1. Integrated Management of Neonatal and Childhood Illness (IMNCI)
Dr. Abdul Rehman Pirzado
Provincial MnCAH Officer Sindh
World Health Organization Pakistan

2. Objectives of IMNCI Strategy
To reduce significantly mortality and morbidity associated with the major causes of disease in children.
To contribute to healthy growth and development of children.

3. Historical Background
Launched globally in 1995
Pakistan adapted
First national clinical course 2000
First clinical course in Sindh 2004
Pre-service adaptation in Pakistan 2004
Pre-service adaptation in Sindh 2009
First Pre-service evaluation in Pakistan – LUMHS 2011.
First logbook on Pakistan- LUMHS 2010

4. Why IMNCI in Pakistan High Infant Mortality Rate – 78/000 live births.
High under 5 year mortality rate
Diarrhea, ARI, Malnutrition and Malaria are major contributors in death of Under 5 children.
Government policy to integrate PHC activities.
PMDC requires to be included in graduate teaching

5. Integrating the Clinical Management of Neonatal and Childhood Illness
RB-03-99
WHO Department of Child and Adolescent Health and Development
Separate disease specific clinical guidelines and training materials
Separate disease specific training courses
Health worker attempts to “Integrate” guidelines
Integrated clinical guidelines and training materials
Integrated clinical training courses
Integrated clinical case management

6. Strategy Is not another vertical program
Incorporates elements of diarrhoeal diseases and ARI control program and child oriented aspects of malaria control, nutrition , EPI and other relevant programs
Depends on: effective functioning of essential drugs and EPI program
Demands and Facilitates: active collaboration of all these existing programs
Improves the quality of care of sick children in the primary health care context

7. Components Improving case management skills of health workers:
Standard guidelines
Training (pre-service and in-services)
Follow-up after training
Improving the health system to deliver IMNCI:
Essential drug supply and management
Organization of work in health facilities
management and supervision
Improving Family and Community practices

8. IMNCI Case Management Process
Classification based on a colour-coded triage system
Red - urgent pre-referral treatments and referral
Yellow - specific medical treatment and advice
Green - simple advice on home management

9. IMNCI Case Management Process (Cont.)
Assess a child
Classify a child’s illnesses
Identify treatments for the child.
Treatment instructions
counsel the mother to solve any feeding problems and her own health.
When a child is brought back to the clinic give follow-up care and if necessary reassess the child for new problems

10. Course methods and materials
Modules include exercises that help in learning new skills
Modules are to be completed by reading it and working through the exercises
Exercises supplemented by videos and photographs.
Clinical practice as part of training

11. Clinical courses 11 day clinical case management
FIVE day facilitator Course
THREE day Follow-up after training
FIVE day community IMNCI

12. Key family Practices Exclusive Breastfeeding
Complementary feeding / Weaning
Micronutrients supplementation for vitamin A, iron and zinc 
Hygiene. Dispose of faeces and wash hands.
Immunization as per EPI.
Preventing Malaria.

13. Key family Practices (Cont.)
Promote mental and social development by responding to a child’s needs for care
Home care during Illness
Give sick children appropriate home treatment for infections.
Care Seeking.
Compliance with advice
Antenatal Care

14. Evaluation of IMCI pre-service education at Liaquat University, Pakistan
A regional team of 8 consultants from WHO evaluated the process and outcomes during October 17-20, 2011.
This was 5th evaluation carried out by WHO in Egypt and Sudan.
Objective of the evaluation was to assess whether the introduction of IMNCI in the department's teaching program in had led to students’ competence in managing sick children with common health problems according to the IMNCI guidelines and make recommendations to further strengthen the teaching program

15. Evaluation of preservice education LUMHS
The evaluation was carried out according to the standard methodology described in the “Guide to the evaluation of IMCI pre-service education”, developed by WHO Regional Office.
After reviewing the information on the pediatric department and IMNCI teaching process and methodology, the team:
observed several outpatient clinical and theoretical teaching sessions;
visited the library and teaching sites;
conducted focus group discussions with students and teachers in both the pediatrics and community medicine departments;

16. Evaluation of preservice education LUMHS
assessed student knowledge through a written test of multiple-choice questions and case scenarios;
assessed student clinical skills through observation of case management practiced by students.
Finally, the team provided feedback to the vice- chancellor and staff of the University, including the dean and heads and teaching staff of the departments
Overall, the environment at Liaquat University is very supportive to IMNCI teaching, which has formally endorsed it at high level in the institution.
A provincial pre-service training committee has also been established to coordinate this initiative

17. Evaluation of preservice education LUMHS
All teaching staff at the pediatrics department have been trained in IMNCI, with a staff-to-student ratio of 1:13 for both practical and clinical sessions.
More than a third (35%) of total teaching hours are allocated to IMNCI.
Teaching of IMNCI is, in general, consistent with traditional, classical pediatric teaching, well integrated throughout the curriculum and materials, interactive and makes use of a variety of teaching methods, with sessions including the full range of theoretical, practical and clinical sessions.
The outpatient department has been set up in a way conducive to teaching IMNCI, with a smooth flow of patients.
IMNCI-related items have been included in student examinations, with 30% of total marks assigned to IMNCI.

18. Evaluation of preservice education LUMHS
Reference materials are available in the library and regularly used by students.
Approaches to sustain the initiative in the long term have been adopted and teaching has been enhanced based on review of the experience.
Teaching staff’s and students’ attitudes towards IMNCI are very positive, with students greatly appreciating the variety of teaching methods and clinical sessions.
Overall, students performed well in both the knowledge and clinical assessment tests, showing confidence with the topics and clinical skills: 79% of the students assessed obtained an overall score of at least 80% in the case management skill test, based on to the IMCI standard protocol as a gold standard. The two tests have helped identify teaching areas which may be further enhanced.

19. Thanks