Towards a Grand Convergence for Child Survival and Health A strategic review of options for the future

building on lessons learnt from IMNCI

October 2016

Context

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• Child mortality has more than halved in the past quarter century, dropping from 91 to 43 deaths per 1000 live births between 1990 and 2015

• However, each year 5.9 million children die before their 5th birthday – the leading causes

are preventable and treatable

• All countries have committed to reducing under-five mortality to 25 or less and newborn mortality to 12 or less per 1000 live births by 2030, and to promote each child’s healthy growth and development

Opportunity for a Grand Convergence within a generation

• Shifting epidemiology: double burden of malnutrition, nearly half of child deaths during the newborn period, environmental challenges to child health …

• New technology and innovations: mHealth, eHealth, new vaccines, diagnostic and treatment innovations …

• Expanded scientific evidence on the best clinical interventions and delivery strategies

• Greater emphasis on community engagement & inequalities in child health

• New global architecture: MDGs SDGs, Global Strategy 2.0, new funding facilities such as the GFF…

Changes since IMNCI was introduced

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Aim of the Strategic Review

Lessons from 20 years of IMNCI implementation

State of the art in care for children

A “big picture” view of the best investments in

child health

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UNIQUE SOURCES OF DATA

IMNCI global survey report, with data from >90 countries

desk reviews of scientific publications and expert opinions

global key informant interview report

in-depth country assessments in Africa, Asia, Europe and the Middle East

vignettes of child health interventions and innovations across the globe

quantitative analyses, using DHS, geo-coded and IMNCI survey data

Data collected

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Formulating recommendations

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OBJECTIVE to end preventable newborn and child mortality and promote each child’s healthy growth and development

…to achieve a Grand Convergence in a generation”

CRITERIA for

RECOMM-ENDATIONS

- Specific - Feasible - Actionable

APPROACH

- Evidence-based - Problem-solution

approach - Reviewed by high-level

global experts

Findings

8 Map of Global Implementation of IMNCI and iCCM

Widespread adoption of IMNCI

• Providers expressed appreciation for IMNCI for its distillation of case management of the major killers of children into a clinical algorithm, and

policy-makers praised its simplicity and comprehensiveness.

• IMNCI’s holistic, child-centred approach transformed how care for children is perceived at global and country levels.

Benefits of IMNCI in design and impact

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“IMNCI is very relevant for the country. It is a

complete holistic module with child health,

development, newborn, etc. Nothing needs to be

taken out.” - Policymaker (Myanmar)

* Cochrane review on IMCI (2016)

• Although it’s difficult to measure, evidence suggests IMNCI was significantly

associated with a 15% reduction in child mortality* when activities were implemented in health facilities and communities.

• Other data have shown positive effects on health worker practices and quality of care.

• However, implementation was uneven with coverage at scale rarely achieved.

• Failure to agree on sustainable funding and fragmentation of support led to a loss of built-in synergy around IMNCI’s three components.

• Implementation focused on health worker training, more than health systems and family/community practices.

• Insufficient attention was paid to programme monitoring, targets and operational research.

Difficulties in implementing IMNCI

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What is needed to implement IMNCI?

“Manpower, materials, and money,” alongside

an explicit prioritization of child

health

- Policymaker (Nigeria)

• WHO and UNICEF did not provide sustained, focused leadership - as time went on, interest and funding for IMNCI waned.

• IMNCI suffered from blind spots in the lack of explicit emphasis on equity, community engagement and linkages to other sectors (education, WASH…).

IMNCI successes

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IMNCI was best implemented when:

a) the health system context was favourable & suited to guidelines,

b) a systematic approach to planning and implementation was used,

c) political commitment allowed for institutionalization.

Health workers in Bihar (India), with their IMNCI booklets

A health information expert surrounded by child health data in Makelle (Ethiopia)

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1. Fragmentation of global child health strategies undermines programming and limits impact.

2. Child health goals will not be met without adequate funding and delivery to marginalized populations.

Problems in past implementation

3. Evidence is not systematically generated, captured and integrated into policy and programming.

4. Strategies are insufficiently tailored to country context, and tools need improved end-user design.

5. There is a lack of accountability and corresponding need for clear targets and strong monitoring

Recommendations

Problem Recommendations

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1. Fragmentation of global child health strategies undermines programming and limits impact.

a) WHO-Unicef issue joint statement to reposition IMNCI, child health;

b) Partners consolidate around one leadership body;

c) Country stakeholders advocate for high-level representation in coordination mechanisms.

2. Child health goals will not be met without adequate funding and delivery to marginalized populations.

a) Global partners develop innovative strategies to target poor populations and support removal of user fees;

b) Country leaders mobilize support and resources and use GFF investment cases to develop ambitious, costed plans;

c) WHO-Unicef develop less resource-intensive training.

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3. Evidence is not systematically generated, captured and integrated into policy and programming.

a) WHO-Unicef establish a global expert advisory group to gain consensus on state-of-the art recommendations;

b) Partners create an online resource hub and forum;

c) Regional actors provide technical & policy support;

d) Countries use implementation science and facilitate shared learning among district teams.

4. Strategies are insufficiently tailored to country context, and tools need improved end-user design.

a) WHO-Unicef harmonize tools into a one flexible, adaptable set w/ input from users, design specialists;

b) Expert advisory group recommends strategies to build upon country strengths (private sector, community …);

c) Combined approach for facility, systems, community.

Problem Recommendations

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5. There is a lack of accountability and corresponding need for clear targets and strong monitoring

a) WHO-Unicef establish a joint leadership process to develop and adopt clear IMNCI targets, alongside global accountability processes;

b) Partners strengthen country capabilities to routinely monitor and evaluate progress using scorecards;

c) Countries scale up monitoring alongside improved community engagement, using data to enhance accountability.

Problem Recommendations

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Joined at the hip!

Report available soon: http://www.who.int/maternal_child_adolescent/en/

Strategic Review study team

Dr Tim Colbourn Lecturer in Global Health

(University College London, U.K.)

Dr Tanya Doherty Chief Specialist Scientist,

Health Systems

(South African Medical

Research Council)

Dr Youssouf Gamatié Independent consultant

Dr Rasa Izadnegahdar Senior Program Officer on Pneumonia

(Bill & Melinda Gates Foundation)

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Dr Samira Aboubaker Medical Officer, Policy, Planning,

Programmes (WHO/MCA)

Dr Rajiv Bahl Coordinator, Health Research

and Development Team (WHO/MCA)

Dr Cynthia Boschi-Pinto Medical Officer, Epidemiology,

Monitoring and Evaluation (WHO/MCA)

Dr Bernadette Daelmans Coordinator, Policy, Planning,

Programmes (WHO/MCA)

Dr Theresa Diaz Chief, Knowledge Management for

Implementation Research (UNICEF)

Dr Elizabeth Mason Independent consultant

Dr Smruti Patel Independent consultant

Dr Alexander Rowe Medical Officer, Malaria Branch

(Centers for Disease Control

and Prevention, U.S.A.)

Dr Eric Simoes Professor of Paediatrics

(University of Colorado, U.S.A.)

Expert Advisory Group

Study Coordinator Dr Sarah Dalglish Independent consultant

Coordinating Group

Mr Nick Oliphant Health Specialist, Monitoring

and Evaluation (UNICEF)

Dr Jonathon Simon Scientist (WHO/MCA)

Ms Joanna Vogel Technical Officer (WHO/MCA)

Dr Wilson Were Medical Officer, Policy, Planning,

Programmes (WHO/MCA)

Dr Mark Young Senior Health Specialist (UNICEF)

Principal Investigator Dr Anthony Costello Director, Department of Maternal, Newborn, Child and Adolescent Health (WHO/MCA)

Thank you!