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CB-IMNCI Program in Nepal
- 1. COMMUNITY BASED INTEGRATED MANAGEMENTOF NEONATAL AND CHILDHOOD ILLNESS (CB-IMNCI) Mohammad Aslam Shaiekh Master of Public Health (MPH)
- 2. BACKGROUND • CB-IMNCI isan integration of CB-IMCI and CB-NCP Programs as per the decision of MoH on 2071/6/28 (October 14, 2015). • This integrated package of child-survival intervention addresses the major newborn care conditions including birth asphyxia, bacterial infection, jaundice, hypothermia, low birth weight and encouragement of breastfeeding. • It addresses the major illnesses of 2 to 59 months old children :Pneumonia, Diarrhoea, Malaria, Measles and Malnutrition, in a holistic way. 2Aslam Aman
- 3. Background (Contd….) In CB-IMNCIprogram, FCHVs are expected to carry out health promotional activities for maternal, newborn and child health and dispensing of essential commodities like distribution of zinc, ORS, chlorhexidine which do not require assessment and diagnostic skills, and immediate referral in case of any danger signs appeared among sick newborn and children. 3Aslam Aman
- 4. Historical Development (CB-IMNCI) •Control of Diarrhoeal Disease (CDD) Program was initiated in 1983. • Acute Respiratory Infection (ARI) Control Program was initiated in 1987. • ARI intervention was combined with CDD and named as CB-AC program in 1997/98. • One year later, Nutrition and Immunization were also incorporated in the CBAC program. • IMCI program was piloted in Mahottari district and was extended to the community level as well. 4Aslam Aman
- 5. • CBAC wasmerged into IMCI in 1999 by the government and was named as Community Based Integrated Management of Childhood Illness (CB-IMCI). CB-IMCI included the major childhood killer diseases like pneumonia, diarrhoea, malaria, measles, and malnutrition. • After piloting of low osmolar ORS and Zinc supplementation, it was incorporated in CBIMCI program in 2005. • Nationwide implementation of CB-IMCI was completed in 2009 and revised in 2012 incorporating important new interventions. 5Aslam Aman
- 6. • State ofworld report, WHO showed that major causes of mortality were infections, asphyxia, low birth weight and hypothermia. • The Government of Nepal formulated the National Neonatal Health Strategy 2004. Based on this 'Community-Based New Born Care Program (CB-NCP)' was designed in 2007, and piloted in 2009. • The government decided to scale up CB-NCP and simultaneously, the program was evaluated in 10 piloted districts. Upto 2014, CB-NCP was implemented in 41 districts covering 70% population. 6Aslam Aman
- 7. • CB-NCP andCB-IMCI have similarities in interventions, program management, service delivery and target beneficiaries. • Considering the management of similar kind of two different programs, MoH decided to integrate CB-NCP and IMCI into a new package that is named as CB-IMNCI on 2071/6/28 (October 14, 2015). • Currently, CB-IMNCI program has been implemented in all the districts. 7Aslam Aman
- 8. Goal and Targets Goal: Improve newborn and child survival and healthy growth and development Targets of Nepal Health Sector Strategy (2015-2020) • Reduction of Under-five mortality rate (per 1,000 live births) to 28 by 2020 • Reduction of Neonatal mortality rate (per 1,000 live births) to 17.5 by 2020 8Aslam Aman
- 9. Objectives • To reduceneonatal morbidity and mortality by promoting essential newborn care services • To reduce neonatal morbidity and mortality by managing major causes of illness • To reduce morbidity and mortality by managing major causes of illness among under 5 years children 9Aslam Aman
- 10. Strategies • Quality ofcare through system strengthening and referral services for specialized care • Ensure universal access to health care services for new born and young infant • Capacity building of frontline health workers and volunteers • Increase service utilization through demand generation activities • Promote decentralized and evidence-based planning and programming 10Aslam Aman
- 11. Major Interventions Newborn SpecificInterventions • Promotion of birth preparedness plan • Promotion of essential newborn care practices and postnatal care to mothers and newborns • Identification and management of non-breathing babies at birth • Identification and management of preterm and low birth weight babies • Management of sepsis among young infants (0- 59 days) including diarrhoea 11Aslam Aman
- 12. Child Specific Interventions Casemanagement of children aged between 2-59 months for 5 major childhood killer diseases (Pneumonia, Diarrhoea, Malnutrition, Measles and Malaria) Cross -Cutting Interventions • Behavior change communications for healthy pregnancy, safe delivery and promotion of personal hygiene and sanitation • Improved knowledge related to Immunization and Nutrition and care of sick children • Improved interpersonal communication skills of HWs and FCHVs 12Aslam Aman
- 13. Vision 90 by20 CB-IMNCI program has a vision to provide targeted services to 90% of the estimated population by 2020 as shown in the diagram below. 13Aslam Aman
- 14. Major Activities (FY2073/74) • Development and certification of Mid-western Regional Hospital as an IMNCI Clinical Training Site as Nepal’s first IMNCI Clinical Training Site • Expansion of IMNCI Training Site at Pokhara (Pokhara Academy of Health Science) and Dang (Rapti Sub-regional Hospital (on-going) • Development of National Medical Standard for Care of Newborns and Children (on-going) • Development of FB-IMNCI package (on-going) • Implementation of Remote Area Guideline for CB-IMNCI program (on-going) 14Aslam Aman
- 15. Major Activities (Contd….) •Development of a pool of IMNCI trainers for CB- IMNCI and Comprehensive Newborn Scale up of Navi care Program in public as well as private sector • Procurement of commodities and equipment related to IMNCI • Establishment/Strengthening of SNCU • Printing of CB-IMNCI, Comprehensive New born Care (Level II) Training Materials (Guidelines, Handbook, Chart, Flex, etc.) • Training of Trainers (TOT) for CB-IMNCI and Comprehensive Newborn Care Training (Level II) 15Aslam Aman
- 16. Major Activities (Contd….) •Implementation of free sick newborn care program through five hospitals (Kanti Children Hospital, Koshi Zonal Hospital, Western Regional Hospital, Lumbini Zonal Hospital and Seti Zonal Hospital) • Initiation of Perinatal Quality Improvement Initiative in 12 hospitals 16Aslam Aman
- 17. CB-IMNCI Program Monitoring Indicatorsby Province (FY 2073/74) 17Aslam Aman
- 18. Classification and treatmentof 0-28 days newborn cases by province (FY 2073/74) Source: HMIS/MD/DoHS 18Aslam Aman
- 19. Classification of DiarrhoealCases by Province (FY 2073/74) 19 Aslam Aman
- 20. Incidence and casefatality of diarrhoea among children under 5 yrs of age by province (FY 2073/74) 20 Aslam Aman
- 21. Treatment of DiarrhoeaCases by Province (FY 2073/74) 21 Aslam Aman
- 22. Acute respiratory infection(ARI) and pneumonia cases by provinces (2073/74) 22 Aslam Aman
- 23. Classification of casesas per CB-IMNCI protocol by province (FY 2073/74) 23 Aslam Aman
- 24. Diarrhoea prevalence byage (NDHS 2016) 24Aslam Aman
- 25. Nutritional status ofchildren 25 Source: NDHS,2016 Aslam Aman
- 26. Trends in earlyChildhood Mortality Rates 26 Source: NDHS,2016 Aslam Aman
- 27. Management Aspect ofCB-IMNCI Program • Planning • Organizing • Staffing • Directing • Coordinating • Recording and Reporting • Budgeting • Monitoring and Evaluation 27Aslam Aman
- 28. Planning • Family WelfareDivision (Child Health and Immunization Services Section) is the main body responsible for formulating plans and activities regarding CB-IMNCI at the central level. • Provincial Health Directorate (Curative Services and Disease Control Section) at provincial level and Health Offices at local level are responsible for planning, implementation and supervision of CB-IMNCI. 28Aslam Aman
- 29. Organizing • CB-IMNCI servicesare provided from Hospitals/ PHCCs/HPs and from out reach clinics at community or peripheral level. • FCHVs carry out health promotional activities for maternal, newborn and child health and help in distribution of zinc, ORS, chlorhexidine which do not require assessment and diagnostic skills. • They also help in the immediate referral of sick newborn and children in case of any danger signs. 29Aslam Aman
- 30. Staffing Central Level (FamilyWelfare Division) Director-11th level (1) Child Health and Immunization Services Section: Sr./ PHA- 9/10 th level (1) Sr. /PHO- 7/8th level (1) Sr. /CNO- 7/8th level (1) HA- 5/6/7th level (1) Provincial Level (Provincial Health Directorate) Director- 11th level (1) Curative Services and Disease Control Section: Medical Superintendent-9/10th level (1) Medical Officer- 8th level (1) Medical Lab Technician- 5/6th level (1) 30Aslam Aman
- 31. Staffing (Contd….) PHCC- TrainedMO,HA, SN, AHW, ANM Health Post- Trained HA, AHW, ANM FCHVs are the pillars of CB-IMNCI program. Local Level: 31 (Not Final) Aslam Aman
- 32. Directing • At centrallevel, MoHP/DoHS is responsible for directing the CB-IMNCI program all over the country. • Family Welfare Division is the chief body of CI-IMNCI program. It supervises, organizes and guides all CB- IMNCI related plans throughout the country. • At provincial level, Ministry of Social Development/ Provincial Health Directorate carries the responsibility. • At local level, Health Office/ Health Section of local unit is responsible for directing and supervising the program. 32Aslam Aman
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- 35. Recording/ Reporting • AtPHCCs/HPs level, the data generated from ORC and health facility are compiled and entered in HMIS report (9.3) and sent to Health Office through Health section of Rural Municipality/Municipalities on monthly basis. • At District level, the report will be collected, compiled, analyzed and sent to Provincial Health Directorate and HMIS section of DoHS. • Quarterly and annual review meeting will be conducted at district, provincial, central level to measure the achievement and guide the program. 35Aslam Aman
- 36. • Reporting mechanismfollows the overall reporting pattern established by DoHS/MoHP. • All facilities follow the pattern through prescribed reporting forms of HMIS. 2.4: CB-IMCI Register 4.1: PHC-ORC Register 9.1: FCHVs reporting collection form 9.2 : Community level health service monthly reporting form - Immunization & PHC-ORC 9.3 : PHCC, HP reporting form 9.4 : Public hospital reporting form 9.5 : Non public health facility reporting form 36Aslam Aman
- 37. HMIS 9.1FCHV reporting collectionform HMIS 9.2 Community level health service monthly reporting form - Immunization & PHC,ORC HMIS 9.3 PHCC, HP reporting form HMIS 9.4 Public hospital reporting form HMIS 9.5 Non public health facility reporting form Municipality/ RM PHDDoHS MIS Section Health Office Aslam Aman 37
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- 46. Budgeting Ministry of Finance Ministryof Health and Population Ministry of Social Development (Provincial) Provincial Health Directorate Health Office 46Aslam Aman
- 47. Monitoring and Evaluation Regularmonitoring is important for better management of program. Therefore, CB-IMNCI program has identified 6 major indicators to monitor the programs that are listed below: Percentage of Institutional delivery Percentage of newborn who had applied Chlorhexidine gel immediately after birth (within one hour) Percentage of infants (0-2 months) with PSBI receiving complete dose of Injection Gentamicin 47Aslam Aman
- 48. Percentage of under5 yrs children with pneumonia treated with antibiotics Percentage of under 5 children with diarrhoea treated with ORS and Zinc Stock out of the 5 key CB-IMNCI commodities at health facility (ORS, Zinc, Gentamicin, Amoxicillin/Cotrim, CHX) 48Aslam Aman
- 49. Responsible Bodies forMonitoring and Evaluation • Ministry of Health and Population • Family Welfare Division • Ministry of Social Development • Provincial Health Directorate • Health Office • Health Section of Municipality/ Rural Municipality 49Aslam Aman
- 50. Major Challenges • Unclarityin roles of staffs (including CBIMNCI focal person) in the new federal context • Frequent stock outs of essential commodities in districts and communities • Poor service data quality • Increase in percentage of severe pneumonia cases • Poor referral mechanism 50Aslam Aman
- 51. Recommendation • Clarification ofroles of staffs in the present context • Timely supply of commodities • Carry out routine data quality assessments • Strengthen regular feedback mechanisms • Targeted interventions (BCC activities); and early detection, treatment and referral of severe pneumonia cases • Strengthening of referral mechanism 51Aslam Aman
- 52. Bibliography • Government ofNepal. Annual Report. Department of Health Services 2073/74 (2016/2017). • Nepal Demographic and Health Survey 2016. 52Aslam Aman
- 53. 53 HAVE A BEAUTIFULDAY ! Healthy Children, Healthy Nation! Aslam Aman