Final Report of IMNCI Training Courses in Five Selected States and Regions 2016-2018 Taungdwingyi Township, Magway Region Ingapu Township, Ayeyarwaddy Region Minbya Township, Rakhine State Tang Yang Township, Northern Shan State Mongyai Township, Northern Shan State Mong Kai Township, Southern Shan State MCSP Child Health Team July 2018 Acknowledgements MCSP is a global USAID initiative to introduce and support high-impact health interventions in 25 priority countries to help prevent child and maternal deaths. MCSP supports programming in maternal, newborn and child health, immunization, family planning and reproductive health, nutrition, health system strengthening, water/sanitation/hygiene, malaria control, prevention of mother to child transmission of HIV, and Paediatric HIV care and treatment. MCSP will tackle these issues through approaches that also focus on household and community mobilization, gender integration and digital health, among others. In Myanmar, under the leadership and direction of the Child Health Development Division (CHD), MCSP collaborated with the MOHS in updating IMNCI guidelines for Basic Health Staff. The CHD has provided guidance and oversight for all aspects of the training cascade, implementation and post-training supervision. State and Regional Child Health teams closely collaborated with MCSP in the township Multiplier training and post-training supervision to the trained BHS and health facilities. This report is make possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents of this report are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government. July 2018 Cover Photo: A midwife conducting patient examination during a post-training supervision visit, Maternal and Child Health center, Mong Kai township, Southern Shan State Contents Page Contents 1 Abbreviation 3 1. Introduction 5 2. Background 6 3. Activity 7 3.1 Developing Updated IMNCI guidelines (2017) 7 3.2 Launching ceremony of Updated IMNCI guidelines (2017) (2-59 months) 7 3.3 Township selection meetings, June and July 2017 7 3.4 Training 10 3.4.1 Central MToT updated IMNCI training, Nay Pyi Taw 10 3.4.2 Central MToT Follow-up training, Nay Pyi Taw 11 3.4.3 State and Regional ToT training 12 3.4.4 State and Regional ToT for follow-up training 12 3.4.5 Township-level multiplier training 12 3.5 CME session 12 3.6 Learning and Performance Improvement Centers (L&PICs) 13 3.7 Post-training supervision visits 13 4. Implementation activity in 5 selected States and Regions 14 4.1 Magway region 14 4.2 Ayeyarwaddy region 16 4.3 Rakhine state 18 4.4 Northern Shan state 19 4.5 Southern Shan state 23 5. Summary of Training and Post-training supervision visits 25 5.1 Training 25 5.2 Post training supervision visits 29 5.2.1 Assessment on clinical skills management 29 5.2.2 Infrastructure 29 5.2.3 Drug stock management 30 6. Key Recommendations 33 7. References 34 8. Annexes 35 Annex 1. Agenda of Central MToT on updated IMNCI guidelines (2017), Nov 2017 35 Annex 2. Agenda for Central MTOT on Follow-up training of updated IMNCI guidelines (2017), January 2018 39 Annex 3. Agenda for State level Follow-up training of updated IMNCI guidelines (2017), S Shan state 42 1 Annex 4. Agenda for Township level Multiplier training, Mong Kai township, S Shan state, February 2018 46 Annex 5. List of participants in training and supervision visits 50 Annex 6. Number and percentage of trained MOHS trainers in the state, regional and township training teams 52 Annex 7. BHS (LHV and Midwife) existing, trained and supervised 52 Annex 8. Health centers (UHC, MCH, RHC, sub-center) existing, trained and supervised 53 Annex 9. (a, b) Pre- and Post-test scores of participants in trainings 54 Annex 10. Case Scenarios (OSCE) for Pre- and Post-tests in updated IMNCI training 55 Annex 11. Follow-up activity after training – Supervision Tools (English translation) 57 Annex 12. IMNCI Materials placed at L&PICs (5 states/regions) 64 Annex 13.Success stories 66 – Magway Region 67 – S. Shan State 69 – N. Shan State 71 – Rakhine State 73 Tables Table 1. Geographical situation and 2017 health profile data of implementing townships 8 Figures Fig 1. Number of participants who attended ToT from States and Regions 23 Fig 2. Percentage of BHS, trained and supervised in six selected townships 24 Fig 3. Percentage of health centers, trained and supervised (Health centers: UHC, MCH, RHC, sub-center) 24 Fig 4. Pre- and Post-test scores achievement 25 Map 1. Locations of six selected townships in five states and regions implementing IMNCI activity 9 2 Abbreviations ART Antiretroviral Therapy BHS Basic Health Staff CHD Child Health Development Division CME Continuing Medical Education EPI Expanded Programme on Immunization IMCI Integrated Management of Childhood Illness IMNCI Integrated Management of Neonatal and Childhood Illness IMR Infant Mortality Rate L&PIC Learning and Performance Improvement Center LB Live Births LHV Lady Health Visitor MW Midwife NAP National AIDS Program NHP National Health Plan NMCP National Malaria Control Program NMR Neonatal Mortality Rate MCH Maternal and Child Health MCSP Maternal and Child Survival Program MDG Millennium Development Goal MR Mortality Rate MTOT Master Training of Trainers OPD Out-patient Department ORS Oral Rehydration Salt/Solution OSCE Objective Structured Clinical Examination RHC Rural Health Center RUTF Ready-to-Use Therapeutic Food SDG Sustainable Development Goals THN Township Health Nurse TOT Training of Trainers U5 MR Under 5 Mortality Rate 3 UHC Urban Health Center WHO World Health Organization UNICEF United Nations Children's Fund 4 1. Introduction The Integrated Management of Childhood Illness (IMCI) is an integrated approach to child health that intends to reduce death, illness and disabilities and promote proper growth and development among under 5 children through both preventive and curative activities1. WHO and UNICEF developed this approach in 1992 and currently more than 100 countries use the IMCI guideline and approach globally. The IMCI approach is mainly focused on improving case management skills of health care providers, improving family and community health practices, and improving overall health systems2. Since 2007 neonatal health has been added to the IMCI approach, as one of the essential components to address overall mortality and morbidity of under 5 children. IMCI or IMNCI (with neonatal care added to IMCI) guidelines and approaches are mainly intended for child health care in the public health sector, especially in developing countries. The IMNCI strategy was introduced in Myanmar in 1999 and the neonatal component was formally incorporated as IMNCI in 2011. Since then, IMNCI training has been ongoing to achieve nationwide coverage. The IMNCI modules used in Myanmar training were updated in 2017, based on the updated WHO IMNCI guidelines. The IMNCI strategy is intended to give under 5 children a better quality of life by promoting both preventive and curative child care and is implemented by the Basic Health Staff (BHS), in partnership with the families and community. The IMNCI strategy also includes improvement of health infrastructure, such as drugs and commodity management, patient data recording, documentation and reporting systems. In the Myanmar National Demographic Health Survey (2015-16) the under-5 mortality rate was reported as 50/1000 live births (LBs), infant mortality rate was 40/1000 LBs and neonatal mortality rate was 25/1,000 live births3. The Millennium Development Goal No. 4, set by the Ministry of Health, aimed to reduce under-5 mortality to 37 per 1,000 live births and infant mortality to 28 per 1,000 live births by 2015 in Myanmar 4. However, in 2016, both U5MR and infant mortality rate (IMR) in Myanmar were higher than the global rates of 40.8 per 1,000 LBs for U5MR and 30.5 per 1000 LBs, although all three mortality rates (under-5, infant and neonatal) declined in Myanmar from 2011 to 2016. At the end of the MDG years, most countries in the world had not reached the MDG 4 target of reducing under-5 mortality by two-thirds. Following the MDG period, a new global development agenda has been established with new targets, referred to as Sustainable Development Goals (SDG) (2015-2030). The child survival targets in the SDG are intended to further reduce the deaths of children under 5 from preventable diseases. By 2030 in Myanmar, the target is to reduce neonatal mortality to 12 deaths per 1,000 live births and reduce under-5 mortality to 25 deaths per 1,000 live births5. 5 2. Background IMNCI trainings are conducted under the leadership of the Child Health Development Division, Ministry of Health and Sports, in Myanmar, and primarily intended for the Basic Health Staff at the township level of States and Regions. The IMNCI guidelines were updated by the MOHS, with technical support from MCSP, in 2017, to ensure that the latest IMNCI information from WHO was incorporated, to be in line with the global IMNCI strategy. The updated IMNCI guidelines (2017) are designed to be user friendly and easily understandable, promoting easy access to updated knowledge, and effective use by the BHS and the community, as well as family members of the child patient. It is composed of five books: Provider Guide, Facilitator Guide, Exercise Book, Handbill or Chart Booklet, Photo Book, plus a DVD with learning video clips and a Power Point CD. The content of the books covers childhood illness and management of sick children from 2 to 59 months old (5 years). In the IMNCI training, the updated IMNCI guideline books (2-59 months) are used, together with the introduction book and the follow-up after training book, for instruction on correct utilization of forms and formats used in the post-training supervision visits.