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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

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

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

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

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

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

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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

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

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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 Where we are.

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Progress for 60 Countdown priority countries in

MeaslesDPT3 CAR, Cote dIvoire, Liberia, Nigeria, PNG, Somalia CAR, Chad, Cote dIvoire, Eq. Guinea, Gabon, Haiti, Liberia, Nigeria, PNG, Somalia >90% 90% 60 Countdown priority countries 10 countries with 90% or more coverage Most countries still below target and need intensified efforts Measles and DTP3

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Insecticide-treated NetsVitamin A Supplementation Prevention

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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 Developing World 61% Vitamin A Supplementation

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Abuja target 2005 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) Sub- Saharan Africa 3% ITNs

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80% (1 dose) Case Management

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80% (1 dose) Pneumonia kills more children than any other illness, accounting for 19% of all under five 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 pneumonia/sepsis is estimated to cause 26% of all neonatal deaths. Pneumonia 19% Neonatal causes 27% Pneumonia Case Management

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80% (1 dose) 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 Pneumonia Case Management

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Nutrition

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+450% +41% 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 +21% +9% Developing World 36% Exclusive Breastfeeding

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

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

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80% (1 dose) Newborn Health

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

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

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

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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

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

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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

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Systematic Scaling Up of Proven Interventions and Appropriate, Situation-Specific Strategies that Benefit Children and Womens Health and Nutrition Under 5 Mortality Rate

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

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ACSD and Malaria

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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

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Years from randomisation Why is T/S Prophylaxis Important for HIV-Infected Children in Resource-Poor Settings? CHAP Study: 43% Decrease Death with T/S Proportion Alive CotrimoxazolePlacebo 0.40 0.60 0.80 1.00 0.511.52 *Source: Chintu C et al. Lancet 2004;364:1865-71

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

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

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

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

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

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0 40 80 120 160 200 199019931996199920022005200820112014 MDG 4 target Current trend ACSD Booster Phase I Phase II Phase III ACSD Booster Initiative Sub Saharan Africa