Components of IMNCI strategy

IMNCI strategy focuses on three major elements.

 Enhancing the case management skills of primary level health facilitators.

 Upgrading the health systems to support IMNCI program

 Promoting the family and community practices.

2.4.1. Enhancing the health worker skills and performance

This component of IMNCI strategy consists of training of doctors; nurses and other health workers during or before service to familiarize them with signs and symptoms of sick child and to manage their illness in an integrated way. The training is based on case management guidelines, so that the health care givers will be able to take complete history, do proper examination, make correct diagnosis, classify common childhood illnesses, advice suitable treatment and counsel the parents for better child health and outcome. The IMNCI training also guides the health professionals to identify anemia and under-nutrition, to check the vaccination status and how to communicate with mother or care giver (WHO 2004,Gouws et al. 2004).

The training of health providers in “IMNCI Case Management” at primary level health facilities is important for improvement in their clinical skills. The 11 day training program is mainly based on practical methods and hands on experience. Most of the training time is used for clinical practice where trainee health workers go to the different clinics and supervised spots to practice clinical skills and get feedback from their instructors. In the class rooms, the lectures are delivered with the help of charts / photographs, videos, readings and other supportive training materials (Lamberchts et al. 1999).IMNCI case management training skills program combines both curative and preventive care along with training in using special case management algorithms is provided (Victora et al.2006).

IMNCI case management training program demands from trainees that they should acquire sound knowledge and skills “to assess, classify and treat sick children” less than 5 years of age and also to counsel the parents. Regarding assessment, first of all, the entire health care givers note the “danger signs such as convulsions, lethargy, unconsciousness, vomit everything and unable to drink or breastfeed”. They inquire about common clinical features like cough with shortness of breath, loose motions, high temperature and ear infection. They also ask from care

givers about the nutrition, vaccination and other health issues. After the assessment, the health care provider classifies the baby with the help of classification chart. Then the health care giver decides a comprehensive treatment for the sick child and if the child needs immediate referral, then health care provide gives a first dose of medicine at the health facility and refers the sick child to hospital. The trained health worker also counsel the mother regarding how to give oral medicines, continue feed during sickness, vaccination, breast feeding and follow up care if necessary (Weber et al. 1997, AMREF 2007).

2.4.2. Upgrading of Health System

This component of IMNCI strategy focuses on strengthening of healthcare system through essential drug availability, availability of adequate equipments, effective organization and supervision, referral system, policy for health information and health reforms (Patwari and Raina 2002).

For proper management of childhood diseases, health system reforms like supervision of managers, provision of trained health providers and improvement of work at health facilities are essential (WHO 2005). So the purpose of improvement in health systems is to strengthen the health facilities. All health facilities should have necessary supplies, equipments, special drugs for IMNCI case management, supplies for vaccination of all children and about 60% of working staff should have IMNCI training (WHO 1999a).

2.4.3. Promoting Family and Community Practices

This component of IMNCI strategy focuses on community and family practices related to growth and health of children. The key issues which are focused in this component are exclusive breastfeeding, age specific childhood nutrition, personal hygiene, micronutrients, vaccination, insecticide treated nets, mental and social development, adequate nutrition during sickness, treatment of common infections at home, antenatal care, care seeking practices and compliance(WHO 2004,Victora et al. 2006).

Care seeking is a primary response of family for any sickness. At caregiver level, late recognition of child disease or illness delays treatment and thus child health outcome. To enhance timely family reaction, research and investigating methods should be adopted to improve the skills for the identification of serious kind of signs and symptoms of childhood illnesses by the caregivers in the home. Counseling of mothers is an important part of clinical

case management of IMNCI strategy. Mothers must obey the advices of primary health worker regarding follow up and referral instructions (WHO 1999c).

This component of IMNCI strategy is also known as household and community IMNCI (HH/C IMNCI). This component was first launched in September 1997 at IMCI Global Review and Coordination Meeting (Lambrechts et al. 1999). In June 2000 in Durban, WHO and UNICEF prepared 16 “Key Family Practices”. The basic purpose of these family and society practices is to improve child growth and progress. These key practices have been divided into four groups (Winch et al. 2002).

THE FIRST GROUP focuses practices for physical growth and mental development. The key issues raised in this group are exclusive breastfeeding (EBF) for 6 months, provision of energy rich complementary food after six months, sufficient amount of micronutrients in diet and special care for the mental and social development of child. Breast milk is the source of all essential nutrients which are needed by infants up to age of six months (Hill et al. 2004).

Continuous breastfeeding for two years of age and energetic, fresh, nutrient rich complementary feeding from 6 months of age was also advocated along with essential nutrients such as iron and vitamin A. Taking care of children’s needs and providing them with supporting environment for social well being and mental growth was also advocated (Winch et al. 2002).

THE SECOND GROUP focuses practices for disease prevention. Immunization, hygienic environment, protection of children from malaria in endemic areas and care of HIV/AIDS affected children are the main practices included in this group. Thus children should have full course of vaccination such as BCG, DPT, OPV and measles up to one year. Personal hygiene particularly washing of hands after defecation, before giving food to children, before food preparation and proper disposal of feces is essential for prevention of diseases. Ensuring provision of bed nets was advocated for children living in malaria endemic regions. Supportive behavior was advocated towards children who born to HIV/AIDS affected parents (Winch et al.

2002).

THE THIRD GROUP focuses practices for appropriate home care. The major practices related to this group are continuation of feed and fluid to children during illness, provision of

appropriate home treatment for infections, provision of safe home environment to avoid injuries and accidents, proper measures to avoid child abuse and neglect, and ensuring that other family members take interest in the healthy growth of child and family. It advocates that if a child is sick, continue good feed and fluids specially the breast milk which work well against disease. It further advocates management of minor infections at home (Winch et al. 2002).

THE FOURTH GROUP comprised of practices regarding care seeking for sick child. When a child is sick and needs treatment outside home, then treatment should be taken from qualified health worker and in all situations such as treatment, referral and follow up advice of health provider must be followed. Another important practice in this group is proper antenatal care for the pregnant women with qualified health care facilitator, recommended doses of tetanus immunization and supportive behavior and cooperation from the family members during delivery, postpartum period and lactation (Winch et al. 2002).

Finally, WHO/UNICEF recommended 12 community and family practices in a meeting held in 2004, which are considered essential for the growth, development, survival, reduction in illnesses and sound health of young kids less than 5 years of age (Hill et al. 2004). These practices are:

 All children should complete the basic vaccination before the first birthday such as BCG, DPT, OPV and measles

 Exclusive breastfeeding (EBF) up to six months

 At the age of six months, start the fresh and energy rich complementary food and continue the breastfeeding till two years or more

 Be sure that the children get proper amount of micro-nutrients especially zinc, iron and vitamin A through diet or in the form of supplementation

 Wash hands properly after defecation, before food preparation and before serving food to children. Safe dispose of children’s feces is essential

 Assure the use of treated bed nets by children in malaria endemic territories.

 During sickness of children, continue food and fluids including breastfeeding

 For minor infections, treat the sick at home

 In case of a sick child, go to qualified health care giver if there is need of advice outside the home

 Obey the health professional’s advice about management, referral and follow-up of sick child

 Provide supportive environment for the better mental and social development of children

 Antenatal care is important for pregnant ladies. So ensure proper antenatal care for a pregnant woman such as four antenatal visits with qualified health provider, recommended dose of tetanus toxoid and support from family for delivery, lactation and postnatal period (WHO 2004).