EXPERIENCES IN COMMUNITY IMCI IN SEAR

1. EXPERIENCES IN COMMUNITY IMCI IN SEAR Dr Neena RainaChild and Adolescent Health and DevelopmentWorld Health OrganizationSouth East Asia Regional Officer

2. IMCI - EVERYWHERE!! IMCI District Health Facility IMCI Basic Health Workers IMCI Community Health Volunteers IMCI IMCI Family/Community

3. 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 Are we reaching the unreached through IMCI? IMCI 11-day 11-day 6 days 5 days ?

4. DIFFERENCES BETWEEN F – IMCI AND C - IMCI

5. 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

6. Training of Basic Health Workers (CHWs) • 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

7. Status of BHWs trained • BHWTOT • 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.

8. Anganwadi • 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.

9. IMCI ICDS Packages of Services • 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 Convergence • Education • 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.

10. Integrated Child Development Scheme (ICDS) in IndiaOpportunities for community based IMCI

11. IMCI 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.

12. CB-IMCI - 1999/2000 Community Level Program Experiences Improve pneumonia/diarrhea case management and nutrition and EPI counseling up to community level IMCI Integrated Management of 5 major childhood killers (pneumonia, diarrhea, measles, malaria, malnutrition) in HF CB-IMCI

13. I/NGOs Partners SCF/US CARE PLAN I/NGOs NEPAS ADRA JICA NTAG

14. 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

15. INTERVENTION MODELS TREATMENT REFERRAL CHWs DIAGNOSE AND TREAT “PNEUMONIA” USING ONLYCOTRIMOXAZOLE CHWs DIAGNOSE AND REFER ALL PNEUMONIA CASES REFER “SEVERE PNEUMONIA AND VERY SEVERE DISEASE” HOME CARE ADVICE AND FOLLOWUP

16. COMMUNITY- LEVEL TRAINING ACTIVITIES (1994/95 - 2001/2002) VHW= Village Health Workers MCHW = Maternal and Child Health Workers FCHV = Female Community Health Volunteer

18. PERCENTAGE OF EXPECTED PNEUMONIA CASES TREATED 60 23

19. QUALITY OF CASES MANAGEMENT

21. Photo: Penny Dawson

22. COMMUNITY-LEVEL ORIENTATION ACTIVITIES (1994/95 - 2001/2002) DLL= District Level Leader LEL = Local Elected Leader

23. 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

24. BUILDING PARTNERSHIPS AT THE COMMUNITY LEVEL Health Volunteers Private Practitioners Water and Sanitation Workers Traditional Birth Attendants Agricultural Workers Basic Health Worker Women’s Groups Youth Groups Social Welfare Opinion Leaders Mother’s Groups Teachers

26. 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

27. Thank You

28. 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.

29. 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.

30. 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.

31. 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.