
IPTi*
Antenatal care+:
Refocused ANC
Tetanus immunization
Intermittent presumptive treatment (IPT) against malaria
Vitamin A (post partum)
PMTCT*
IMCI +
Exclusive Breastfeeding
ORT
ITNs (pregnant and under 5 children)
Community management of Malaria and ARI
Issue is which of the slides 18 or 19 is more appropriate for SAGE for which high impact interventions are needed.

31. Systematic Scaling Up of Proven Interventions and Appropriate, Situation-Specific Strategies that Benefit Children and Women’s Health and Nutrition
Under 5 Mortality Rate
10. Systematic scaling up of proven interventions and appropriate, situation-specific strategies that benefit children and women’s health and nutrition. Countries experiencing the greatest challenges in accelerating progress towards achievement of the health and nutrition Millennium Development Goals are often, not surprisingly, characterized by weak and inequitable health and nutrition systems and poor governance.
Hence, reaching the health and nutrition Goals will require:
(a) More effective national capacity-building to address system-wide operational problems and social mobilization issues. Even in countries with weak systems, national health/nutrition days, periodic outreach services and improvement of family and community- level care practices can trigger rapid improvements in young child survival, growth and development;
(b) Strengthening facility-based health and nutrition systems is time-consuming but essential, so that gains in capacity are consolidated and sustained. For example, strengthening district health/nutrition systems is key to the sustainable scaling-up of services for the prevention of mother-to-child transmission of HIV, and to increasing the proportion of HIV- infected children receiving appropriate care and treatment.
In the High Impact demonstration Districts in Mali, the estimated reduction in the U5MR is close to 25% compared to the 2001 baseline. Over half of this impact is attributable to Family/Community level Care, thanks to the combination of massive distribution of free ITNs to all pregnant women and door-to-door re-impregnation, community management of Malaria, and use of ORT. Most of the rest is due to outreach services, particularly Vitamin A supplementation and Measles vaccination where coverage of both interventions increased by 50%.
The estimated U5MR reduction in the control areas is very modest so the “controlled impact” (i.e. ACSD increased coverage minus control area coverage, shown in red) is only 3% less than the actual impact in the ACSD areas, namely 21%.

32. Impact of ACSD package on DPT3 coverage in selected districts of 3 West African Countries
2001 Baseline
2003 Survey

33. ACSD and Malaria

34. Using immunization as a platform for delivery of package of child survival interventions
Help countries to tailor integrated packages of interventions at immunization contacts with priority on outreach and strategies for hard to reach
Ensure selected additional interventions are included in the multi-year plan
Assist in effective implementation and monitoring of the joint interventions
Continue to learn and adapt packages and implementation

35. Why is T/S Prophylaxis Important for HIV-Infected Children in Resource-Poor Settings? CHAP Study: 43% Decrease Death with T/S
1.00
0.80
Proportion Alive
0.60
Cotrimoxazole
Placebo
0.40 .5 1
1.5 2
Years from randomisation
*Source: Chintu C et al. Lancet 2004;364:

36. Afghanistan; under five child survival indicators as of 2004 U5MR 257 per 1000 live births- Ranked 4
Source: SOWC 2006

37. DR Congo; under five child survival indicators as of 2004 U5MR 205 per 1000 live births- Ranked 8
Source: SOWC 2006

38. Rwanda; under five child survival indicators as of 2004 U5MR 203 per 1000 live births- Ranked 10
Source: SOWC 2006

39. Ethiopia; under five child survival indicators as of 2004 U5MR 166 per 1000 live births
Source: SOWC 2006

40. Nigeria; under five child survival indicators as of 2004 U5MR 197 per 1000 live births- Ranked 13
Source: SOWC 2006

41. ACSD Booster Initiative Sub Saharan Africa40 80
120
160
200
1990
1993
1996
1999
2002
2005
2008
2011
2014
MDG 4 target
Current trend
ACSD Booster
Phase I
Phase II
Phase III
<5 MR
1000 LBs
Year

42. Next Steps Formal independent evaluation ACSD Refine costing tool
Mobilize partners: WHO, WB, AU, GAVI, GFATM, CIDA, USAID, Norway, PMNCH
Investment case
Implementation plan
Continue to support government scale-up
Monitoring framework
Lessons learned