Reducing child mortality with improved IMNCI uptake via IeDA and e-IMNCI scaleup in India

Annually, 5 million children under five (U5) die from preventable and treatable causes (2020). To address this, WHO and UNICEF developed Integrated Management of Childhood Illness (IMCI) in 1995 as an integrated approach to increase coverage of evidence-based, high-impact interventions to reduce under five mortality rate (U5MR), prevent illness and disability, and promote development and growth of children U5. A Cochrane review found that IMCI has been associated with a 15% reduction in child mortality (Gera 2016),1 and other research has shown positive effects on healthcare worker (HCW) practices and quality of care.2 There is near universal adoption of the IMCI strategy by target countries; however, countries continue to have challenges in adherence to and scaling up IMCI, which limits the potential impact on U5 morbidity and mortality. Evidence has indicated that electronic technology using digital job aid for IMCI (IeDA) considerably improves adherence, including the completeness and consistency of clinical assessments.3 

Despite a reduction in U5MR over the past decade, India ranks number 2 in total number of U5 deaths globally. With a neonatal and U5 mortality rate at 20.3 neonatal deaths and 32.6 U5 deaths per 1,000 live births (2020). More specifically, in Jharkhand, neonatal and U5MR stand at 28.2 and 45.5 per 1,000 live births, respectively, which soars above the national average. Integrated Management of Neonatal and Childhood Illness (IMNCI) was launched in India in 2005 under the National Rural Health Mission (now National Health Mission) and is considered a critical strategy for improving child health and reducing mortality. However, implementation of IMNCI in India lacks quality. A recent survey in Jharkhand showed that the last IMNCI review happened in 2017, and it revealed low adherence to IMNCI protocol among frontline HCWs. The findings suggest that currently there is no proven methodology that ensures consistent and correct use of IMNCI protocol at the primary care level. India and similar LMICs will need to develop a methodology that supports consistent and correct implementation of IMNCI at scale. 

IeDA is a first of its kind, android-based mobile application with multi-pronged solutions to support IMCI adherence improvement. It includes a digital job aid component, that guides frontline HCWs through the IMCI algorithm by running clinical assessments of a child, then aids in classification, prescription, referral, and counselling. With the help of IeDA, HCWs can accurately identify danger signs and symptoms, make correct diagnoses, and prescribe right treatments. In addition to e-consultations, there is an accompanying coaching application to support during consultation, and tasking functionality features to generate prioritized lists of tasks for HCWs. Additionally, Tdh has enriched IeDA with point of care tests, use of medical instruments to better identify severe symptoms, interactive web maps and dashboards, early warning systems for disease outbreaks, artificial intelligence analyses and perinatal health digitalization. IeDA reduces classification and prescription errors, improves accuracy of diagnoses and treatment, increases quality of data, measures individual performance, detects dysfunctional health facilities, identifies training needs, and provides customized training and follow up of users.  

IeDA is proven to reduce time required for IMCI and eliminate the need for paper-based reports. It helps in customizing supportive supervision, management of stocks, and supports policy and programmatic decision making by simplifying complex data analysis through data visualization. A London School of Hygiene and Tropical Medicines evaluation of IeDA showed significant improvements in quality of care, a 50% improvement of primary HCWs’ adherence to IMCI clinical guidelines, and an operational cost reduction after initial investments. A pilot rollout of IeDA in India was initiated in Ranchi District of Jharkhand State in 2020. A total of 6,059 children up to July 2023 were classified with danger signs where no mortality was reported due to timely detection and counselling of caregivers. Based on the pilot success, the State Government’s proposal was approved by Government of India to scale up IeDA and cover the entire state. IMNCI trainings have been included in the State Program Implementation Plan, with trainings of Master Trainers and mobile tablets for HCWs to be partially covered under the state budget. Both the State and Central Government have committed to invest in IeDA programmatically and financially and would strategically monitor the progress as Jharkhand is the first state to implement a digital strategy for U5 at scale in India. 

There currently are no other digital health solutions in India to support the government in implementing IMNCI at quality. IeDA is a first of its kind, android-based mobile application with multi-pronged solutions to support IMCI adherence improvement. It includes a digital job aid component, that guides frontline HCWs through the IMCI algorithm that runs clinical assessments of a child, then aids in classification, prescription, referral, and counselling. With the help of IeDA, HCWs can accurately identify danger signs and symptoms, make correct diagnoses, and prescribe right treatments. In addition to e-consultations, there is an accompanying coaching application to support continuous quality improvement during consultation, and tasking functionality features to generate prioritized lists of tasks for HCWs. Additionally, Tdh has enriched IeDA with point of care tests, use of medical instruments to better identify severe symptoms, interactive web maps and dashboards, early warning systems for disease outbreaks, artificial intelligence analyses and perinatal health digitalization.

IeDA is proven to reduce time required for IMCI and eliminate the need for paper-based reports. It helps in customizing supportive supervision, management of stocks, and supports policy and programmatic decision making by simplifying complex data analysis through data visualization. A London School of Hygiene and Tropical Medicine (LSHTM) evaluation of IeDA showed significant improvements in quality of care, a 50% improvement of primary HCWs’ adherence to IMCI clinical guidelines, and an operational cost reduction after initial investments.

Based on the success of IeDA in Jharkhand since 2020, IMNCI trainings have been included in the State Program Implementation Plan (PIP), with trainings of Master Trainers and mobile tablets for HCWs to be partially covered under the state budget. Both the State and Central Government have committed to invest in IeDA programmatically and financially and would strategically monitor the progress as Jharkhand it is the first state to implement a digital strategy for U5 at scale in India.