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With training materials for first-level health facilities completed, WHO/CHD is now focusing on supplementing this training with tools and materials to support the adaptation of IMCI to specific country needs, to reinforce health worker performance after training, and to ensure that potential barriers to IMCI in first-level facilities are identified and reduced. Development efforts are also targeting the quality of care at referral-level facilities, the potential for conducting IMCI training in preservice as well as inservice settings, and interventions to improve household behaviours related to child health. The following is a brief overview of selected IMCI development projects. More detailed information is available from WHO/CHD.
Guiding the adaptation process for IMCI training in first-level facilities
Before conducting IMCI training, each country must adapt the generic IMCI guidelines and training materials to fit national guidelines and policies, and to cover the most serious childhood illnesses that their first-line health workers must be able to treat. In 1996, CHD produced an IMCI Adaptation Guide for programme staff, advisors and adaptation consultants, which describes the overall adaptation process and the specific steps to be completed by the national team.
Work continues on revision of the guide based on early country experiences and the need for modification of some technical content, and a new edition will be available in December 1997.
Training in management of drug supplies at first- level health facilities
In collaboration with the USAID-funded BASICS project, a new training package - the Drug Supply Management (DSM) course - for workers responsible for managing drug supplies in first-level health facilities has been developed. It was field tested in July 1996 in the Republic of South Africa where fifteen health workers from first-level health facilities were trained. The field test demonstrated that the procedures presented in the training materials were relevant and appropriate for the intended audience. The DSM course teaches the recommended standard procedures for improving the ordering, organizing, receiving, storage, and dispensing of drugs, and also how to instruct caretakers on giving drugs correctly to their children.
The course has two parts: a four-day DSM workshop that teaches health workers the recommended standard procedures, and a one-day field training in which trainers visit health facilities to work with staff on the application of the skills learned during the workshop. The field training ensures that the standard procedures are properly implemented at facilities, and visits are tailored to meet the educational needs of participants and to address the drug supply situation in the facility where they work.
To prepare for the DSM workshop, a five-day Training of Trainers workshop (TOT) is held the week before, to train selected district-level staff in drug supply management procedures and effective training techniques. An additional day is also spent at the close of the workshop to prepare trainers for the field training. Materials have been developed for each aspect of the process, including a Training Director's Guide, a Trainer's Guide, a Manual for First-Level Facilities and a reference Handbook. The DSM package will be finalized and made available for national use in 1997.
DSM training includes topics not covered in the IMCI course but which
are essential for improving care at first-level facilities, and is therefore
an important part of the overall strategy to improve the quality of care
at this level of the health system. The supply of drugs is assessed
during planning for IMCI implementation, and in countries where drug management
in health facilities is identified as a problem, the DSM course may be
offered as part of the support to district health system.
Reinforcing skills learned in initial IMCI training
To support staff trained in the IMCI course in applying the case management approach at first-level health facilities, the training includes a follow-up visit within a month, to reinforce newly acquired skills and assist health workers to use the skills in the clinic.
Generic follow-up materials have been developed and are being revised. CHD is also assisting countries to adapt these materials to national circumstances.
Improving the quality of care in referral-level facilities
Improving case management at first-level outpatient health facilities will contribute significantly to the reduction of child mortality. Further mortality reduction can be achieved by providing effective care for children with severe disease at referral-level facilities such as hospitals. The criteria for referral are clearly defined in the IMCI guidelines for managing childhood illnesses at first-level facilities.
CHD commenced work on guidelines for improving the management of childhood illness in referral facilities in 1994. Materials currently in development include a manual on the Management of the child with a serious infection or severe malnutrition, which will be completed in August 1997, and training materials on severe malnutrition, expected to be available in mid-1998. In addition, studies are underway to determine the validity and feasibility of draft guidelines on triage and emergency care, and to describe the factors that influence child mortality associated with referral-level facilities. Final guidelines and training materials for the purpose of modifying major factors will then be developed. Training approaches to improve management of childhood illness in referral facilities have yet to be defined, but will address both inservice and preservice training.
Planning and programme management guidelines
Guidelines for planning and managing IMCI programme activities are being finalized. These guidelines reflect early country experiences with IMCI implementation, and address monitoring and evaluation issues.
Aimed at national staff responsible for the planning and management of IMCI activities and international consultants who assist them, the guidelines describe a phased process for IMCI implementation in a country. The initial orientation of decision-makers, technical staff and partner agencies in countries is emphasized, prior to selection of a limited geographical area to gain experience with early implementation of IMCI.
Finally, the guidelines will emphasize the need to consider the three main components of the IMCI strategy during implementation:
(1) Improvements in the case management skills of health staff through the provision of locally adapted guidelines for integrated management of childhood illness and activities to promote their use;
(2) Improvements of the health system required for effective management of childhood illness;
(3) Improvements in family and community practices.
A first draft of the guidelines for the planning and management of IMCI
activities will be available in early 1998.
Promoting family behaviours that improve child health and development
As the implementation of IMCI expands, it will be necessary to work with communities , as well as through health facilities, to reach more families. To promote child health, especially for those children who need care but who are not brought to health facilities, CHD has developed a planning guide: Selecting and Designing Interventions to Improve Family Practices.
The guide describes a systematic process that countries can use in choosing effective interventions and implementing them in communities. Designed for use by a planning team with diverse experience in implementing health programmes and research, the guide will help planners to identify current practices as well as the factors that influence those practices, and to develop culturally and socially appropriate intenventions for improving family behaviours.
The planning guide will be tested by the Division in 1997 in a project to improve breastfeeding and complementary feeding practices through community-based interventions.
CHD began, in 1996, to explore the rationale and feasibility of intervention research aimed at improving careseeking for acute illness in infants and young children, starting with a review of the evidence concerning the following questions:
1. What is the nature and extent of problems in careseeking, and what evidence is there that family behaviours with respect to careseeking contribute significantly to infant and young child mortality and morbidity?
2. Is there sufficient knowledge about the determinants of careseeking to allow interventions aimed explicitly at this behaviour to be designed?
3. Is there evidence that careseeking behaviours can be changed?
The findings of this review showed that:
1. Scientific documentation of the extent to which initial delays in careseeking affect mortality is very limited, but there is considerable evidence that family decision-making with respect to the utilization of health care services is often not optimal.
2. In general, the determinants of careseeking have been well described, although there is greater knowledge about household decisions on where to seek care than about initial decisions concerning when to seek help.
3. Interventions aimed specifically at improving careseeking for sick children have not been rigorously evaluated, but changing patterns of health service utilization indicate that these behaviours can be changed.
On the basis of these results, CHD is developing and evaluating culturally-appropriate interventions to improve family careseeking.
Preservice training in IMCI for paramedical staff
A longer term aim is to introduce IMCI into the basic training of health workers. This would have two advantages. First, it would be more sustainable than inservice training and, second, would reach health workers in both the private and public sectors.
Most first-level facilities in developing countries are staffed by health
workers who are not physicians, and the Division is exploring approaches
to preservice training of these cadres of workers in IMCI. Plans
have been developed with the Tanzanian Ministry of Health to assess the
potential for using existing IMCI training materials in preservice training
as a three week block of training near the end of the course.
The first teaching of the IMCI block in a school for Assistant Medical
officers and a school for Clinical Officers is planned for November 1997.
The teaching process and its effect will be closely monitored using protocols
similar to those used in the field test of the IMCI course for inservice
training of health workers in first-level facilities. Discussions
are also being held with the Ministry of Health of Ethiopia to plan a similar
test in the Health Officer School in Gondar.