This initiative by GOI is commendable but its implementation in our country is facing several challenges. The strategy seems to be limited by the expenses of training, insufficient supervision, the time taken to follow the IMCI chart booklet and decreased adherence to protocols. This mobile application will improve adherence and efficiency of HW to IMNCI guidelines by facilitating in clinical examination through relevant gifs, videos and separate library version. In addition, it will automatically classify the patient into colour coding based on their clinical status and assist in treatment and referral. The additional features like auto-generation of monthly reports which can be shared online with the supervisors, daily planner of HW activities, messaging and calling patients through application, counselling of mothers regarding child health care will also provide boost towards health seeking of children in vulnerable settings. It will also strengthen follow-up via online referral system and supervision of HW through QR code assisted attendance system and GPS supported tracking.
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At the current rate of decline in infant mortality, India is unlikely to achieve the Millennium Development Goal on child survival. This paper assessed the progress of IMNCI in India, identified the programme bottlenecks, and also assessed the effect on coverage of key newborn and childcare practices. Programme data were analyzed to ascertain the implementation status; rapid programme assessment was conducted for identifying the programme bottlenecks; and results of analysis of two rounds of district-level household surveys were used for comparing the change in the coverage of child-health interventions in IMNCI and control districts.
More than , community health workers and first-level healthcare providers were trained during at a variable pace across districts. Poor supervision and inadequate essential supplies affected the performance of trained workers. During , 12 early-implementing districts had covered most key newborn and child practice indicators compared to the control districts; however, the difference was significant only for care-seeking for acute respiratory infection net difference: Based on the early experience of IMNCI implementation in different states of India, measures need to be taken to improve supportive supervision, availability of essential supplies, and monitoring of the programme if the strategy has to translate into improved child survival in India.
One of the major reasons for the slow decline in the IMR is the stagnation in neonatal mortality. In the current decade, neonatal mortality is declining sluggishly, moving from 40 per 1, livebirths in to 36 per 1, livebirths in The coverage of child-health interventions remains highly inadequate in India. The programme planned a comprehensive package of newborn and child-health interventions aiming at achieving a decisive decline in neonatal, infant and child mortality.
The aim was to implement IMNCI at the household level in districts and at the facility level across the country by 6. The guidelines relied on the detection of cases using simple clinical signs without laboratory tests and offered empirical treatment.
IMCI only covered children aged seven days to five years excluding the early neonatal period and targeted health workers at primary-care facilities 7. Two features distinguish this approach from the generic IMCI.
Recognizing newborn care as critical for improving child survival, it was strengthened in IMNCI by increasing the newborn-care component of the training programme and including prevention and management of health conditions in the first week of life. Second, recognizing that a large proportion of sick children do not come in contact with health workers but most of them can be reached by community-based workers, IMNCI in India focuses on community-based rather than facility-based healthcare providers.
The AWWs manage a village-level community nutrition centre, called Anganwadi, and provide a set of services for promoting the growth and development of under-six children. They receive a fixed remuneration for the services. The IMNCI training programme focuses on building of individual skills and includes practice sessions in the field and in the hospital.
Each training programme is run for eight days. The training batch is restricted to about 24 participants with the facilitator-participant ratio of about Frontline community-based workers and auxiliary nursemidwives ANMs are trained together in basic health workers course. Supervisors are trained additionally in a two-day course 10 - Following training, workers are supposed to make home-visits to all newborns within their areas on day 1, 3, and 7 of life.
During these visits, the health workers assess the newborns, ensure breastfeeding, counsel on warmth and danger-signs, treat local infections, and refer to appropriate facilities for possible serious bacterial infections. In addition, the workers are expected to assess sick children, manage children with minor illness, and refer severelyill children.
Line supervisors are supposed to supervise the trained workers, using the structured supervisory checklists. There is limited information and evidence on the quality of its implementation, operational constraints, and facilitating factors and its effectiveness in improving the coverage of key newborn and childcare practices and interventions.
Such information is critical to guide the further implementation of the programme and to modify the course. This information will also be useful to other countries that are implementing large-scale community-based newborn and child-health interventions.
While doing so, it seeks to answer the following questions:. What proportion of newborns was the CHW able to visit in the first week of life?
What was the quality of care they provided to sick infants and children? What programme bottlenecks affect the effective implementation of the strategy and how have they been addressed so far, if at all?
The paper is based on review of information generated from different sources, using a mix of methods as described below. Incomplete and inconsistent data were corrected by contacting and seeking clarifications from the district and state authorities. Of the districts in India, A detailed report on progress in training was available for 99 Data from supervisors and data from programme reports coverage of home-visits for newborns. Follow-up after training by supervisor: visits to 3 states quality of care to sick children.
The quality of training programmes was also assessed based on quality checks on a random subset of 70 training programmes across 14 states. The trained supervisors conducted the quality checks using a standard tool. The tool scores on different dimensions of quality, and the range of score achievable is The median quality score was used as the indicator for the quality of training programme.
After training, the community health workers recorded the home-visits in a case record form. They then reported on the key coverage indicators. The performance of the health workers on the coverage of home-visits to newborns was assessed from the monthly reports.
The key indicators used for assessing the coverage of home-visits are shown in Table 1. In three states, the trained supervisors assessed the performance of a sample of community workers during home-visits to newborns using a standard checklist. The proportions of workers who appropriately classified, identified treatment, and counselled were used as key indicators to assess the quality of home-visits.
Besides, their performance was also assessed during the rapid programme assessment of IMNCI in seven districts across seven states as described in the next section. A systematic assessment of the programme implementation was carried out among seven early-implementing districts across seven states. A team of external supervisors visited the districts and collected information using semi-structured sets of questionnaires as follows: a Interviews with district health and nutrition officials; b Interviews with faculty and review of records of the District Training Centre; c Interviews with PHC staff and review of records of one PHC from each administrative block; d Interviews with ANMs and review of records of two sub-centres from each block; e Interviews with AWWs and review of records of two Anganwadis from each sub-centre area; and f Home-visits and observation of worker-family interface of families with newborns.
Each component training, supervision, supplies, and performance had a set of five indicators, i. Each member of the team reviewed the collected information. The team jointly assigned the final score by consensus. Finally, each component received a score that was the total of all the scores of its indicators: a possible score from Weighted averages of the percentage change in coverage levels were calculated for the intervention and control districts.
The net difference in changes in coverage was then compared between the intervention and the control districts using linear regression adjusting for clustering and for sampling weights. The key indicators analyzed to assess the effectiveness of the programme are listed in Table 1 , which also summarizes the methodology of the assessment.
Of these districts, 39 were in the introduction phase, in the early-implementation phase, 30 in the expansion phase, and 43 in the consolidation phase. By this date, , workers had been trained. Distribution of category of workers trained in IMNCI, total , workers in districts.
The number of workers trained per year per district ranged from to 1, across different states, with a median of Only two states, i. Chattisgarh and Gujarat, were able to train more than 1, workers per year per district Table 2. Based on assessment of the quality of training from 70 training programmes for frontline workers across 14 states, the median quality score was 88 out of These amounted to about 1. Of these births, 72, During the same period, the frontline workers also assessed , older children and advised referral to about , Of 1, health workers who observed across three districts in three states, 1, Of the seven district where a systematic programme review was conducted, three fared good on the performance of trained workers; three fared average, and two fared poor.
Despite the variations in the performance of workers across the districts, there was a pattern. While weighing and assessment were fair, handwashing and counselling were weak components. Supervision was the weakest component of programme implementation across all the districts Table 4. Table 4 summarizes the bottlenecks in programme implementation, as identified by programme reviews in seven districts.
Training was assessed to be good in six of seven districts and average in the remaining district. Supplies were assessed as good in five of the seven districts and poor in the remaining two districts. Table 5 summarizes the comparison between changes in the coverage of key indicators between the IMNCI districts and the control districts. In the intervention districts, the coverage levels of all the indicators were higher at the endline compared to the baseline; the differences were least in the case of ORS-use rates and immunization 1.
During this period, there was also an increase in the coverage levels of all the indicators in the control districts, except for the proportion of children with acute respiratory infection ARI , who sought care. Except for the indicator—percentage of children fully immunized—the net change in the coverage levels of all other indicators was higher among the intervention districts than among the control districts.
After adjusting for clustering and sampling weights, however, the difference was significant only for the proportion of children with ARI seeking care net difference: Change in coverage of key indicators in early-implementation IMNCI districts compared to control districts, Compared to the target of implementing IMNCI in districts by , the strategy was introduced in districts, of which 73 The study suggests that the training programme led to the uptake of skills among the trained workers and, importantly, also to contacts of the newborns with the trained health workers within the first week of their life.
The comparison of the DLHS data also provides an early evidence of the effectiveness of the programme on the coverage of some key newborn and childcare practices, such as care-seeking for ARI, institutional delivery, early initiation of breastfeeding, and exclusive breastfeeding. When compared with the improvements in the control districts during the same period, improvements in the intervention districts were higher on all indicators, except the immunization coverage, although improvement in care-seeking for ARI was the only indicator that assumed statistical significance.
No apparent explanation could be found for the poor performance of the intervention districts on the immunization coverage. There are several areas of concern. While a large number of workers have been trained, at the current pace, considering that the average number of workers to be trained in each district is close to 2,, it would take about years to complete the training load.
Some states have been able to scale up training programmes at a faster pace using different approaches, such as engagement of private sectors Gujarat and full-time stand-alone trainers Mayurbhanj, Orissa. There is a need to explore these approaches and adapt these in different states and districts. The information on the coverage of home-visits is based on those districts from where information was available.
Little information was available on the coverage from other districts. Rapid programme assessment also highlighted that reporting on implementation has been a weak component of the programme and requires mainstreaming with the national HMIS. The newborns not reached are likely to be the ones who are most vulnerable. There are several reasons why home-visits did not reach about one-third of all newborns: absence of workers in several villages, poor supervision, and lack of motivation of the workers for this additional task.
e-Integrated Management of Neonatal and Childhood Illnesses Mobile Application (IMNCI)
As part of its response to the global epidemic of obesity, WHO is releasing guidelines to support primary healthcare workers identify and help children who are overweight or obese. In an estimated 41 million children under 5 were affected by overweight or obesity. Without effective treatment they are very likely to remain overweight and obese throughout their lives, putting them at risk of cardiovascular disease, diabetes and premature death, as well as suffering physical and psychological consequences in childhood. Taking as its departure point the implementation of Integrated Management of Childhood Illness IMNCI , developed by WHO and UNICEF in , this strategic review shares analysis from 20 years of implementation of child health strategies and provides direction to the global child health community on how to better assist countries to deliver the best possible strategies to help each child survive and thrive. Every day, millions of parents seek health care for their sick children, taking them to hospitals, health centres, pharmacists, doctors and traditional healers. Surveys reveal that many sick children are not properly assessed and treated by these health care providers, and that their parents are poorly advised. At first-level health facilities in low-income countries, diagnostic supports such as radiology and laboratory services are minimal or non-existent, and drugs and equipment are often scarce.
Integrated management of neonatal and childhood illness: An overview. Seven in ten under-five deaths in such countries are from illnesses such as diarrheal dehydration, acute respiratory infections, measles, malaria, and malnutrition. All these five conditions can either be treated or prevented. Factors that contribute to illness are poor living conditions like lack of safe water supply, poor hygiene, overcrowding; inability of parents to recognize danger signs; and delay in seeking appropriate treatment. The problem is compounded by the poor quality of care provided at the health facilities.