Millennium Development Goal (MDG): Reduce child mortality
CORE COMPETENCY: DEVELOP AN INTERVENTION
Context: The child mortality rates in Kenya are as high as 126 males per 1000 and 120 females per 1000 live births. The majority of children’s deaths are caused by diarrhea, acute respiratory infections, measles, malaria, dengue fever, and malnutrition. Infants deaths, however, are mostly caused by congenital phenomenon exacerbated by low birth weight, poor sanitation and water supply, poverty, inadequate food supplies, lack of education and information to mothers on how to take care of their infants, and inadequate healthcare, including lack of proper pre-natal care for the mother. The fourth United Nations Millennium Development Goal (MDG) is to reduce the under-five child mortality rate by two-thirds by 2015. An overview of the steps taken by a joint initiative of the World Health Organization and UNICEF (United Nations Children’s Fund) to develop an intervention specific to Kenya and the African context in general is as follows.
IDENTIFY WHAT NEEDS TO HAPPEN FOR THE COMMUNITY'S GOALS TO BE MET :
The goal is to reduce child mortality in Kenya. This involves addressing various factors associated with mortality rate including nutritional status, breastfeeding, maternal and child health status, environmental health factors, and socioeconomic factors (Rutstein, 2000), and developing appropriate interventions.
ASSESS THE LEVEL OF THE PROBLEM OR GOAL:
Kenya is one of the 42 countries that account for 90% of all under-five deaths in the world. Findings of the 2003 Kenya Demographic and Health Survey (KDHS) reveal that one in every nine children born dies before age five, mainly of acute respiratory infection, diarrhea, measles, malaria, and malnutrition. According to reports from the Central Bureau of Statistics and the National Coordinating Agency for Population and Development (NCAPD) in Kenya, the infant mortality rate increased from about 60 per 1,000 in 1990 to 74 in 1998 and 77 in 2003, while under-five mortality continued to increase from about 90 per 1,000 in 1990 to 112 in 1998 and 115 in 2003. This is a reversal in trend after global initiatives to improve child health caused a decline in infant and child mortality in Kenya in the 1970s and 1980s.
DESCRIBE THE PRIORITIZED GROUPS TO BENEFIT AND THOSE IMPLEMENTING THE INTERVENTION:
This intervention would be targeted towards mothers, infants, children, families, and the environments in which they live. An improvement in child health services, one of the components of reducing infant and child mortality, would benefit the whole community because it would provide both preventative and tertiary care. The government of Kenya’s Ministry of Health has developed and implemented new approaches to child survival efforts. One of these strategies is Integrated Management of Childhood Illnesses (IMCI), a program developed by WHO. IMCI is an integrated approach to child health that focuses on the well-being of the whole child. This program aims to reduce death, illness, and disability, and to promote improved growth and development among children under five years of age. IMCI includes both preventive and curative elements that are implemented by families and communities as well as by health facilities. IMCI has three main components that include improving case management skills of healthcare staff, improving overall health systems, and improving family and community health practices (WHO). Other agencies that will aid in the intervention by providing financial support and resources include WHO, Doctors without Borders, United Nation Children’s Fund (UNICEF), and World Vision.
This initiative, however, only addresses the improvement of health services but does not address other social determinants of health such as income and education of guardians, early childhood development programs, food insecurity, and housing. The World Health Organization (WHO) established the Commission on Social Determinants of Health (CSDH) in 2005 to provide advice on how to reduce these inequities. They compiled and launched a report in August 2008 with three overarching recommendations that include improving daily living conditions, tackling the inequitable distribution of power, money, and resources, and measuring and understanding the problem, and assessing the impact of action.
An abbreviated version of the report is also available.
INDICATE HOW YOU WILL OBTAIN CLIENTS' INPUT, IDENTIFYING AND ANALYZING PROBLEMS AND GOALS TO BE ADDRESSED BY THE INTERVENTION
In order to identify and analyze this problem, data was first collected on the current status of the health care system. An analysis of child health service provision was collected using facility inventory questionnaires, health worker interviews, observation of sick-child consultations, and an exit interview of the caretaker of a sick child. The facility inventory questionnaire was intended to get information on departments, staff, and equipment at the healthcare facility. The healthcare worker interviews surveyed training (pre and in-service) and supervision of the healthcare workers. For the sick-child consultations, the health provider’s interaction with the caretaker and sick child was observed. Information on the assessment, diagnosis, and treatment of the sick child, as well as the counseling of the caretaker, was also collected. In the exit interview, a questionnaire was given to the caretaker of the sick child and it aimed to find out the knowledge given to the caretaker by the health workers about how to continue with care. Information on client satisfaction was also collected. In total, 1,211 children were observed and 1,165 caretakers were interviewed.
ANALYZE THE PROBLEM OR GOALS TO BE ADDRESSED BY THE INTERVENTION:
In addition to the lack of proper health service facilities and professionals to care for sick children, factors such as lack of proper nutrition, access to clean water and food, access to childhood immunizations, and poverty contribute to infant and child mortality. Although this intervention does not directly address these issues, there are other programs that have currently been implemented in Kenya that address these other issues. For example, the Gender Equality Action Plan implemented by the Department for International Development (DFID) works in Kenya to reduce levels of morbidity and mortality in children by providing equipment and training in obstetrics care within health institutions and also social marketing of family planning. In order to improve maternal health and reduce infant mortality specifically, DFID has funded a motorbike ambulance to take women who are in labor to hospital, therefore cutting down on the number of expectant mothers who have to walk for several hours to receive medical attention. This is part of DFID’s Essential Health Services program that also provides care and support for women through pregnancy and childbirth, and immunization and treatment for their babies. The program has also funded training for nurses and midwives and is helping to build better clinics to meet increased demand for maternal healthcare. Approximately 60,000 women in Kenya have benefited from the program so far. (Africa Gender-Equality Action Plan)
This intervention, however, also addresses the problem of lack of proper training of healthcare workers and lack of counseling of the caretakers of sick children.
SET GOALS AND OBJECTIVES FOR WHAT SUCCESS WOULD LOOK LIKE:
The aim of the UN Millennium Development Goal Number 4 is to reduce the under-five child mortality rate by two-thirds (from 32 to 21 or less per 1000 childbirths) between 1990 and 2015. In Kenya, success of this intervention would be evident in an increased number of children receiving immunizations, improvement in maternal healthcare system, an increase in the number of women receiving prenatal care, and an increase in the knowledge of the caretakers as evidenced by the improved care given to the children. Success of other programs implemented would be evident in clean water wells sprouting up in every village across the country, an increase in government aid and provision of healthy food (e.g., maize and beans) to regions that suffer from seasons of drought and famine(e.g., Eastern and North Eastern regions), and better access to health services(e.g., creating more clinics in the affected areas and/or providing public transport to and from hospitals so that the community members do not have to walk long distances to receive care).
IDENTIFY AND ASSESS “BEST PRACTICES ” OR “EVIDENCE-BASED INTERVENTIONS ” THAT COULD HELP ADDRESS THE PROBLEM OR GOAL IN YOUR SITUATION:
IMCI is an evidence-based intervention that was developed by WHO and tested in Bangladesh, India, Indonesia, Myanmar and Nepal Tanzania. The strategy was then chosen to be implemented by the Kenyan government as a new approach to child survival efforts. The IMCI strategy has been a promising strategy to reduce morbidity and infant and child mortality by implementing three main components: improving health workers' skills in case management, improving the health systems, and improving family and community childcare practices. This strategy also encompasses a range of interventions that combines prevention and better management of childhood illness with nutrition, immunization, maternal health, and other health programs. IMCI was implemented in Tanzania, a neighboring country of Kenya and evaluated by the WHO in the Multi-Country Evaluation (MCE) and it was found to be both cost-effective and efficient in affecting health outcomes. According to this report and a study done by Victoria and Schellenberg (2002), children seeking care at the health facilities in IMCI districts were more thoroughly assessed and received better quality care in comparison to districts where IMCI had not yet been implemented. Also the annual cost of providing healthcare per child for children under five years old was 44% lower, US $11.19 versus US $16.09 respectively, in districts with IMCI than those without.
SPECIFY THE CORE COMPONENTS AND ELEMENTS OF THE INTERVENTION:
IMCI is an approach to taking care of sick children and thus reducing instances of child mortality and morbidity. It incorporates three major principles which include full assessment of a sick child, counseling of caretakers, and healthcare facility support. For the first principle, IMCI stresses thorough assessment of the major childhood symptoms and a complete physical examination of the child, checking of immunization and Vitamin A status of sick children, and monitoring growth. In this way, the skills of the healthcare workers are enhanced. IMCI also stresses that caretakers of sick children should be counseled on the illness of the child and how to cope with it, how to administer drugs given, and how to maintain healthy nutrition and feeding practices for the sick child. In regards to the healthcare facility, IMCI guidelines require that health workers be given IMCI training and that facilities have essential equipment, for example: thermometers, and a child scale, and medical orderlies.
This intervention also emphasizes enhancing support and services and also modifying access, barriers, and opportunities. It does so by making upgraded care possible by ensuring that enough of the right low-cost medicines and simple equipment are available, strengthening care in hospitals for those children too sick to be treated in an outpatient clinic, and developing support mechanisms within communities for preventing disease, for helping families to care for sick children, and for getting children to clinics or hospitals when needed. Another core component of this intervention is that it modifies the existing health system by adopting an integrated approach to child health and development in the national health policy that ensures the combined treatment of the major childhood illnesses, prevention of disease through immunization, and improved nutrition.
IDENTIFY THE MODE OF DELIVERY THROUGH WHICH EACH COMPONENT AND ELEMENT OF THE INTERNVENTION WILL BE DELIVERED IN THE COMMUNITY:
According to experiences in IMCI introduction in Bangladesh, India, Indonesia, Myanmar and Nepal, this intervention is first introduced in pre-service education of doctors, nurses, other healthcare workers and the Ministry of Health in order to provide knowledge on how the intervention works so that it can be implemented successfully.
INDICATE HOW YOU WILL ADAPT THE INTERVENTION OR “BEST PRACTICE” TO FIT THE NEEDS AND CONTEXT OF YOUR COMMUNITY:
In order for this intervention to be successful in Kenya, it requires coordination among existing health programs and services and also working closely with local governments and the Ministry of Health to plan and adapt the principles of the approach to the local context. This intervention was implemented in Tanzania and according to the Multi-Country Evaluation (MCE) undertaken by WHO it showed success. Tanzania neighbors Kenya to the south and the cultures, traditions, societal and governmental systems in both countries are very similar. This then indicates that this intervention could yield promising results in Kenya as well. However, IMCI implementation in Tanzania was coupled with the Canadian-funded TEHIP (Tanzania Essential Health Interventions Project), a project which includes a strong research component in two of the target districts, covering a detailed description of changes in provision and utilization of health services and behavioural changes at population level.
DEVELOP AN ACTION PLAN FOR THE INTERVENTION:
IMCI implementation in Tanzania consisted of local as well as international partners. Partners assisted in the assessment of the problem, planning of implementation in the target districts, monitoring behavior change associated with the problem, and evaluating community-level outcomes. Local partners included Ifakara Centre Demographic Surveillance system, AMMP (Adult Morbidity and Mortality Project), and TEHIP (Tanzania Essential Health Interventions Project). International partners include the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). Basic components of the intervention were kept the same for implementation in Kenya. There was local planning and implementation support from the Ministry of Health in Kenya, local healthcare partners, and other international partners.
PILOT TEST THE INTERVENTION ON A SMALL SCALE:
IMCI was implemented in Tanzania beginning in 1997 in two pioneer districts (Morogoro Rural and Rufiji) with support from the Canadian-funded TEHIP (Tanzania Essential Health Interventions Project). In 2002, IMCI was also implemented in two other districts (Kilombero and Ulanga) that served as comparison districts. Collaborating partners that assisted in morbidity and mortality data collection and continuous mortality surveillance included Ifakara Centre Demographic Surveillance system, AMMP (Adult Morbidity and Mortality Project), and TEHIP (Tanzania Essential Health Interventions Project). A Multi-Country Evaluation (MCE) of IMCI coordinated by World Health Organization in 1999-2002 found that in Tanzania IMCI improved quality of care for children under 5 years of age, reduced child mortality by 13% and was cost-effective. However, several challenges have emerged with the IMCI program including low training coverage and poor adherence to IMCI protocol. As a result, the training of health workers remains the main activity implemented. (Experiences, challenges, and lessons of IMCI implementation in Tanzania)
IMPLEMENT THE INTERVENTION, AND MONITOR AND EVALUATE THE PROCESS
For this intervention to be successful in Kenya, it has to be well implemented at all levels of health delivery systems including both public and private facilities. This required both process and outcome evaluation. Process evaluation was conducted on the ICMI training and related supervision of health care providers by governmental agencies concerned with child health. Outcome measures included quality of care in health facilities, the cost of care at these facilities, and under-five mortality rates.
EVALUATION OF ICMI EFFORTS IN TANZANIA
In Tanzania, a considerable effort was made to establish supportive partnerships for the Multi-Country Evaluation (MCE). Several meetings of stakeholders included representatives of local research institutions, the Ministry of Health, WHO and UNICEF, District representatives, and national IMCI stakeholders, to seek initial input, and to review and develop the draft design and results as they become available. The MCE findings showed that IMCI was associated with improved quality of care in health facilities at no additional cost. Under-five mortality levels were 13% lower in the IMCI districts at the end of the two years of the evaluation, and there was also a significant reduction in stunting. The Tanzania MCE results were fed back to local policy makers and received wide attention and as a result IMCI implementation was expanded to all districts in the country.
EVALUATION OF ICMI EFFORTS IN OTHER DEVELOPING COUNTRIES
According to the World Health Organization, MCE findings in other developing countries including Brazil, Bangladesh, Peru, and Uganda indicate that IMCI improves health worker performance and their quality of care; IMCI can reduce under-five mortality and improve nutritional status, if implemented well; IMCI is worth the investment, as it costs up to six times less per child correctly managed than current care; child survival programs require more attention to activities that improve family and community behavior; the implementation of child survival interventions needs to be complemented by activities that strengthen system support; and a significant reduction in under-five mortality will not be attained unless large-scale intervention coverage is achieved (WHO; Integrated Management of Childhood Illness (IMCI)).
RESOURCES
Analysis Report on the Costs of IMCI in Tanzania. Multi-Country Evaluation: Integrated Management of Childhood Illnesses. MCI Sites: Tanzania. World Health Organization 1999-2002.
Central Bureau of Statistics (CBS) [Kenya], Ministry of Health (MOH) [Kenya], and ORC
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Gender Equality Action Plan African Division 2009-20012. Department for International Development.
IMCI implementation in Tanzania: Experience, Challenges, and Lessons. CREHS Policy Brief. June 2009.
Mortality Country Fact Sheet 2006 World Health Organization [WHO], 2006
National Coordinating Agency for Population and Development (NCAPD) [Kenya], Ministry of Health (MOH), Central Bureau of Statistics (CBS), ORC Macro. 2005. Kenya Service Provision Assessment Survey 2004. Nairobi, Kenya: National Coordinating Agency for Population and Development, Ministry of Health, Central Bureau of Statistics, and ORC Macro.
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