Integrated management of neonatal and childhood illness (

Presenter :-Dr. Vaibhav Gupta, MPH2nd year
Moderator - Dr. Sunil Kumar D.
( Ast.Prof.)
Dept. of community medicine
JSSMC
11/01/2014
13/01/2014 1

 Introduction-(IMCI)
 Why integrated management
 IMCI- Component & Process
 Differences; IMCI/IMNCI
 IMNCI: Components, Objectives, Strategies
 Process of IMNCI
 IMNCI Plus
 F-IMNCI ,Pre service IMNCI
 Home based New Born care
 JSSK,NSSK,C-IMCI
 SWOT analysis
 Current Status
 conclusion
13/01/2014 2

 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.
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IMR 42/1000 and Under 5 mortality 95/1000 live births
per year.
Neonatal mortality contributes to 64% of infant deaths
mostly occurring during first week of life.
According to report released on 12 September 2013 by
United Nations Children's Fund (UNICEF) the global
Infant Mortality rate (IMR) decreased from 61 deaths in
1990 to 37 deaths in 2011.
Annual infant deaths declined from 8.4 million in 1990
to5 million in 2011.
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 According to the report India’s infant mortality rate
shown a minor decline in 2012 compared to 2011. Infant
Mortality rate decreased from 44 deaths for every 1000
live births in 2011 to 42 deaths for every 1000 live in
2012.
 IMCI seeks to reduce childhood mortality and
morbidity by improving family and community
practices for the home management of illness, and
improving case management of skills of health workers
in the wider health system.
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 An integrated approach was needed to manage sick
children to achieve better outcomes.
 Child health programmers needed to move beyond
tackling single diseases in order to address the overall
health & well being of the child
 During mid 1990s, WHO & UNICEF developed a
strategy – IMCI
13/01/2014 6

Cont..
IMCI has been expanded in India to include all
neonates and renamed as IMNCI
Govt of India has made newborn health a priority in
the nation’s next five year plan
Govt is working with WHO and UNICEF to adapt
IMCI guidelines to include newborn care, creating
new guidelines called IMNCI
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 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.
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 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.
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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
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 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.
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Source: IMCI; Student’s Handbook, WHO
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Features: WHO – UNICEF IMCI IMNCI
Coverage of 0 to 6 days
(early newborn period)
No Yes
Basic Health Care Module NO Yes
Home visit by the provider
for newborn and Young
Infant
No Yes
Training
Training Home based Care No Yes
Training days for newborn
and young infants
2 out of 11 days 4 out of 11 days
Sequence of training Child (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.)
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 Reduce infant and child mortality rates
 Improving child health and survival
 Currently in India, it is 42 deaths/1000 live births.
 Decline not uniform across states.
 Malnutrition and low birth (LBW) are contributors to
about 50% deaths.
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13/01/2014 16
 Strategy encompasses a range of interventions to prevent and
manage five major childhood illnesses
 Acute Respiratory Infections,
 Diarrhoea,
 Measles,
 Malaria
 Malnutrition
 The major causes of neonatal mortality such as prematurity
and sepsis.

 Survival has been an important goal of the Family Welfare
Programmes in India.
 During the period 1977 to 1992 programmes like universal
immunization programme;
 oral rehydration therapy (ORT) programme and programme
for prevention of deaths due to acute respiratory infections
(ARI) were implemented as vertical programmes.
13/01/2014 17

 These programmes were integrated in 1992 under the Child
Survival and Safe Motherhood Programmes and have
continued to be a part of the Reproductive & Child Health
Programme implemented since 1997.
 IMNCI is an integrated to child health that focuses on the well
being of the whole child.
 affecting children aged 1week – 2month , 2months - 5years
including both preventive and curative elements to be
implemented by families.
13/01/2014 18

 It also teaches about nutrition including breast feeding
promotion, complementary feeding and micronutrients. It
focuses on preventive, promotive and curative aspects.
 IMNCI is the Indian adaptation of the WHO- UNICEF generic
IMCI( integrated management of Childhood Illness.)
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 Care of Newborns and Young Infants (infants under 2
months):
◦ Keeping the child warm.
◦ 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. 13/01/2014 20

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).
13/01/2014 21

Improve health worker
skills
Improve health systems Improve family and
community practices
Case management standards
and guidelines
District and block planning
management
Appropriate Care seeking
Training of facility- based
public health care providers
Availability of IMNCI drugs Nutrition
IMNCI roles for private
providers
Quality improvement and
supervision at health facilities –
public and private
Home case management and
adherence to recommended
treatment
Maintenance of competence
among trained health workers
Referral pathways and services Community services planning
and monitoring
Health information system
13/01/2014 23

 Implement by 2010 a comprehensive new born and
child health package at the household level
Three complementary elements :
 care at birth
 IMNCI
 Immunization
13/01/2014 29

 Evidence – based intervention
 approach integrated with RCH program
 equity –drive implementation and monitoring
 rational mix of community and facility based
interventions .
 phased decentralized priority setting at state and
district levels.
 Participate of the private sector.
13/01/2014 30

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
13/01/2014 31

 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.
13/01/2014 32

 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.
13/01/2014 34

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.
13/01/2014 35

13/01/2014
 To enhance the skills and to overcome the acute shortage of
paediatricians in the country.
 No. of posts of paediatricians in rural health facilities:
Required = 4045
In position = 898*
*www.unicef.org/India
36

 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.
13/01/2014 37


PRE-TRAINING STATUS PACKAGE TO BE USED DURATION
IMNCI not trained F-IMNCI complete package 11 days
IMNCI trained Facility based care package
of F-IMNCI
5 days
13/01/2014 38

13/01/2014
 In medical colleges will need to include training on F-
IMNCI in the training schedules –
 undergraduate students and interns, during their postings
in the Departments of Paediatrics and Preventive &
Social Medicine.
 Staff Nurse’s training schools - training on F-IMNCI in
their training schedules.
39

 The government of India has approved the implementation
of Home Based new-born care based on the Gadchirolli
model, where appreciable decline in the infant mortality
rates has been documented .
 Appreciable decline in the infant mortality rates has been
documented.
 ASHAs and ANM are being trained in the state of
Rajasthan, Bihar, Madhya Pradesh, Orissa and Uttar
Pradesh.
13/01/2014 40

 The new initiative of jssk would provide completely
free and cashless services to pregnant women
including normal deliveries and caesarean operations
and sick new born (up to 30days after birth ) in
government health institutions in both rural and urban
areas.
 Jssk initiative is estimated to benefit more than one
core pregnant women & new born who access public
health institutions every years in both urban & rural
areas.
13/01/2014 41

The free Entitlements under JSSK include:
 free and cashless Delivery
 free C section
 free treatment of sick new born up to 30days
 free drugs consumable , Diagnostics , Diet during stay
in health institution – 3days ND, 7days- CS
 free transport Home to Health institutions
13/01/2014 42

 Every year 12 lakh new-born babies die in India.
 India lunched a program on 15sept.2009 train the
health care providers at district hospitals. CHC, PHC,
across the country in management of – prevention of
infection, hypothermia (temperature management)
early initiation of breast-feeding of the new borns.
13/01/2014 43

 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.
 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.
13/01/2014 44

 Strengths :
 IMNCI focuses on enhancement of the skills of
health care personnel.
 strengthening the health system and creating
community participation.
 Provide the home based care to the baby and the
mother.
 Weaknesses :
 IMCI strategy is for sick child and not for promotion
of child health.
 IMNCI is very exhaustive and difficult to practice in
felid by health workers mainly AWW, ASHA, and
ANM.
13/01/2014 46

 Opportunities:
 Home based training for ANMs, ASHA
 Entitlements facility available
 Threats:
 Referral system and proper feedback is still lacking in
majority of areas. More monitoring and supervision is
needed for proper implementation of program.
13/01/2014 47

 IMNCI programme is currently being implemented in
359 districts. IMNCI fact sheet is based on analyses of
the IMNCI standard formatted reports submitted
quarterly by the MoHFW, GOI.
 The positive trends in IMNCI trainings of health workers
and submission of IMNCI implementation status reports
by the states. Trained IMNCI workers are providing care
to a huge number of new-borns and children as shown by
the number of new born home visits and sick children
assessed.
13/01/2014 48

13/01/2014
INDIA
(Period 2010)
KARNATAKA
(Period 2010)
No. of districts IMNCI to
be implemented.
452 30
No. of districts IMNCI
implemented
309* 14
Health personnel to be
trained
674491 35347
Health personnel trained 398184(59%) 17997(50.9%)
49

 Close to 50 per cent of new-born deaths in India occur during
the first seven days of birth.
 Many young lives are lost due to parents failing to recognise
warning signs and sick children not being taken to health
facilities on time, and because many mothers do not have
sufficient knowledge on the protective value of breastfeeding.
The IMNCI addresses such issues.
 It focuses on strengthening home based care and provides
special care for under-nourished new-borns. During home
visits by health workers the mother is taught how to recognise
diseases early and when to seek medical help.
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1.Operational Guidelines for Implementation of Integrated Management of
Neonatal and Childhood Illness.[cited on 2012 Nov 20]. Available from : URL :
www.similima.com
2.Integrated management of childhood illness. [cited on 2012 Nov 20]. Available
from: URL: http://www.unicef.org/health/23958_imci.html
3.Kishore J. National Health Programs of India, 10th edition. New
Delhi:Century;2012
4. Student’s Handbook for IMNCI. Integrated Management of Neonatal and
Childhood Illness. Ministry of Health and Family Welfare , Government of
India; 2003
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5.Integrated Management Of Neonatal and Childhood Illness
Fact Sheet- India, UNICEF India;2010.
6.http://censusindia.gov.in/vital_statistics/SRS_Bulletins/SRS
_Bulletin_December_2011.pdf
7. Improving Child Health; IMCI, The Integrated Approach.
WHO, 1997. Downloaded on 04/ 06/2011 from URL:
http://www.who.int/imci-mce/publications.htm
8.World Health Statistics 2011. Downloaded from URL;
http://www.who.int/whosis/whostat/EN_WHS2011_Full.pdf
13/01/2014 52

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