GIVS and UNICEF: Strategic Priorities For Immunization and Child Survival

1. GIVS and UNICEF: Strategic Priorities For Immunization and Child Survival Dr. Peter Salama, Chief Child Survival and Immunization Unit Health Section, Programme Division UNICEF GIM, March 28th 2006

2. Outline • UNICEF context • UNICEF and GIVS • Progress in 60 countries • Programme models • CS indicators- some examples • Next steps

3. New UNICEF Context • UN reform • Paris Principles • Child survival and MDG 4 • New partnerships • GIVS and strategic frameworks • New Executive Director

4. Health and Nutrition Strategy:Conceptual implementation framework Policies, plans & budgets Leveraging policies, plans and budgets through enhanced Knowledge & evidence Translating policies, plans and budgets into large scale action All MDGs Impact MDGs 1, 4, 5 & 6 MDG 4 Knowledge & Evidence Large scale action Learning by doing, and doing better by learning

5. Global Causes of Under 5 Mortality* Malnutrition Contributes to about 50% of this mortality *Source: Lancet Child Survival Series, (measles data revised). Total 10.8 milliondeaths per year

6. Global Causes of Under 5 Mortality By Vaccine-Preventable Status* *Source: WHO/UNICEF Total 10.8 million deaths per year

7. GIVS and UNICEF • 1) Reaching the unreached • Complete ADC agenda • Large countries, marginalized pops, complex emergencies • 2) New vaccines • 3) Linking child survival interventions • 4) Global interdependence • Forecasting, supply and procurement • Financing

8. Priority Countries Child Survival Countdown - 60 priority countries • Criteria: • Either total number of under-five deaths ≥ 50,000 • Or under-five mortality rate ≥ 90 per thousand

9. Where we are…. We know: ● How many children are dying ● What they are dying of ● Which interventions can prevent most child deaths Need to know: ● What are current coverage levels of interventions ● Is progress being made ● Where do we need to focus programs

10. Under 5 Mortality Progress for 60 Countdown priority countries in <5 MR

11. Immunization

12. Measles and DTP3 • Major progress during the 1980s • Coverage stagnated since 1990 DPT3 Developing World 76% Target Measles Developing World 74%

13. Measles and DTP3 60 Countdown priority countries • 10 countries with 90% or more coverage• Most countries still below target and need intensified efforts Measles DPT3 CAR, Chad, Cote d’Ivoire, Eq. Guinea, Gabon, Haiti, Liberia, Nigeria, PNG, Somalia CAR, Cote d’Ivoire, Liberia, Nigeria, PNG, Somalia >90% >90% <50% <50%

14. Prevention Insecticide-treated Nets Vitamin A Supplementation

15. Vitamin A Supplementation Developing World 61% • 3-fold increase in % children fully protected by two doses • Greatest gains in least developed countries • Among the 60 priority countries, 26 have 70% or more coverage with at least one dose, and 7 have unacceptably low coverage

16. ITNs Sub- Saharan Africa 3% Sub-Saharan Africa: malaria endemic countries • Low rates of ITN use • Major investments in • recent years • Rapid increases expected soon; 10-fold increase in nets distributed in • Sub-Saharan Africa • (1999-2003) Abuja target 2005

17. Case Management 80% (1 dose)

18. Pneumonia Case Management •Pneumonia kills more children than any other illness, accounting for 19% of all under five deaths Neonatal pneumonia/sepsis is estimated to cause 26% of all neonatal deaths. • Only 1 in 5 caregivers know the ‘danger signs’ of pneumonia – cough and fast or difficult breathing • 54% of children with pneumonia are taken to an appropriate health care provider Neonatal causes 27% Pneumonia 19% 80% (1 dose)

19. Pneumonia Case Management Roughly 20% of children with pneumonia received antibiotics (based on limited data from the early 1990s) ● Current estimates not available ● Questions on antibiotic use for pneumonia included in current round of MICS and DHS ● Rapid progress is possible 80% (1 dose)

20. Nutrition

21. Exclusive Breastfeeding Developing World 36% • Significant progress has been made since 1990 • Sub-Saharan Africa, in particular, has made significant • gains during the 1990s • Rates continue to be low across the developing world +41% +9% +21% +450%

22. Exclusive Breastfeeding Rapid progress is possible Rapid progress Higher rates achieved Rapid progress Rates still low

23. Exclusive Breastfeeding 60 Countdown priority countries23 countries with unacceptably low rates

24. Newborn Health 80% (1 dose)

25. Summary of Findings ● Coverage levels remain too low for most indicators ● Rapid progress is possible ● Analysis needed of why rapid progress occurs in some countries, and for some interventions, but not others

26. Summary of Findings Coverage too low for most causes of child death Cause of death Intervention coverage Malaria Pneumonia Diarrhea Undernutrition Neonatal Measles ITN use ORT Antibiotics ORT/continued feeding Exclusive breastfeeding Vitamin A supplementation (> 1 dose) Exclusive Breastfeeding Skilled attendant at birth Measles vaccine

27. Surveys for 2005-6 national household survey activity 2005-2006 MICS DHS Other surveys

28. GIVS Strategy 3 • Integrating immunization, other linked interventions and surveillance in the health systems context • UNICEF Approach: • Using immunization to deliver evidence-based packages of child survival interventions at country level

29. Evidence-Based Selection will Lead to a Mix of Interventions and Operational Strategies

30. SELECTION OF EVIDENCE BASED HIGH IMPACT INTERVENTION PACKAGES • EPI+ • Strengthening routine EPI • Vitamin A supplementation • ITNs* • Cotrimoxazole prophylaxis* • IPTi* • Antenatal care+: • Refocused ANC • Tetanus immunization • Intermittent presumptive treatment (IPT) against malaria • Vitamin A (post partum) • PMTCT* • IMCI+ • Exclusive Breastfeeding • ORT • ITNs (pregnant and under 5 children) • Community management of Malaria and ARI

31. Systematic Scaling Up of Proven Interventions and Appropriate, Situation-Specific Strategies that Benefit Children and Women’s Health and Nutrition Under 5 Mortality Rate

32. Impact of ACSD package on DPT3 coverage in selected districts of 3 West African Countries 2001 Baseline 2003 Survey

33. ACSD and Malaria

34. Using immunization as a platform for delivery of package of child survival interventions • Help countries to tailor integrated packages of interventions at immunization contacts with priority on outreach and strategies for hard to reach • Ensure selected additional interventions are included in the multi-year plan • Assist in effective implementation and monitoring of the joint interventions • Continue to learn and adapt packages and implementation

35. Cotrimoxazole Placebo Why is T/S Prophylaxis Important for HIV-Infected Children in Resource-Poor Settings? CHAP Study: 43% Decrease Death with T/S 1.00 0.80 Proportion Alive 0.60 0.40 0 .5 1 1.5 2 Years from randomisation *Source: Chintu C et al. Lancet 2004;364:1865-71

36. Afghanistan;under five child survival indicators as of 2004U5MR 257 per 1000 live births- Ranked 4 Source: SOWC 2006

37. DR Congo;under five child survival indicators as of 2004U5MR 205 per 1000 live births- Ranked 8 Source: SOWC 2006

38. Rwanda;under five child survival indicators as of 2004U5MR 203 per 1000 live births- Ranked 10 Source: SOWC 2006

39. Ethiopia;under five child survival indicators as of 2004U5MR 166 per 1000 live births Source: SOWC 2006

40. Nigeria;under five child survival indicators as of 2004U5MR 197 per 1000 live births- Ranked 13 Source: SOWC 2006

41. ACSD Booster Initiative Sub Saharan Africa 200 Current trend 160 Phase I ACSD Booster 120 Phase II 80 Phase III MDG 4 target 40 0 1990 1993 1996 1999 2002 2005 2008 2011 2014 <5 MR 1000 LBs Year

42. Next Steps • Formal independent evaluation ACSD • Refine costing tool • Mobilize partners: WHO,WB, AU, GAVI, GFATM, CIDA, USAID, Norway, PMNCH • Investment case • Implementation plan • Continue to support government scale-up • Monitoring framework • Lessons learned