CB-IMNCI Program in Nepal

1. COMMUNITY BASED
INTEGRATED MANAGEMENT OF
NEONATAL AND CHILDHOOD
ILLNESS (CB-IMNCI)
Mohammad Aslam Shaiekh
Master of Public Health (MPH)

2. BACKGROUND
• CB-IMNCI is an 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.
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3. Background (Contd….)
In CB-IMNCI program, 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.
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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.
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5. • CBAC was merged 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.
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6. • State of world 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.
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7. • CB-NCP and CB-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.
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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
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9. Objectives
• To reduce neonatal 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
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10. Strategies
• Quality of care 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
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11. Major Interventions
Newborn Specific Interventions
• 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
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12. Child Specific Interventions
Case management 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
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13. Vision 90 by 20
CB-IMNCI program has a vision to provide targeted
services to 90% of the estimated population by 2020
as shown in the diagram below.
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14. Major Activities (FY 2073/74)
• 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)
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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)
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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
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17. CB-IMNCI Program Monitoring
Indicators by Province (FY 2073/74)
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18. Classification and treatment of 0-28 days
newborn cases by province (FY 2073/74)
Source: HMIS/MD/DoHS 18Aslam Aman

19. Classification of Diarrhoeal Cases by
Province (FY 2073/74)
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20. Incidence and case fatality of diarrhoea among
children under 5 yrs of age by province (FY 2073/74)
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21. Treatment of Diarrhoea Cases by
Province (FY 2073/74)
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22. Acute respiratory infection (ARI) and
pneumonia cases by provinces (2073/74)
22
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23. Classification of cases as per CB-IMNCI
protocol by province (FY 2073/74)
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24. Diarrhoea prevalence by age (NDHS 2016)
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25. Nutritional status of children
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Source: NDHS,2016
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26. Trends in early Childhood Mortality Rates
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Source: NDHS,2016
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27. Management Aspect of CB-IMNCI Program
• Planning
• Organizing
• Staffing
• Directing
• Coordinating
• Recording and Reporting
• Budgeting
• Monitoring and Evaluation
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28. Planning
• Family Welfare Division (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.
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29. Organizing
• CB-IMNCI services are 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.
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30. Staffing
Central Level (Family Welfare 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)
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31. Staffing (Contd….)
PHCC- Trained MO,HA, SN, AHW, ANM
Health Post- Trained HA, AHW, ANM
FCHVs are the pillars of CB-IMNCI program.
Local Level:
31
(Not Final)
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32. Directing
• At central level, 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.
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33. Central
Provincial
Local level
Departments
Divisions/
Centres
Governmental
line agencies
Non
governmental
partners
Level
Coordination
Various bodies
33
Coordinating
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34. Supporting Partners
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35. Recording/ Reporting
• At PHCCs/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.
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36. • Reporting mechanism follows 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
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37. HMIS 9.1FCHV reporting
collection form
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
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38. Recording Tools
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40. 40
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45. Reporting Form
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46. Budgeting
Ministry of Finance
Ministry of Health and Population
Ministry of Social Development (Provincial)
Provincial Health Directorate
Health Office
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47. Monitoring and Evaluation
Regular monitoring 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
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48. Percentage of under 5 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)
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49. Responsible Bodies for Monitoring 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
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50. Major Challenges
• Unclarity in 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
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51. Recommendation
• Clarification of roles 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
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52. Bibliography
• Government of Nepal. Annual Report. Department of
Health Services 2073/74 (2016/2017).
• Nepal Demographic and Health Survey 2016.
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53. 53
HAVE A BEAUTIFUL DAY !
Healthy Children, Healthy Nation!
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