EXPERIENCES IN COMMUNITY IMCI IN SEAR

Dr Neena RainaChild and Adolescent Health and Development

World Health OrganizationSouth East Asia Regional Officer

IMCI - EVERYWHERE!!

IMCI

IMCI

IMCI

IMCI

District

Health Facility

Basic Health Workers

Community Health Volunteers

Family/CommunityIMCI

Are we reaching the unreached through IMCI?

Bangladesh Example

Upzila Health complex: 200,000-450,000

Doctor, nurse

FWV

Doctor± MA Union Health & FW : 21,000

Centre

FWV, HA Community clinics: 5000-7000

FWA : 3000-4000

TBA,Female union Family : 500-1000

Parishad Member,

± local initiative prog.

Volunteers.

± BRAC volunteers

[208,000]

Facility based IMCI has limited outreach for sick children

Improving access to

IMCI increases use

rate Army of volunteers

available. Need to train in specific tasks to promote child health and development

CBV will improve

care seeking

behaviour

IMCI

11-day

11-day

6 days

5 days

?

DIFFERENCES BETWEEN F – IMCI AND C - IMCI

F – IMCI C - IMCIGovernment/Organized Sector

Remuneration/ Salary

Number manageable

Pre-service training

Job description defined

In-service training – 11 day

Training based on job description

Disease focus, Limited Health Promotion

Community/ Families

Recognition/ Rewards

Number large.

Limited or No Pre-service Training

Job expectations varied, determined by community

5 day training

Ongoing training needed

Profile based (one size will not fit all)

Focus on health promotion. Simple treatment of common illness.

THE NEED FOR TRAINING BHWs

The workers have knowledge about diseases and child health but this is superficial.

In communication skills, familiarity with the message is present but problem analysis and solution skills are poor.

They know many facts but are often confused.

Only a few priority problems should be short-listed and addressed.

Focus on quality

not only on quantity

SEAR is first region to develop CHW training package.

CHW 5-day training package developed in joint partnership with CARE and GOI.

Field tested in 6 states of India. Training package refined after each course. Experience shared during dissemination meeting with other Member Countries.

Demonstration model course and orientation in Bangladesh,Nepal,India and Indonesia and adaptation done

Malaria and young infant added for BHW

Training of Basic Health Workers (CHWs)

Status of BHWs trained

70

90

7064 67

0

10

20

30

40

50

60

70

80

90

100

Recognition ofillness

B.F. advice Correct treatment Home care Feedingcounselling

BHW TOT

India 512 70

Nepal 291 51

Myanmar 12916 758 (IMMCI) Bangladesh -- 24 (Demo course)

Regional Follow-up after training guidelines developed. Adaptation done in India

Supervisory checklist - Myanmar

Weak in counting RR

checking chest indrawing

Vit A deficiency, and

checking BCG scar.

Anganwadi is the Focal Point for Delivery of ICDS Services.

Located in a Village/Slum.

Anganwadi is run by an AWW, supported by a Helper.

AWW is the 1st Point of Contact for Families Experiencing

Nutrition and Health Problems.

Anganwadi

Health Nutrition

• Immunization Supplementary Feeding

• Health Check-ups Growth Monitoring & Promotion

• Referral Services Nutrition and Health Education (NHED)

• Treatment of Minor Illnesses

Early Childhood Care & Preschool ConvergenceEducation

Of other Supportive Services, Such as Safe

• Early Care and Stimulation for Younger Drinking Water, Environmental Sanitation,

Children Under Three Years. Women’s Empowerment Programmes, Non- formal Education and Adult Literacy.

• Early Joyful Learning Opportunities to Children in the Three to Six Years Age Group.

ICDS Packages of Services

Integrated Child Development Scheme (ICDS) in India

Opportunities for community based IMCI

Sanctioned Functioning Gap

No. of Blocks 5652 4545 19.6%

No. of AWW 608,066 546,434 11.2%

Children (0 - 6 years) : 35.39 million

Expectant and Nursing mothers : 6.38 million

The Project

The Pilot Project on IMCI is an action research project.

Pilot Project is being implemented in 3 States - Haryana,

Rajasthan & Uttar Pradesh

Action Plan of the project includes

Training of Trainers and AWWs

Implementation of IMCI Strategy

Follow-up-After Training

Impact Assessment

Adaptation of IMCI Strategy in ICDS Program

Introduce IMCI Strategy in the Job Training Curriculum of

ICDS Functionaries.

CB-IMCI - 1999/2000

Community LevelProgram Experiences

Improve pneumonia/diarrheacase management and

nutrition and EPI counselingup to community level

IMCI

Integrated Management of 5 major childhood killers

(pneumonia, diarrhea, measles, malaria,

malnutrition) in HF

CB-IMCI

I/NGOs Partners

I/NGOs

CARE

SCF/US

PLAN

NEPAS ADRA

JICANTAG

WHO ARE FCHVs

Local Married Women Selected by the Community (by mothers’ group) willing to serve voluntarily in health related

activities for and in the community

INTERVENTION MODELS

HOME CARE ADVICEAND FOLLOWUP

TREATMENT

CHWs DIAGNOSE ANDTREAT “PNEUMONIA” USING

ONLYCOTRIMOXAZOLE

REFER “SEVERE PNEUMONIA AND

VERY SEVERE DISEASE”

REFERRAL

CHWs DIAGNOSE ANDREFER ALL PNEUMONIA

CASES

COMMUNITY- LEVEL TRAINING ACTIVITIES (1994/95 -

2001/2002)

FCHVs-8,871

Health Facility Staff-2,057

VHW/MCHWs-1,155

Traditional Healers-2,164

VHW= Village Health WorkersMCHW = Maternal and Child Health WorkersFCHV = Female Community Health Volunteer

PERCENTAGE OF EXPECTED PNEUMONIA CASES TREATED

0

20

40

60

80

100

Non-Intervention Districts Intervention Districts

% of Expected Pneumonia Cases Treated by CHW

% of Expected Pneumonia Cases Treated by HF

23

60

QUALITY OF CASES MANAGEMENT

929298

0

20

40

60

80

100

% Cases Marking 3rdDay Followup

(Treated/Referred)

% Cases MarkingConsistent Age and

Dose

% Cases MarkingConsistent Age/Dose

and 3rd Day Followup

Photo: Penny Dawson

COMMUNITY-LEVEL ORIENTATION ACTIVITIES (1994/95 - 2001/2002)

Mothers Group-133,737

DLL/LEL-10,381

DLL= District Level LeaderLEL = Local Elected Leader

ACHIEVEMENTS 420,000 pneumonia cases treated in program districts

Over 17,000 deaths averted*

Over Rs. 167 million saved **

The Community-Based IMCI now reaches 35% of the population under 5 years of age.

* Meta-analysis of intervention trials on case-management of pneumonia in community settings, Black R. and Sazawal S. assumes 20% mortality reduction for < 1 year olds and 25% mortality reduction for 1-4 years of age

** According to A Study Conducted by JSI Caregiver spend Rs. 397/Pneumonia Case

BUILDING PARTNERSHIPS AT THE COMMUNITY LEVEL

Basic Health Worker

Water and SanitationWorkers Health Volunteers

AgriculturalWorkers

Youth Groups

Opinion Leaders

Mother’s Groups

Teachers

Social Welfare

Women’s Groups

Traditional BirthAttendants

PrivatePractitioners

CHALLENGES AHEAD

Keeping the issue alive and active.

Profile based – need based response (Tailor made)

Link with Health System. Builds credibility.

Partnerships – Public-private mix.

Converting knowledge into action (the right mix of Science and Art).

Decentralization and capacity development.

Resources. Issues of monetary incentives?

Tapping the vast potential

LOCAL PARTNERSHIPS FOR

SUCCESS OF IMCI Independently workers or volunteers / traditional providers not

effective even after training. Utilization rates are poor. Volunteers / traditional providers may have technical

limitations. Together they can be very successful. FCHV referral of sick child successful when traditional healers

(Dhamis, Jhakris) convince the family to use referral facility. Trained Midwife is acceptable in providing skilled birth

attendance when she teams up with Traditional Birth Attendant. Health volunteer and village practitioners can team

up in providing curative care. AWW and RMP can team up to promote exclusive

breastfeeding and complementary feeding practices.

COMPLIMENTARITY OF F-IMCI and C - IMCI

F – IMCI falls short in access of IMCI to families. BHWs and CHVs link F – IMCI to families.

F – IMCI provides integrated management of selected diseases in children but requires a lot of support from C – IMCI to promote health.

C – IMCI can succeed only if well supported by F – IMCI through training, ongoing supplies, logistic support and management.

C – IMCI is important for success of F – IMCI through increased demand for appropriate and timely care, improved compliance and participation in immunization and other preventive programmes.

C – IMCI can complement F – IMCI by volunteers providing selected IMCI components on health care in areas where F – IMCI falls short because of missing health workers.

INCREMENTAL BUILD UP OF C - IMCI

Develop capacity of local communities through guided education so that they can plan, support and monitor C – IMCI.

Plan an incremental, block by block development of capacity through on going training.

There cannot be a universal recipe for all CHVs because of their varied background and differing potential and contributions. Each one can provide a piece and for that must be skilled.

Logistics and supplies to be ensured with community assuming responsibility at least partly in covering the costs.

C – IMCI TO BE SUCCESSFUL MUST BE THE RIGHT MIX OF ART AND SCIENCE OF

KNOWLEDGE Knowledge which is evidence based and acceptable must be

converted to action.

Existence of knowledge is of no use unless it is accepted and adopted.

Creativity is required in C – IMCI to provide knowledge and promote its widespread use at the community and family level.

All knowledge is not evidence based but practices have existed for centuries and longer. If they have not caused harm these need not be discontinued This is the art part of C – IMCI.

The programme should find the right mix.