Bernadette Daelmans Department of Child and Adolescent Health and Development

1. Scaling up effective child health interventions:Where do we come from… … breaking new frontiers Bernadette Daelmans Department of Child and Adolescent Health and Development World Health Organization

2. Where do we come from … From delivery of specific child health interventions for single diseases to ... • the major causes of under five mortality • the integration of care at various levels of service delivery From vertical programmes to … • addressing health system functions for quality, coverage and efficiency

3. Improving Health Systems Improving family & community practices • Appropriate careseeking • Nutrition • Other care practices • Home case management • and adherence to • recommended treatment • Community involvement • in health services • planning and monitoring • District planning and • management • Availability of IMCI drugs • Organization of work at • health facilities • Quality improvement and • supervision at health • facilities • Referral pathways and • services • Health Information Systems • IMCI and health sector • reforms • Case management • standards & guidelines • Training of facility-based • public health care • providers • IMCI roles for private • providers • Maintaining competence • among trained health • workers Improving health worker skills IMCI components and intervention areas (1995)

4. Coverage remains too low • Immunization interventions reach about 80% • Maternal health interventions reach about 50% • Pneumonia, diarrhoea and malaria treatment and EBF interventions reach 30–40% Source: Countdown 2008

5. Trends in coverage of ORT Source: Ram PK et al. Bull WHO 2008

6. Child health interventions NOT reaching the poor Source: Countdown 2008

7. …what we must do… …who is at risk… ..where they live… …and how to do it. An unprecedented opportunity: we know…

8. For effective coverage…. Actions are needed beyond the usual … then send them back to the conditions that made them sick?

9. … Breaking new frontiers • Development of evidence-based national policies and strategies • Outcome-oriented scaling-up plans and national coordination mechanisms for implementation • Attention to new delivery channels and creating demand • Tracking progress to inform programme planning and management

10. 1. Evidence-based national policies and strategies • Country specific epidemiological profiles • Translating global estimates to national and district level • High impact interventions • Using the Lives Saved Tool (LiST) for prioritization • Updated technical and health system policies • Translating state-of-the art knowledge into action • Effective strategies • Addressing major causes of underfive mortality and morbidity

11. Disaggregated country data for child health programming China, MCH surveillance system Western Pacific, WHO estimate

12. Adoption of evidence-based technical policies Midwives authorized to deliver life-saving interventions Policy indicators for service delivery Integrated Management of Childhood Illness adapted to cover first week of life 1-2 policies adopted No policy adopted 3 policies adopted All 4 policies adopted Data not complete Community health workers authorized to identify and manage pneumonia 14 31 2 3 18 Promotion of low Osmolarity ORS and zinc for management of diarrhoea Source: Countdown 2008

13. Do strategies reflect the major causes of death? Source: WHO review in 13 countries

14. 2. Outcome-oriented plans and coordination • District-by-district planning and capacity building • Epidemiological profile • Coverage data • Health system profile • Clustering of districts to build capacity • The three ones • One national costed implementation plan • One financing plan • One monitoring and evaluation plan • Integration in health sector development and large funding initiatives • Sector-wide approaches • Global Fund (GFATM), GAVI, International Financing Facility (IFF)

15. Countries with national MNCH strategy and/or costed action plan (s)

16. Causes of under five deaths Is allocation appropriate?Bangladesh Budget does not reflect childhood burden of disease

17. Managing programmes to improve child health

18. 3. New delivery channels and demand • Simplifying interventions: • Simplified management of sepsis (Bangladesh, Pakistan, SSA) • Community management of severe pneumonia (Pakistan) • Identifying new delivery channels: • Postnatal home visits by CHWs for improving newborn survival in Africa (Ghana, Mozambique) • Engaging non-government sector: • Increasing coverage of diarrhoea management (ORS/Zinc) through public and private providers (Ethiopia, India) • Mobilizing community resources: • Community helpline to increase use of referral care for severely ill newborns (India)

19. From research to action Diarrhoea Pneumonia Severe acute malnutrition Home visits for newborn care

20. Caring for the sick child in the community Referral of children with danger signs and severe acute malnutrition Treatment in the community Diarrhoea Fever (malaria) Pneumonia Caring for the older child at home Care-giving skills and support for child development Infant and young child feeding Family response to child’s illness Prevention of illness New training materials for community health workers • Caring for the newborn at home • Promotion of ANC and skilled care at birth • Care in first week of life • Recognition and referral of newborns with danger signs • Special care for low-birth-weight babies

21. Effectiveness of home visits for newborn care

22. Assessment of 21 hospitals in 7 countries. Key findings: • 76% of hospitalized children receive substandard care • Lack of triage • Drug supply inadequate, especially emergency drugs • Inadequate assessment and late treatment • Poor knowledge of treatment guidelines • Inadequate oxygen supplies • Insufficient monitoring of sick children • Many deaths in hospital occur within 24 hours of admission • Deaths can be prevented if very sick children are identified quickly and treated accordingly

23. Improving quality care in referral health facilities Triage and emergency care, Blantyre, Malawi Molyneux E. et al. Improved triage and emergency care for children reduces inpatient mortality in a resource-constrained setting, Bull World Health Organ, 2006

24. Ensure quality of care at all levels Caring for newborns and children in the community and at home Integrated management at first level facility Quality emergency, triage and treatment at referral level And health care providers have the necessary skills and competencies IMCI in-service training IMCI pre-service training IMCI distance learning IMCI computerized adaptation and training tool (ICATT) Improving access and coverage

25. Responding to consumer needs and creating demand • Community mobilization and participation • Simplified instruments for formative research • Community participation as part of planning • Promoting community accountability and oversight • Commodities • Development of child-size medicines • Flavoured ORS • User-friendly packaging, e.g. blister packs, ORT kits in the home • Provision of commodities and medicines through informal and formal private sector • Services free at the point of use • Prepayment • Risk pooling

26. 4. Tracking progress • Countdown to 2015 • Tracking coverage country by country – every two year • District level assessments • MNCH district survey tool: Measuring coverage district by district • Programme reviews • Evidence-based programme management – using LiST • Health Metrics Network • Agreed upon simple set of core indicators • Strengthening health information systems and use of data routinely • Global monitoring • Policy and health system indicators • Human resources density and skills mix • Domestic and international financing and resource flows

27. An example of success Tanzania 2000 - 2005 Mortality 10.8% pa 1990-1999 Mortality 1.4% pa Tanzania MDG target: 47 Source: Masanje H et al. Lancet 2008:371:1276-83

28. What contributed? •  Govt expenditure on health ($4.7 – $11.7 pp) • SWAP approach with additional $0.5 pp to districts • Scale up of key child survival interventions

29. What can we learn? The Tanzania experience points the way forward Resources + health system strength + high coverage with effective interventions = Increased mortality reduction, improved nutritional status