EXPERIENCES IN COMMUNITY IMCI IN SEAR Dr Neena Raina Child and Adolescent Health and Development World Health Organization South East Asia Regional Officer.
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EXPERIENCES IN COMMUNITY IMCI IN SEAR Dr Neena Raina Child and Adolescent Health and Development World Health Organization South East Asia Regional Officer IMCI - EVERYWHERE!! IMCI District IMCI Health Facility IMCI Basic Health Workers IMCI Community Health Volunteers IMCI Family/Community Are we reaching the unreached through IMCI? IMCI Bangladesh Example Upzila Health complex: 200,000-450,000 Doctor, nurse FWV Doctor± MA Union Health & FW : 21,000 Centre FWV, HA 11-day 11-day Community clinics: 5000-7000 6 days FWA : 3000-4000 TBA,Female union Family Parishad Member, ± local initiative prog. Volunteers. ± BRAC volunteers [208,000] : 500-1000 5 days ? 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 DIFFERENCES BETWEEN F – IMCI AND C - IMCI F – IMCI Government/Organized Sector Remuneration/ Salary Number manageable Pre-service training Job description defined C - IMCI Training based on job description 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) Disease focus, Limited Health Promotion Focus on health promotion. Simple treatment of common illness. In-service training – 11 day 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 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 Status of BHWs trained BHW India Nepal Myanmar (IMMCI) Bangladesh (Demo course) TOT 512 70 291 12916 51 758 -- 24 Regional Follow-up after training guidelines developed. Adaptation done in India Supervisory checklist - Myanmar 100 90 90 80 Weak in counting RR 70 60 70 70 64 67 50 40 checking chest indrawing Vit A deficiency, and 30 checking BCG scar. 20 10 0 Recognition of illness B.F. advice Correct treatment Home care Feeding counselling 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. 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 Education • Early Care and Stimulation for Younger Children Under Three Years. • Early Joyful Learning Opportunities to Children in the Three to Six Years Age Group. Convergence Of other Supportive Services, Such as Safe Drinking Water, Environmental Sanitation, Women’s Empowerment Programmes, Nonformal Education and Adult Literacy. Integrated Child Development Scheme (ICDS) in India Opportunities for community based IMCI No. of Blocks No. of AWW Children (0 - 6 years) Sanctioned Functioning Gap 5652 4545 19.6% 608,066 546,434 11.2% : Expectant and Nursing mothers : 35.39 million 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 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 I/NGOs Partners SCF/US CARE PLAN I/NGOs NEPAS ADRA NTAG JICA 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 TREATMENT CHWs DIAGNOSE AND TREAT “PNEUMONIA” USING ONLYCOTRIMOXAZOLE REFER “SEVERE PNEUMONIA AND VERY SEVERE DISEASE” REFERRAL CHWs DIAGNOSE AND REFER ALL PNEUMONIA CASES HOME CARE ADVICE AND FOLLOWUP COMMUNITY- LEVEL TRAINING ACTIVITIES (1994/95 - 2001/2002) Traditional Healers-2,164 Health Facility Staff-2,057 FCHVs-8,871 VHW/MCHWs1,155 VHW= Village Health Workers MCHW = Maternal and Child Health Workers FCHV = Female Community Health Volunteer PERCENTAGE OF EXPECTED PNEUMONIA CASES TREATED 100 80 % of Expected Pneumonia Cases Treated by CHW % of Expected Pneumonia Cases Treated by HF 60 60 40 23 20 0 Non-Intervention Districts Intervention Districts QUALITY OF CASES MANAGEMENT 100 92 98 92 80 60 40 20 0 % Cases Marking 3rd Day Followup (Treated/Referred) % Cases Marking Consistent Age and Dose % Cases Marking Consistent Age/Dose and 3rd Day Followup Photo: Penny Dawson COMMUNITY-LEVEL ORIENTATION ACTIVITIES (1994/95 - 2001/2002) DLL/LEL10,381 DLL= District Level Leader LEL = Local Elected Leader Mothers Group133,737 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 Water and Sanitation Workers Health Volunteers Private Practitioners Traditional Birth Attendants Agricultural Workers Basic Health Worker Women’s Groups Youth Groups Social Welfare Opinion Leaders Teachers Mother’s Groups 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.