Strategic Framework for Integrating Additional

Child Survival Interventions with Immunization

in the African Region












WHO Regional Office for Africa
August 2006



1
Table of Contents


Acronyms . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2

3
1. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1.2. Why integrate additional child survival interventions with immunization? . . . . . .
1.3. The scope of integration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . .. .
1.4. Overview of strategic framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . .

4
4
5
6
5
2. Experiences in integrating child survival interventions with EPI . . . . . . . . . . . .
2.1. Definition of integration of health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.2. Vehicles for integration with EPI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.3. Lessons learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7
7
7
10
3. Planning integration of additional interventions with EPI . . . . . . . . . . . . . . . . . .
3.1. Criteria for prioritizing interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2. Selecting which interventions to integrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3. Policy considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.4. Operational considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12
12
12
13
14
4. Implementation process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1. Critical Elements in implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2. Co-ordination and organizational support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15
15
16
5. Monitoring and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1. Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.2. Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17
17
17
6. Roles and responsibilities . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.1. National level .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.2. Sub-national level (Province and District) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6.3. Partners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18
18
18
18
7. Annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7.1. Country ranking by number of child deaths and under 5 mortality rates . . . . . .
7.2. Communicable diseases prevention interventions . . . . . . . . . . . . . . . . . . . . . . . . .
7.3. Indicators to monitoring child survival interventions. . . . . . . . . . . . . . . . . . . . . . . .
7.4. Programme managers checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . .
19
19
20
21
23





2


Acronyms

ACDI Accelerated Child Development and Survival Initiative
ACSD Accelerated Child Survival and Development
AFP Acute Flaccid Paralysis
AFRO WHO Regional Office in the African Region
ANC Antenatal Clinic
ARICC Africa Regional Inter-Agency Coordination Committee
CHWs Child Health Weeks
CSM Cerebrospinal Meningitis
EPI Expanded Programme on Immunization
EOS Expanded Outreach Services
GIVS Global Immunization Vision and Strategy
IMCI Integrated Management of Childhood Illnesses
ITN Insecticide Treated Nets
LIDs Local Immunization Days
MCH Mother and Child Health Clinics
MDGs Millennium Development Goals
MNTE Maternal and Neonatal Tetanus Elimination
NIDS National Immunization Days
PEI Polio Eradication Initiative
PROM Premature Rupture of Membranes
RED Reaching Every District
SIAs Supplemental Immunization Activities
SOS Sustainable Outreach Services
TFI Task Force on Immunization
TT Tetanus Toxoid
SAGE Strategic Advisory Group of Experts
YF Yellow Fever

3
Executive Summary

The 12
th
Task Force on Immunization in Africa (TFI) meeting recommended the
establishment of a working group to discuss policy and programmatic issues on
integrating additional child survival interventions with immunization
1
. The 12
th
TFI
meeting also recommended that WHO/AFRO should develop a strategic framework on
integration taking into account experiences to strengthen health systems.

In line with the 12
th
TFI recommendations on integration, WHO/AFRO convened a
workshop in May 2005 on integrating additional child survival interventions with
immunization activities
2
. This workshop brought together participants from Ministries of
Health from 10 member states in WHO/AFR and WHO/EMRO as well as representatives
of 6 partner agencies. The workshop reviewed a draft strategic framework and draft
guidelines on integration of additional child survival interventions with immunization.
The comments, suggestions and recommendations of the May 2005 workshop, along with
feedback from partners, have been used to revise the strategic framework on integration.

This strategic framework on integration of additional child survival interventions with
immunization services presents the rationale for considering integrating additional child
survival interventions with immunization as well as lessons learned from recent
experiences in delivering integrated child survival interventions in the African Region.
Three main vehicles have been used to deliver integrated interventions with
immunization, namely routine services, enhanced routine services and campaigns.

Based on the lessons learned, this framework presents strategic options to be considered
by national policy makers and programmes involved in planning and implementing child
survival interventions.

Key issues are discussed regarding planning integration of additional child survival
interventions with immunization, including priority-setting, policy implications and
operational considerations. Although monitoring and evaluation issues are introduced,
these are covered in greater depth in the report of a workshop on monitoring and
evaluation of integrating ITN distribution with other child survival interventions
3
and the
resultant framework for monitoring and evaluation of integrated child survival
interventions
4
.




1
WHO, 2005. Report of the Task Force on Immunization in Africa (TFI) 12
th
Annual Meeting and the African Regional
Inter-Agency Coordination Committee (ARICC) 11
th
Annual Meeting, Bamako, Mali, 7-9 Dec 2004.
2
WHO/AFRO, 2005. Report of a workshop on framework and guidelines for integrating additional child survival
interventions with immunization. Harare, 2-5 May 2005.
3
WHO/AFRO, 2005. Report of a workshop on monitoring and evaluation of integrating ITN distribution with other
child survival interventions, 16-18 August 2005.
4
WHO/AFRO, 2006. Draft framework for monitoring and evaluation of integrated child survival interventions.

4
1. Background

1.1. Introduction

Sub-Saharan Africa continues to bear the highest burden of childhood mortality in the
world. Of the 10.8 million child deaths in 2000, over 4.4 million occurred in sub-Saharan
Africa (see annex 7.1). It is estimated that six communicable diseases (diarrhoea,
pneumonia, malaria, measles and HIV/AIDS) accounted for close to 50% of childhood
deaths in 2000.

The unacceptably high childhood mortality in sub-Saharan Africa occurs because
effective low cost interventions are not delivered to mothers and children who need them
most. A working group
5
on child survival recently reviewed child survival interventions
feasible for delivery at high coverage levels in low income settings, and classified them
into three categories i.e. level 1 (sufficient evidence for effect), level 2 (limited evidence
for effect) and level 3 (inadequate evidence for effect). A full list of interventions against
the communicable diseases responsible for up to 50% of childhood mortality is shown in
annex 7.2.

The urgency to scale-up child survival interventions that have been proven cost-effective
is especially important at this point when countries are implementing national plans to
achieve Millennium Development Goals, including the reduction of child mortality by
two-thirds

by 2015 as compared to 1999 levels
6
(MDG 4).

The 12
th
Task Force on Immunization in Africa (TFI) meeting recommended that a
working group should be established to discuss policy and programmatic issues on
integrating additional child survival interventions with immunization. The 12
th
TFI also
recommended that WHO/AFRO should develop a strategic framework on integration
taking into account experiences to strengthen health systems.

WHO/AFRO convened a workshop in May 2005 on framework and guidelines for
integrating additional child survival interventions with immunization activities. The
workshop reviewed recent experiences in delivering integrated interventions during
immunization activities, agreed on criteria to evaluate interventions for integration,
reviewed a draft strategic framework on integration of additional child survival
interventions with immunization, as well as draft guidelines for integrating additional
child survival interventions with immunization services. This document has taken into
account the comments, suggestions and recommendations of the May 2005 workshop as
well as comments from partners.




5
Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS and the Bellagio Child Survival Study Group. How many
child deaths can we present this year? Lancet 2003: 362: 65-71
6
United Nations. General Assembly, 56
th
Session. Road map towards the implementation of the United Nations
Millennium Declaration: report of the Secretary General. New York: United Nations, 2001

5
1.2. Why integrate additional child survival interventions with immunization?

In May 2005, the 58
th
World Health Assembly endorsed the Global Immunization and
Vision Strategy (GIVS). It recommended that member states use GIVS as the framework
for strengthening national immunization programmes during the period 2006-2015
7
.
Integrating immunization, other health interventions and surveillance in the context of
health system strengthening is one of the four strategic areas of GIVS.

Integration of additional child survival interventions with immunization is being
promoted in order to achieve the following specific outputs
8
:
Improved efficiency and productivity
Improved health status
Improved user satisfaction and convenience, and
Improved equity

Immunization is attaining increasing coverage in the WHO African Region. DPT-3
coverage increased from 54% in 2000 to 66% in 2004
9
. In 2004, twenty-two countries in
the African Region achieved DPT-3 coverage of at least 80%. An additional six countries
achieved DPT-3 coverage between 70 and 79%. Innovative strategies such as Sustainable
Outreach Services (SOS) and Reaching Every District (RED) have been developed to
increase routine immunization coverage.

In addition to routine immunization activities, immunization campaigns conducted as part
of accelerated control, elimination and/or eradication programmes of vaccine-preventable
diseases offer opportunities to reach a significant proportion of the population.

There is a growing realization that linking additional interventions to immunization can
rapidly scale up available effective child survival interventions, while at the same time
boost quality and coverage of immunization activities
10
.

The delivery of a package of high impact child survival interventions in targeted districts
in four West African countries reduced under-five mortality by 20% through increasing
utilization of routine preventive services and by increasing coverage of immunization,
vitamin A supplementation, antenatal care attendance and Insecticide Treated Net (ITN)
use
11
.

The opportunity presented by a nation-wide measles supplementary immunization
activity (SIA) in Togo in December 2004 was used to distribute ITNs, Oral Polio Vaccine
(OPV) and the anti-helminthic, mebendazole. A survey conducted at the end of the

7
58
th
World Health Assembly, May 2005. WHA Resolution 58.12
8
WHO, Geneva, 1996. Integration of health care delivery. Report of a WHO study group. WHO Technical Report
Series 861.
9
WHO/IVB/2005. WHO Vaccine preventable diseases: monitoring system 2005 global summary
10
Victoria CG, Hanson K, Bryce J, Vaughan P. Achieving universal coverage with health interventions. Lancet. 2004.
364: 1541-1548
11
UNICEF, 2005. Accelerating child survival and development. A results-based approach in high under 5 mortality
areas.

6
campaign showed that 93% of the target age children had received measles vaccine, 94%
had received OPV, 91% had received an ITN while 93% had received mebendazole
12
.

Strong health systems are the most effective way of delivering cost effective child
survival interventions in a most sustainable manner. The reality in many African
countries is that health systems are weak for a number of reasons including weaknesses in
planning and forecasting; shortages of human, financial and material resources; paucity
of data for decision making; weaknesses in institutional processes; and weaknesses in
monitoring of performance and impact. It is therefore necessary to use innovative
delivery mechanisms to scale up effective child survival interventions in a manner that
will complement ongoing efforts to strengthen national health systems.

1.3. The scope of integration

The focus of this document is on integrating child survival interventions with
immunization. However, integration of health services cannot be limited to the marriage
of theses two areas alone. For instance, it can be argued that, in locations where
immunization performance is stronger than that for other services, immunization contacts
may also be critical opportunities for providing care of the newborn, emergency obstetric
and postpartum care for women, or messages about birth spacing all of which affect
child survival. This discussion is ongoing.

1.4 Overview of the strategic framework

1.4.1 Objective of strategic framework

The main objective of the strategic framework is to present strategic options for the
integration of additional child survival interventions with immunization in an effort to (a)
promote the most efficient and effective use of limited resources and (b) scale-up
delivery of cost-effective child survival interventions.

1.4.2. Target Audience

The main target audiences for this framework are:

Policy makers within the government system
Programme managers at national level involved with child survival programmes
District health management teams
Policy makers within the non-governmental sector e.g. multi-laterals, bi-laterals,
national and international NGOs.




12
Nation-wide distribution of insecticide-treated bednets during a child immunization campaign, Togo, West Africa,
December 2004. Weekly Epidem Record: 38: 2005, 322-326.

7
2. Experiences in integrating interventions with immunization


2.1. Definition of integration of health services

Integration of health services has been defined as the process of bringing together
common functions within and between organizations to solve common problems,
developing a commitment to a shared vision and goals, and using common technologies
and resources to achieve these goals
13
.

2.2. Vehicles for integration with immunization

Potential vehicles for delivering additional child survival interventions with
immunization have been categorized into three broad groups, namely (a) routine services,
(b) expanded routine services and (c) campaign
14
.

2.2.1. Routine services

Routine immunization for both infants and mothers is delivered at Mother and Child
Health (MCH) clinics. Infants are expected to have at least 5 contacts with routine
immunization services before they reach one year of age i.e. at birth or shortly after birth,
at 6 weeks, 10 weeks, 14 weeks and at 9 months. These contacts can be used to promote
or deliver additional child survival interventions appropriate for these ages (see annex 7.).

Tetanus Toxoid (TT) vaccination of women of child bearing age is also delivered during
antenatal clinics. All pregnant women are expected to receive at least 2 doses of tetanus-
containing vaccine before delivery. Interventions that can be promoted and/or delivered
at these contacts include provision of ITNs and Intermittent Presumptive Treatment of
malaria in pregnancy (IPTp). The latest WHO position paper
15
recommends booster
doses of tetanus-containing vaccine at 4-7 years and at 12-15 years. Such potential
contacts with children and adolescents open up opportunities to explore the delivery of
other appropriate services to these age groups at the same time.

Ultimately, the delivery of additional child survival interventions together with routine
immunization services is the most sustainable approach. However, in most counties in the
African Region, routine immunization services, which are part of the district health
system, are often afflicted by the challenges of health systems described in section 1.2. In
many areas, a significant proportion of the target population does not have access to fixed
health facilities.




13
WHO, Geneva, 1996. Integration of Health Care Delivery. Report of a WHO Study Group. WHO Technical Report
Series 861.
14
Webster J, Hill J. Draft Framework of Strategic Options for the integrated delivery of ITNs and immunization.
15
Tetanus vaccine. WHO position paper. Weekly Epidem Record 2006, 81, 198-208.

8
2.2.2. Expanded routine services

The expanded routine model includes those activities that involve regular reach-out into
communities who do not have access to health facilities. These activities include regular
outreach activities as well as Child Health Weeks (CHWs). Immunization services are
delivered through regular outreach to those areas with poor access to fixed facilities i.e.
more than 5 kilometers from a fixed facility. Since 2002, the RED strategy has promoted
the re-establishment of well planned outreach services that are implemented with full
involvement of target communities and that take into account local resource
availability/limitations. To enhance the opportunity provided by outreach services,
additional interventions have been added to the activities of outreach teams.

Child Health Days (CHDs) and Child Health Weeks (CHWs) represent an intensified
one stop delivery of broad packages of child survival interventions. CHDs/CHWs are
usually conducted twice or three times a year. Interventions usually delivered during
CHDs/CHWs include vaccinations, vitamin A supplementation, growth monitoring, ITN
distribution, ITN re-treatment, health education on home management of fever,
HIV/AIDS awareness, family planning services, distribution of iron tablets as well as the
distribution of anti-helminthics. During CHDs/CHWs, immunization is given in
accordance with primary schedules, and vaccination cards are issued for safe-keeping.

2.2.3. Campaigns

Immunization campaigns have been implemented in many African countries either in an
effort to increase routine immunization coverage (multi-antigen catch up campaigns), as
part of accelerated control, elimination and/or eradication programmes (measles SIAs,

Table 1
Types of immunization campaigns and their merits for additional interventions

Type of campaign Target group and expected
coverage
Advantages and limitations
Polio supplementary
immunization
activities (SIAs)
0-59 months, coverage +90%.
Reach children not reached by
routine
At least two rounds of
contacts with target group at
least twice a year. Fewer
NIDs conducted as polio
approaches eradication
Measles SIAs 9m-14 years or 9-59 months,
coverage +90%. Reach school
children not reached by other
health interventions
Repeated every 3-4 years.
Campaigns likely for many
years. Clear overlap with
vitamin A supplementation
Tetanus toxoid SIAs Women of child-bearing age,
not always high coverage
because of difficulties in
accessing the target group
One-off. Tends to be only in
high risk areas/districts. May
be compatible with antenatal
or other MCH interventions.
Likely to be needed long-term

9
Tetanus SIAs, polio eradication SIAs), or in response to disease outbreaks such as yellow
fever and meningitis.

Recent immunization campaigns conducted in the African Region have been used to
deliver additional interventions such as vitamin A supplementation, anti-helminthics and
ITNs. Adding other interventions such as vitamin A supplementation to immunization
campaigns has generally greatly improved coverage of the added intervention to the
extent that coverage becomes similar to the vaccine coverage levels.

2.2.4. Reaching Every District (RED) Strategy

The RED strategy was developed and introduced in the African Region in 2002 to
increase immunization coverage through improved quality and sustainable fixed and
outreach immunization activities. This strategy has five operational components:

Planning and management of resources
Supportive supervision
Re-establishment of outreach services
Community links with service delivery
Monitoring and use of data for action

The May 2005 workshop on integrated child survival interventions recommended that
countries in the African Region should prioritize RED as a vehicle for delivering
integrated child survival interventions
16
.

2.2.5. Integrated Surveillance

Surveillance is an integral component of all accelerated vaccine-preventable disease
control programmes. In this regard, standard operating procedures are implemented in the
countries of the African Region for case-based surveillance of acute flaccid paralysis
(AFP), measles, yellow fever and neonatal tetanus.

Provincially-based active surveillance is the main strategy used to support case-based
surveillance. Health staff based at provincial (sub-national) level are supported with
transport, communication and data processing equipment. These staff conduct regular
(weekly or fortnightly) visits to priority health facilities to actively seek out cases of the
priority conditions. The opportunity provided by the regular surveillance visits have been
optimized and used to support other important activities, including:

Monitoring aspects of routine immunization such as immunization coverage or
logistics monitoring including vaccine supplies.
Monitoring data for IMCI and malaria programme indicators, initially by using exit
interviews and more recently through integrated child survival tally sheets

16
WHO/AFRO, 2005. Report of a workshop on monitoring and evaluation of integrating ITN distribution with other
child survival interventions, 16-18 August 2005.

10
Collecting and submitting integrated disease surveillance and response data (IDSR)
Preparing for and investigating suspected outbreaks. In several countries in the region
e.g. Nigeria and Ethiopia, the provincial active surveillance infrastructure has been
used to support preparedness for avian influenza outbreaks
Monitoring and evaluating anti-retroviral therapy .
Monitoring the cold chain.
Monitoring injection safety and waste disposal practices

The laboratory networks set up to support polio, measles and yellow fever surveillance
have been used as models for the establishment of surveillance networks for pediatric
bacterial meningitis surveillance (PBMS) as well as rotavirus surveillance.

2.3. Lessons learned

2.3.1. Advantages of delivering additional interventions

Advantages of delivering integrated interventions with routine immunization services
routine and/or enhanced routine strategies include:
More efficient use of scarce resources such as trained health workers, funds, transport
and other logistical equipment.
Coverage rates for the linked intervention may rapidly increase to the levels of the
immunization programme's rates where an intervention is linked to a robust
immunization programme with high coverage rates
17,18
.
Reduction in operational costs and decreased competition this can happen when two
programmes integrate that had previously been competing for the same resources.
Increased community acceptance of integrated interventions. The integrated
programmes offer multiple services at once. Communities prefer combined
programmes because it saves them multiple trips from their village to health clinics.
Opportunity for a better balance between global/regional priorities and local needs.

2.3.2. Potential challenges and risks of delivering additional interventions

Common challenges with regard to delivering integrated interventions with routine and/or
enhanced routine strategies include:
Supplies. Maintaining adequate supplies of multiple products e.g. ITNs, drugs,
vaccines.
Timing. Failing to adhere to set schedules for the delivery of services e.g. lack of
follow up and/or frequent changes in dates of outreach activities. Timing may not be
compatible - polio SIAs should be carried out midway through the dry season and
ITN distribution is best just before the rainy season. Outreach activities may be
inappropriate during e.g. rainy seasons

17
Webser J, Hill J. Draft Framework of Strategic Options for the integrated delivery of ITNs and immunization.
18
UNICEF, 2005. Accelerating Child Survival and Development. A Results-based approach in high under 5 mortality
areas.

11
Resource allocation - after integration, one intervention may still continue to receive
disproportionately more resources than the other intervention.
Components of a semi-integrated programme that are not linked my be ignored.
Staff can become overburdened with a high workload in an integrated programme.
This risk may be most prevalent when the frontline staff receive inadequate training
for both interventions.
Operational difficulties when some of the interventions are targeted at different age
groups.
A reduction in coverage for some interventions compared with delivering them singly
e.g. low OPV coverage in Ethiopia, Mali, Burkina Faso, Togo, Niger, when delivered
in multi-interventional campaigns.
Difficulties with developing a clear social mobilization message for several
interventions at once.

2.3.3. Elements of success

To ensure successful implementation of integrated campaigns, the following should be
put in place:

Consensus-building in the central coordinating committee/task force and between
programme managers of the various interventions.
Clarification of roles and responsibilities of the different players/stake-holders
Development of clear planning and implementation guidelines
Early planning and multi-sectoral involvement
Development of appropriate training materials.
Timely implementation of training of involved workers
Careful preparation of social mobilization messages
Timely arrival and monitoring of all supplies and materials such as vaccines.








12
3. Planning integration of additional interventions with EPI


3.1. Criteria for prioritizing interventions

The May 2005 workshop
19
proposed the following criteria for prioritizing child survival
interventions for integration:

A high burden of disease
Cost-effectiveness of the intervention. When assessing cost-effectiveness, there
should be an assessment of outcomes (e.g. coverage) and impact (e.g. morbidity
and mortality)
Availability of supplies and materials
Availability of human resources
Feasibility
Partnerships that support the interventions
Acceptability of interventions by community and political leaders

When considering which interventions should be included in an integrated package for
delivery through either the routine services, enhanced routine services and/or campaign,
the proposed interventions should be carefully evaluated against the above seven criteria.
Only a limited number of interventions should be considered so as not to overwhelm
the delivery vehicle.

3.2 Selecting which interventions to integrate

Choosing which intervention(s) to integrate into an existing programme can be complex.
The decision may be taken centrally and imposed on districts as a policy that must be
implemented nationally. This has the advantage of consistency and ease of
implementation and can still take into account district point of view. But there may be
advantages in allowing the decision to be made at province or district level.
Empowerment of the district to plan, implement and monitor is key to the success of the
integrated package. This will also strengthen the entire health system for primary health
care delivery, and is an important element for sustainability. Decisions at district level
have the added advantage that they can involve local communities. Table 2 lists some of
the alternatives.








19
Workshop on framework and guidelines for integrating additional child survival interventions with
immunization activities

13
Table 2
List of possible child survival interventions that might be integrated with
immunization*

Disease/health problem Intervention
Malaria - prevention through
distribution of mosquito bed nets
Nets, insecticide
Scabies Topical treatment with benzyl benzoate
Vitamin A deficiency Supplementation with capsules
Soil-transmitted helminth
infections
Drugs: albendazole, medendazole, levamisole or
pyrantel
Schistosomiasis Drug: praziquantel
Malaria drug treatment Effective first-line treatment of malaria
(chloroquine in sensitive areas, sulfadoxine -
pyrimethamine or amodiaquine)
Iodine deficiency Supplementation with iodized oil
Iron deficiency Supplementation with ron/foliate tablets
Lymphatic filariasis mass chemotherapy: albendazole with either Di
Ethyl Carbamazine or ivermectin
Guinea worm Eradication through case-containment, health
education, improvement of drinking water
quality
Vector-borne diseases malaria,
schistosomiasis, filariasis,
dengue/dengue haemorrhagic fever,
leishmaniasis, Chagas disease
Disease
Vector control through environmental
management
Onchocerciasis Drug: mectizan (ivermectin).
Childhood illness ORT, growth monitoring, care of the sick child
Infant malnutrition Promotion of breastfeeding and proper weaning
practices

* Source: Sustainable outreach services. WHO/V&B/00.37, pps 27-55. This list is not
exhaustive.


3.3. Policy decisions on interventions

When additional interventions are added to immunization services, there are a number of
key policy issues related to the added interventions that required careful consideration.
These include:

Which target group?
At which level of intervention e.g. one intervention such as ITN per child or one
intervention such as ITN per family.

14
Will the additional intervention be delivered free, subsidized or at the market
value? In most countries in the African Region, immunization delivered through
the public health system is free. Each infant, child and pregnant woman is
expected to receive the full number of doses according to established schedules
without payment.
Will the product be delivered at the time the infant, child, mother or pregnant
woman receives the immunization or will the beneficiary receive a voucher that
can be used to redeem the actual intervention at a later time?
Timing e.g. at which routine contact should additional interventions be delivered?
For example should ITNs be delivered at the DPT-3 contact or at the measles
contact when the infant completes the primary vaccination schedule?

3.4. Operational Considerations

Adequate operational planning is absolutely crucial to the successful delivery of child
survival interventions, either singly or as an integrated package. In response to recent
experiences, the following are very important in planning the delivery of integrated child
survival activities through either routine or enhanced routine services and/or campaigns.
There should be:

Consensus among all the main stakeholders
Effective coordination
Timely planning with full involvement and participation of all key stakeholders
and partners.
Effective tracking and targeting
Appropriate forecasting and procurement
The development and dissemination of pilot-tested social mobilization messages.
Joint refresher training
Joint supportive supervision


15
4. Implementation Process

It is at the district level where the operational aspects of implementation of integrated
child survival interventions must take place, whether the elements are to be delivered
using routine services, enhanced routine services or during campaigns.

4.1. Critical Elements in implementation

Community participation in micro-planning: Implementation begins with the
development of a micro-plan. The micro-plan should be developed bottom-up from the
community level. As part of the micro-plan, a map showing locations of houses and
villages together with transportation routes and health facilities greatly helps in both
planning and supervising activities. The micro-plan must also document the requirements
for ensuring that the interventions are delivered effectively to the target group in a
consumable form e.g. the appropriate personnel, cold chain and transport.

To ensure that all local variables are taken into account, as well as ensuring full
ownership of micro-plans, all stakeholders should be involved in the micro-plan
preparation. The stake-holders should include community members, local health workers,
supervisors and managers.

Personnel: All personnel involved in supporting integration should be adequately trained
before the start of the activities. The profile of the personnel involved in the delivery of
an integrated package of interventions will be determined by the type of interventions.
Injectable interventions and medications have to be delivered by trained health workers.
Interventions such as Oral Polio Vaccine (OPV) can be delivered by trained volunteers.
In several situations, additional selection criteria for the personnel involved in service
delivery may be required to ensure that services are accepted by the target communities
and caretakers.

Communication. Communicators capable of stimulating community demand for the
interventions are also key components in the implementation process. Such
communicators have often been community leaders, volunteers from Red Cross societies,
NGO workers or volunteers, not only health staff. The same persons should also be
involved in micro-planning and developing social mobilization plans whenever possible.
Because a significant proportion of integrated activities involve health staff delivering
health education messages to clients, appropriate training of staff in this activity is needed
as well as the preparation of clear messages.

Supervision: Supportive supervision is a critical component of ensuing high quality
implementation. Structured supervision with formal supervisory tools and feedback to
service providers at all levels is critical. However, such supervision can be challenging
because it requires the supervisor to be familiar with all aspects of the integrated
programmes. The requirements on supervisors should not be too complex, and lengthy
checklists should be avoided. But tools and checklists should not be so general that they
collect data with insifficient specificity. For integration using routine and enhanced

16
routine vehicles, regular (bi-monthly) meetings of key stake-holders offer additional
opportunities for experience-sharing, capacity-building and provision of feedback.

Materials and supplies: Ensuring that all supplies are available in the required quantities
at the locations required on time is a crucial aspect of implementation of integrated child
survival interventions. Materials and supplies required will be determined by several
factors including which interventions are to be delivered, the size of the target population,
the selected strategies for delivery of the interventions and the available resources.
Accurate forecasting of all required materials, an inventory of what is available, and
activities to overcome any shortfalls should be undertaken.

4.2. Coordination and organizational support

Coordination and organizational support is critical for effective implementation of
integrated activities. District health teams should have coordination mechanisms e.g.
inter-agency coordination committees or inter-sectoral coordination committee with
representation of all collaborating programmes. The coordinating committee should be
responsible for:
Reviewing the programme work-plan that identifies all key activities and time-
lines
Putting in place mechanisms for accountability for implementation of planned
activities
Ensuring availability of the necessary human, financial and material resources
Clear delineation of roles and responsibilities of the various players/stake-holders




17
5. Monitoring and Evaluation

Monitoring and evaluation of integrated child survival interventions are critical to
provide reliable information on the progress towards the achievement of programme
targets and objectives. A framework for such monitoring and evaluation has been
developed
20
. Only the major highlights of this framework are described below.
Monitoring and evaluation of integrated programmes and activities raises some difficult
issues. There may be separate data collection systems in place that will have to be
integrated. Immunization services tend to corroborate routine data with coverage surveys
done at 2-5 year intervals. But such coverage surveys only measure coverage for 12-23
month-olds, an age group that may not correspond with other interventions. For this
reason it is important that routine reporting systems be as strong as possible.

5.1. Monitoring

Monitoring is the routine tracking of key elements of programme performance through
record keeping, regular reporting, surveillance activities and periodic surveys. Key
information must be collected on a selected number of monitoring indicators (see annex
7.3).

Monitoring tools include standardized reports submitted at an agreed frequency (e.g.
monthly), standardized surveillance reports and tally sheets. Regular (bi-monthly)
monitoring meetings are also important monitoring tools.

A regular review of monitoring indicators helps to identify the progress rapidly as well as
detect problems or lack of progress. Monitoring data should trigger the appropriate
action.

5.2. Evaluation

Evaluation is the periodic assessment of the change in outcomes or impact indicators that
can be attributed to a given intervention. Evaluation aims to link particular health
outcomes and/or impact to particular programme activities.

Outcome indicators include changes in
overall health sector performance
coverage
access to services
use and quality of service

Impact indicators include changes in:
health (e.g. morbidity, mortality)
socio-economic well being.

20
WHO/AFRO. Feb 2006 (Draft). Framework for monitoring and evaluation of integrated child survival interventions.

18
6. Roles and Responsibilities

The proposed roles and responsibilities of the different tiers of government as well as
other key stake-holders, in the planning, implementation, monitoring and evaluation of
integrated child survival activities are summarized below:

6.1. National Level

Providing political leadership and commitment
Adaptation of regional strategies
Developing national policies, plans and strategies
Undertaking advocacy and programme communication
Securing resources and infrastructure
Providing umbrella coordination
Ensuring clear designation of roles and responsibilities of all collaborating
programmes and stake-holders
Promoting participatory joint macro-planning
Ensuring joint supervision by all collaborating programmes
Preparing guidelines for integrated training
Standardizing tools and guidelines
Documenting and disseminating best practices

6.2. Sub-national level (Province and District)

Micro-planning
Training
Implementation
Field supervision and monitoring
Surveillance and response
Logistics management

6.3. In association with partners

Building consensus among partners
Developing strong coordination among partners
Providing financial and technical support
Documenting and disseminating best practices








19
Annexes

Annex 7.1. Number of child deaths and under 5 mortality ranked by African
country with the highest childhood mortality in 2000
21


Country Child Deaths in 2000 Under 5 yrs mortality (per
1,000 births
Nigeria 834,000 187
DR Congo 484,000 205
Ethiopia 472,000 174
Tanzania 223,000 165
Angola 169,000 260
Niger 156,000 270
Mozambique 155,000 200
Uganda 145,000 127
Mali 128,000 233
Kenya 125,000 120
Sudan 116,000
Burkina Faso 104,000 198
Cote DIvoire 97,000 173
Malawi 96,000 188
Madagascar 93,000 139
Zambia 88,000 202
Cameroon 83,000 154
South Africa 77,000
Chad 73,000 200
Sierra Leone 69,000 316
Ghana 65,000
Guinea 62,000 175
Rwanda 54,000 187

















21
(Adapted by permission from Black RE, Morris SS, Bryce J. Where and why are 10 million children
dying every year? Lancet 2003; 361: 2226-34).

20
Annex 7.2. Interventions against common communicable disease causes of childhood
mortality in Africa
22


Intervention Communicable
Disease Level 1
23
Level 2
24
Level 3
25

Preventive Intervention
Breastfeeding
Complementary Feeding
Zinc
Vitamin A
Therapeutic Interventions
Diarrhoea
ORT
Preventive Interventions
Breastfeeding
Hib Vaccine
Zinc
Therapeutic Interventions
Pneumonia
Antibiotics for pneumonia
Preventive Interventions
Complementary feeding Vitamin A
Measles vaccine
Therapeutic Interventions
Measles
Vitamin A
Preventive Interventions
ITNs
Complementary feeding
Therapeutic Interventions
Malaria
Anti-malarials
Preventive Interventions
Nevirapine
HIV/AIDS
Replacement feeding
Preventive Interventions
Tetanus Toxoid
Neonatal Tetanus
Clean Delivery
Preventive Intervention
Breast feeding Antibiotics for PROM
Clean Delivery
Therapeutic Interventions
Neonatal Sepsis
Antibiotics for sepsis



22
Adapted by permission from Jones G, Steketee RW, Black RE, Bhutta ZA, Moriss SS and the Bellagio Child
Survival Study Group. How many deaths can we prevent this year? Lancet 2003; 362: 65-71.

23
Level 1: Sufficient evidence of effect: the Working Group believed that a casual relationship had been established
between the intervention and reductions in cause-specific mortality among children younger than 5 years in developing
countries
24
Level 2: Limited evidence of effect: the Working Group believed that an effect was possible, but available data was
not sufficient to establish a causal relationship because (a) there was conflicting evidence from several studies (b) low-
income countries were not adequately represented in the studies and/or (c) there were too few studies to generalize
globally
25
Level 3: Inadequate evidence of effect: the available data could not be interpreted as showing either presence or
absence of an effect on under 5 mortality because of major qualitative or quantitative limitations.

21

Annex 7.3: Child surveillance monitoring and evaluation indicators
26


Data Collection Method Indicator
Routine Survey
IMPACT
General
< 5 yr all-cause mortality rate Survey
Neonatal mortality rate Survey
Malaria
< 5 yr in-patient malaria cases and deaths IDSR Monthly Form
< 5 yr in-patient malaria with severe anemia (<5g)
cases and deaths
IDSR monthly Form
Low birth weight Maternity Data
% children with anemia Survey
IMCI
< 5yr in-patient diarrhoea cases and deaths IDSR monthly Form
< 5yr in-patient pneumonia cases and deaths IDSR monthly Form
< 5yr out-patient diarrhoea with some dehydration IDSR monthly Form
< 5yr out-patient diarrhoea with severe dehydration IDSR monthly Form
< 5yr out-patient with severe pneumonia IDSR monthly Form
EPI
Reported measles cases and deaths Surveillance

OUTCOMES
Malaria
% households with a net Survey
% appropriate malaria treatment Integrated Tally Sheet Survey
% ITN use among < 5 yr Integrated Tally Sheet Survey
% ITN use among pregnant women Integrated Tally Sheet Survey
% IPT at least 2 doses in pregnant women Integrated Tally Sheet Survey
IMCI
% appropriate treatment for pneumonia Integrated Tally Sheet Survey
% appropriate treatment for diarrhoea Integrated Tally Sheet Survey
% appropriate treatment for malaria Integrated Tally Sheet Survey
% exclusive breast feeding until 6 months Integrated Tally Sheet Survey
% Vitamin A supplementation Integrated Tally Sheet Survey
% neonate with timely initiation of breast feeding Labour HMIS Survey
EPI
% measles coverage Integrated Tally Sheet Survey
% DPT3 coverage Integrated Tally Sheet Survey
% TT2+ coverage Integrated Tally Sheet Survey


26
WHO/AFRO (Feb 2006 Draft). Framework for monitoring and evaluation of integrated child survival
interventions

22
Annex 7.3 (continued): Child surveillance monitoring and evaluation indicators
27


Data Collection Method Indicator
Routine Survey
OUTPUTS
General
% Health facility receiving supervisory visit in
last 6 months
District Report Survey
Malaria
ITN distributed by service Integrated Tally Sheet
Nets retreated Integrated Tally Sheet
No of vouchers distributed Integrated Tally Sheet
No of vouchers redeemed Integrated Tally Sheet Survey
IMCI
% Health facilities with stock out of 1
st
and 2
nd

line drugs
Integrated Tally Sheet
% Health workers trained in IMCI District Report
% Health workers trained in infant and young
child feeding
District Report
No of community health workers appropriately
trained in home management of malaria,
pneumonia and diarrhoea
District Report
% community health worker with supervisory
visit at least once a month
District Report
EPI
% Drop out (BCG-Measles, DPT1-3) Integrated Tally Sheet
% Districts with vaccine stock out Integrated Tally Sheet
% wastage rate Integrated Tally Sheet
PROCESS
Data Management
% District reports received timely IDSR
%District IDSR monthly reports reported timely IDSR
District Management
% Districts with integrated (EPI, MAL, IMCI)
micro-plans
Supervisory Reports
Community contact
% health facilities with at least quarterly contact
with community
Supervisory Reports
INPUTS
National Logistics Logistics Monitoring
Nets Logistics Monitoring
Re-treatment tabs or kits Logistics Monitoring
ACTs, SP Logistics Monitoring
1
st
and 2
nd
line IMCI Drugs Logistics Monitoring
Vaccines Logistics Monitoring
Funds Logistics Monitoring




27
WHO/AFRO (Feb 2006 Draft). Framework for Monitoring and Evaluation of Integrated Child Survival
Interventions.



23
Annex 7.4: Programme managers checklists

The checklist is split into critical questions and important questions programme managers
should ask as they move through implementing an integration strategy. Critical questions
are the most vital for programme managers to consider, and important questions should
be asked if time permits but are not considered critical for integration implementation.

EPI Program Managers Critical Checklist for Integrated Services
Unilateral Planning Phase
Compatibility Considerations
1. Second intervention targets same age of children as EPI or else targets the
mothers?
Yes No
2. Second interventions worker skill requirements are at equivalent or lower level
of difficulty to vaccinations?
Yes No
3. Both interventions have similar distribution systems and can be distributed from
the same facility?
Yes No
4. Second intervention is not time-consuming? Yes No
5. Integration only considered where both diseases epidemiologically overlap within
the country?
Yes No
Multilateral Planning Phase
Stakeholder Acceptance Considerations
6. Both programs upper management teams are willing to meet often to plan joint
activities?
Yes No
7. Management incorporates the opinions of community, frontline staff and donors?
Yes No
8. Donors are supportive and willing to let their funds be shared to control both
diseases?
Yes No
9. Politicians are highly supportive of integrated activities?
Yes No
10. Both programme managers are willing to share leadership of integrated activities?
Yes No
11. Staff members are willing to take on added work and are highly supportive of
integration?
Yes No
Cost-Sharing & Other Considerations
12. Does at least one of the two interventions have high coverage rates?
Yes No
13. Will costs of joint activities be equally shared between both programmes?
Yes No
Implementation Phase
Supervision, Training, Community Education and Outreach Considerations
14. Are integrated education materials available and heavily distributed to the
community?
Yes No
15. Are frontline workers given adequate training on the linked intervention?
Yes No
16. Do frontline workers make parents aware of the existence and benefits of the
integrated service?
Yes No
17. Supervisors exist to ensure strong community education, worker training and
coverage?
Yes No
18. Strong integrated outreach exists where communities cannot access health
facilities.
Yes No


24
Annex 7.4 (continued): Programme managers checklists

The checklist below includes other important questions programme managers should
consider during the process of integration involving integration services.


Other Important Considerations when Implementing an Integration Strategy

Unilateral Planning Phase
Compatibility Considerations
19. Second intervention is not time sensitive?
Yes No
20. Second intervention is well-funded, on the same scale as EPI?
Yes No
Multilateral Planning Phase
Stakeholder Acceptance Considerations
21. Are funds available as incentives for frontline workers to do extra work?
Yes No
22. Are frontline workers already involved in the second intervention?
Yes No
Cost-Sharing & Other Considerations
23. Do competing treatment methods exist for control of the second disease?
Yes No
24. Does at least one of the two interventions have high coverage rates?
Yes No
25. Are there other components of each program which are not being
integrated
Yes No
26. If there are other non-integrated components, are they still receiving
adequate resources?
Yes No
Implementation Phase
Supervision, Training, Community Education and Outreach Considerations
27. Does community education stress how integration will save client time and
provide multiple services during the same visit?
Yes No
28. Does worker training stress the diverse workload and new opportunities to
learn?
Yes No
29. Have frontline workers been evaluated to ensure they know how to co-
distribute both interventions?
Yes No
30. Frontline workers spent adequate time with parents explain and deliver
both interventions well?
Yes No
31. Workers record administration of both treatments on same record sheet?
Yes No
32. Workers accurately recording necessary data for both interventions?
Yes No