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Integrated Management of Neonatal & Childhood Illness(IMNCI) Presenter :-Dr. Vaibhav Gupta, MPH2 nd year Moderator - Dr. Sunil Kumar D. ( Ast.Prof.) Dept. of community medicine JSSMC 11/01/2014 13/01/2014 1
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Integrated management of neonatal and childhood illness (

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Page 1: Integrated management of neonatal and childhood illness (

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Integrated Management of Neonatal & Childhood Illness(IMNCI)

Presenter :-Dr. Vaibhav Gupta, MPH2nd yearModerator - Dr. Sunil Kumar D.

( Ast.Prof.)Dept. of community medicine

JSSMC11/01/2014

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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

Plan of presentation

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Introduction 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.

Cont.…

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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.

Cont.

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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

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History of IMCI

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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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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.13/01/2014

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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.13/01/2014

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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

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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.

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IMCI Process:

Source: IMCI; Student’s Handbook, WHO 13/01/2014

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

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Difference between IMCI and IMNCI: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.

Why IMNCI

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What is IMNCI?

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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.

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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.

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Cont..

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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.

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Cont.

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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.)

Cont.

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IMNCI Package: 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

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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).

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COMPONENTS

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What Needs to be done in IMNCI 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

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Management Algorithm:

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The IMNCI Process for Children < 2 Months of Age

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

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Implement by 2010 a comprehensive new born and child health package at the household level

Three complementary elements : care at birth IMNCI Immunization

objectives

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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.

Strategies

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IMNCI PLUS

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

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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.

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IMNCI strategy under RCH-2

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F- IMNCI: (facility based IMNCI)

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.

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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.

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Why F-IMNCI ?

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Need for F- IMNCI

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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

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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.

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TRAININGS in F- IMNCI

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Personnel to be Trained:

There are 2 types of trainings under F-IMNCI:            

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

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PRE- SERVICE IMNCI

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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.

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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.

Home Based New Born Care

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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.

Janani Shishu suraksha karyakram (JSSK)

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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

Cont.…

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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.

NAVJAAT SHISHU SURAKSHA KARYAKRAM(NSSK)

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C - IMNCI: (Community and Household) 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.

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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.

Swot analysis

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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.

Cont..

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  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.

CURRENT STATUS

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IMNCI : Status

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INDIA(Period 2010)

KARNATAKA(Period 2010)

No. of districts IMNCI to be implemented.

452 30

No. of districts IMNCIimplemented

309* 14

Health personnel to be trained

674491 35347

Health personnel trained 398184(59%) 17997(50.9%)

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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.

CONCLUSION

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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

REFERENCES

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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

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Cont..

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