Newborn and Child Health Case Team

The newborn and child health case team is among the five case teams under the MCHN directorate established to assist the directorate in executing the Newborn and Child survival Strategy of Ethiopia. It works in collaboration with all directorates of the ministry with special relationship to the Disease Prevention and Control, Medical Services, Primary Health Care and Health Extension Program, Human Resources directorates and the Pharmaceutical Logistics Management Unit.

The team strives to decrease preventable newborn and child deaths in line with the health sector transformation plan (HSTP).

Particularly, the following are the main initiatives/packages and targets of the Newborn and Child health Case Team

Community based Interventions

• Community Based Newborn Care (CBNC)

A package of interventions aimed at reducing newborn mortality at a community level. The target coverage is to provide CBNC at every health post in the four major regions by the end of EFY 2007.

• Integrated Community Case Management (iCCM)

A package of interventions aimed at reducingchild mortality through community level interventions. The goal is to achieve the greatest possible reduction of child mortality to meet the MDG 4 and post MDG targets. The coverage target is to provide iCCM at every health post in the country by the end of EFY 2007.

Facility based Interventions

• Integrated Management of Newborn and Childhood Illness (IMNCI)

It is an approach used for delivering a package of newborn and child health interventions at health centers and hospitals. The target coverage is 100% of facilities to provide Newborn and Child Health interventions at the under five clinic using the IMNCI principles.

• Newborn Corner Initiative (NBC)

A package of interventions delivered at the delivery room by midwives and other health professionals targeting the three main causes of newborn mortality; prematurity, asphyxia and infection. The target coverage for this intervention is that by the end of 2015 all delivery rooms at health centers and hospitals will have NBC service.

• Neonatal Intensive Care Unit (NICU) Initiative

A package of interventions that is delivered at different levels in health facilities.

Based on the current status of hospitals in the country, the NICU is classified into three different categories. The target coverage is to ensure all primary hospitals will have level I NICU and level II NICU will be operational in 90 hospitals across the countryby the end of 2008 EFY.

INTEGRATED COMMUNITY CASE MANAGEMENT (ICCM)

Based on the growing demand from rural communities in Ethiopia, coupled with the presence of ample evidence-based and cost-effective interventions, the Ethiopian Ministry of Health (MOH) introduced community-based management of common childhood illnesses by health extension workers (HEWs) through an iCCM package of interventions in 2010. iCCM is a version of the IMNCI at a community level.

Components of the iCCM package are:

 

• Assess, classify, treat and follow up of pneumonia cases.
• Assess, classify, treat and follow up of malaria (fever) cases.
• Assess, classify, treat and follow up of diarrhea and
• Assess, classify, treat and follow up of severe acute malnutrition.

Goal of iCCM:Through Community-based Case Management of Common Childhood Illnesses, ensure the greatest possible reduction of mortality in children less than five years of age in order to achieve the Millennium Developed Goal 4 by 2015.    

General Objective:Improving Community-based Case Management of Common Childhood Illnesses including pneumonia using the Health Extension Program as a major vehicle.

Specific Objectives:

1. Strengthen the capacity of HEWs to properly assess, classify and manage common childhood illnesses at the community level;
2. Introduce CCM of pneumonia by HEWs;
3. Reinforce CCM of malaria, diarrhea, malnutrition and other common childhood illnesses by HEWs;
4. Strengthen the capacity of HEW supervisors' skills to properly supervise HEWs management of CCM;
5. Strengthen the capacity of the Woreda health departmentto coordinate the CCM by HEW and HEW supervisors;
6. Ensure regular and continuous supply of equipment and consumables required for CCM;
7. Establish a mechanism of regular and continuous monitoring and evaluation of CCM.

Target: To provide iCCM at more than 95% of the health posts in the country by EFY 2007

Coverage/achievement: By mid-2007 EFY, a total of 92% health posts in rural woredas throughout the country are providing iCCM package of interventions to the community.

INTEGRATED MANAGEMENT OF NEWBORN AND CHILDHOOD ILLNESS (IMNCI)

IMNCI is a globally promoted integrated package of preventive and curative child health services provided at health facility level (health centers and hospitals). At the health facility, each sick child is assessed for general danger signs, IMNCI main symptoms (cough or difficulty breathing, fever, diarrhea, ear problem), nutritional status, immunization status and any other complaint. Each child's condition will be classified and treatment will be provided based on the classification (assess, classify and treat). Ethiopia endorsed IMNCI in 1996 and started to implement it soon after.

The generic IMNCI was designed to manage sick children and young infants at a health facility level by a front line health worker. It was later modified to include newborns as well as additional common health problems.

Conditions covered under IMNCI include:

• Essential newborn care, including assessment for sepsis, asphyxia etc.

• Acute respiratory infections, including pneumonia
• Diarrhea, including dehydration, persistent diarrhea, and dysentery
• Meningitis
• Sepsis
• Malaria (fever)
• Measles
• Malnutrition
• Anemia
• Ear infection
• HIV/AIDS
• Common skin conditions

General Objective:To reduce mortality and morbidity by combining improved management of common childhood illnesses with proper nutrition and immunization and to promote proper growth and development among children under five years of age to achieve the MDG 4.

Specific Objectives/Strategies       

1. Improving the health workers skill through:
   1. Adoption of guidelines and consensus on the approach
   2. Provide training (pre-service and in-service) to strengthen the capacity of health workers to properly assess, classify and manage common childhood illnesses at a health facility level
   3. Referral and linkage
2. Improving the health system to support IMNCI
   1. Ensure availability of drugs and supplies
   2. IMNCI planning and management
   3. Organization of work environment for IMNCI at health facility level
   4. Health management information systems strengthening
   5. Health sector reform
3. Improve the family and community practice on child health and nutrition.

Target: By the end of 2007 EFY to ensure availability of IMNCI services in 100% of the health facilities (HCs and hospitals) in the country.

Coverage/achievement: By the end of 2006 EFY 89% of health centers have been providing IMNCI in the country.

NEWBORN CORNER (NBC) INITIATIVE

The Newborn Corner initiative is a package of interventions to address gaps in preventing newborn morbidity and mortality by ensuring standard newborn care (essential newborn care and basic neonatal life support) immediately after birth in every health facility. The initiative was piloted in 100 health facilities in 2011. The NBC initiative will tackle the three main causes of neonatal mortality (prematurity, asphyxia and neonatal sepsis) and is to be implemented at each delivery room in all facilities. It has three components; (1) Trained health personnel to care for the baby, (2) A newborn area for Essential Newborn Care (ENC) and bag mask resuscitation, and (3) ENC and adequate resuscitation equipment and supplies.

Interventions addressed through the NBC package are:

• Essential newborn care for every baby
• Newborn resuscitation
• Care for premature babies
• Management of neonatal sepsis
• Breastfeeding (counseling and coaching of mothers)
• Kangaroo Mother Care (KMC)and postnatal care
• Referral and linkage

Goal of NBC:Through NBC, ensure the greatest possible reduction of mortality in newborns in order to achieve the Millennium Developed Goal 4 by 2015 and narrow the gap in newborn and child health interventions.

General Objective: To further strength health facilities in delivering quality MNCH services through efficient and effective linkages between health centers and health posts.

Specific Objectives:

1. Strengthen the capacity of the health professionals attending delivery to asses, classify and mange common newborn health problems.
2. Introduce injectable (IM) antibiotics for newborn sepsis management at health facility.
3. Introduce KMC at health facility level.
4. Reinforce facility IMNCI and strengthen referral and linkage.
5. Maintain regular and continuous supply of equipments and consumables required for NBC.
6. Establish a mechanism of regular and continuous supervision, monitoring and evaluation of NBC.

Target: To provide NBC in delivery rooms at all the health centers and hospitals in the country by EFY 2008.

Coverage/achievement: By mid-2007 EFY, a total of 57% of health centers and 27% hospitals have started the NBC package in the country

NEWBORN INTENSIVE CARE UNIT (NICU) INITIATIVE

The NICU initiative is a facility based package of interventions to address newborns who need further/advanced care and to complete referral and linkage. While working towards meeting international standards facilities should start providing the best possible care for newborns with the minimum set of equipment and supplies available. The implementation followed operational standards to classify NICU into three levels; Level I (Basic) for district hospitals, Level II (Specialty) for regional hospitals and Level III (Subspecialty) for tertiary hospitals.

Intervention packages in each level of facility include:

• Level I (basic): a hospital organized with the personnel and equipment to perform neonatal resuscitation, evaluate and provide postnatal care of healthy newborn infants, stabilize and provide care for infants born at 35 to 37 weeks gestation who remain physiologically stable, and stabilize newborn infants born at less than 35 weeks gestational age or ill until transfer to a facility that can provide the appropriate level of neonatal care. 
• Level II (specialty): a hospital special care nursery organized with the personnel and equipment to provide care to infants born at more than 32 weeks gestation and weighing more than 1500 g who have physiologic immaturity such as apnea of prematurity, inability to maintain body temperature, or inability to take oral feedings; who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis; or who are convalescing from intensive care.
• Level III (subspecialty): a hospital NICU organized with personnel and equipment to provide continuous life support and comprehensive care for extremely high-risk newborn infants and those with complex and critical illness. Level III is subdivided into 3 levels differentiated by the capability to provide advanced medical and surgical care.

General Objective: To reduce newborn mortality and morbidity by combining improved management of neonatal conditions and the referral linkage.

Specific Objectives:

1. Strengthen the capacity of the health professional in caring and managing newborn health conditions
2. Strengthen the capacity of health facility supervisors' skill to properly supervise and manage NICU
3. Ensure basic equipment and supplies are in place
4. Strengthen facility infrastructure to accommodate NICU
5. Strengthen referral and linkage among NICU care providers and facilities

Target:

• By the end of EFY 2008 all hospitals will have at least level I NICU
• By the end of EFY 2007 90 hospitals will have level II NICU

Coverage/achievement: By mid 2007 EFY, 100% of the target hospitals have received training, 49% NICUs have been operational throughout the country.

Community Based Newborn Care (CBNC)

Community Based Newborn Care (CBNC) is a package of nine different interventions delivered to the community by the health extension worker. This initiative draws a lesson from the iCCM platform for better newborn survival. The guiding principles of the initiative are government leadership and ownership, balance between preventive and curative care at the community level, continuum of care, health system support, partnership, quality, community participation, phased approach, and scale-up approach. It uses the four C's in implementing the intervention packages; (1) prenatal and postnatal Contact with the mother and newborn; (2) Case-identification of newborns with signs of possible severe bacterial infection; (3) Care, or treatment that is appropriate and initiated as early as possible; and (4) Completion of a full 7-day course of appropriate antibiotics even when referral is not possible.

The CBNC package of interventions includes:

• Early Identification of pregnancy
• Provision of focused Antenatal Care (ANC)
• Promotion of institutional delivery
• Safe and clean delivery including provision of misoprostol in case of home deliveries or deliveries at health post level.
• Provision of immediate newborn care, including application of Chlorhexidine on cord, recognition of asphyxia, initial stimulation and resuscitation of the newborn and prevention and management of hypothermia.
• Management of pre-term and/or low birth weight neonates
• Management of neonatal sepsis at the community level

Goal of CBNC initiative:Reduce newborn and child mortality to accelerate the achievement of MDG 4 and post MDG agenda

General Objective: To further strengthen the Primary Health Care Unit and the Health Extension Program in delivering quality MNCH services through efficient and effective linkages between health centers and health posts.

Specific objective

1. To scale up community based MNH services including introduction of newborn sepsis management;
2. To strengthen the capacity of health centers in providing quality maternal, newborn and child health services;
3. To further strengthen logistics and information systems within the PHCU context;
4. To improve maternal and newborn care practices and care seeking through Health Development Armies (HDAs) and other existing effective community mobilization mechanisms;
5. To draw experience and lessons from the initial phase to inform the scale up phase.

Target: The coverage target is to provide CBNC at every health post in the four agrarianregions by the end of EFY 2007 and expand to pastoral regions by EFY 2008.

Coverage/achievement: By mid 2007 EFY a total of 3223 health posts in the four agrarian regions have started providing CBNC package.

National Newborn and Child Survival Technical Working Group

Implementation of the National Newborn and Child Survival Strategy requires involvement of national and international partners, including the private sector and NGOs, through participation, coordination and mobilization of resources. This calls for advancing of the "one plan, one budget and one report" approach. Partners are expected to advocate for equitable access for evidence-based newborn and child survival interventions, provide financial and technical support including monitoring and evaluation and implementation of high impact newborn and child survival interventions.

General Objective

• To assist the Ministry of Health (MOH) in implementing the Newborn and Child Survival Strategy of Ethiopia
• To provide technical support and resource identification and mobilization that are essential for the implementation of the MOH plan

Specific objectives

1. Provide policy guidance and institutionalization of high impact newborn & child survival interventions
2. Advocate and mobilize more resources for improving maternal, newborn & child survival
3. Ensure universal coverage of key interventions with focus on equity and quality of services
4. Overall coordination, planning, implementation, and monitoring & evaluation of Newborn and Child Health services

Major Responsibilities of the Newborn and Child Survival Technical Working Group

• Coordinate the planning and implementation of all programs that relate to newborn & child health, in line with the revised national Child Survival Strategy
• Advocate for adoption of child friendly policies and evidence-based newborn & child survival interventions
• Mobilize additional resources for newborn & child survival
• Develop, harmonize and disseminate technical and managerial guidelines for all aspects of newborn & child survival
• Intensify social mobilization and advocacy for newborn and child survival
• Support regional planning for newborn and child survival
• Support regional problem-solving and planning for child survival in special population groups
• Improve the quality of health service curricula with the introduction of key Newborn and Child Health packages
• Monitor and evaluate the national implementation of the Strategy – including periodic reviews of the implementation process
• Improve health information system and local use of data for decision making
• Support operational researches and periodic surveys on newborn and child health interventions
• Transfer of good practices and experiences in newborn and child survival interventions

Accountability

• The newborn and child survival technical working group is accountable to the MCHN directorate

Members of the Newborn and Child Survival Technical Working Group

• MOH Child Health Coordinator: Chair
• UNICEF: Secretary
• MOH: MOH Nutrition coordinator, MOH EPI coordinator, MOH MSD representative, MOH PHCU and HEP directorate representative, MOH DPC directorate representative, MOH HSS directorate representative, MOH PPD representative, MOH resource mobilization representative
• Partners: WHO, USAID, Bill and Melinda gates Foundation, DIFID, CIDA, WORLD BANK, CHAI, Irish Aid, Save the Children Federation, World Vision, L10K, and other relevant partners
• Professional Associations: Ethiopian Pediatrics Society, Ethiopian Society of Obstetricians and Gynecologists, Ethiopian Midwives Association, Addis Ababa University

Frequency of the TWG meeting

The TWG convenes every 3 to 6 months, with extra meetings as needed.

STATUS OF NEWBORN AND CHILD SURVIVAL IN ETHIOPIA

Under five mortality rate has declined significantly in the past two decades. Ethiopia has already achieved the MDG 4 target 3 years ahead of schedule.

Figure:  Trends in under-five mortality rate per 1,000 live births

Source: EDHS 2000, 2005, 2011 and UN- IGME 2013

Figure: Percent of people with access to health services within 5 Kms in Amhara, Oromia, and SNNP in 2005, 2007 and 2011

Source; CNHDE, The third round of evaluation of Health Extension Program, 2011

Figure: iCCM and/CBNC coverage

Source: Reaching every newborn and child, MOH June 2014.

Trends in IMNCI coverage in health centers

Source: EHHRI 2004, 2005 and FMOH APR 2006