Summary of Main Findings on IMCI Implementation in Peru, 1996-2001
Training of health workers in IMCI increased up to 1999 but decreased in 2000 and 2001 (Figure 1). So far, about 10% of doctors and nurses employed by the Ministry of Health have been trained, but this may be an underestimation by about 30%. The highest training coverage in any district is 77%. In addition, 43% of trained staff had already been rotated by 2001. Training of community health workers, on the other hand, increased from 2000 onwards (Figure 2). The districts where clinical training was more intense, however, were not those in which community IMCI training was strongest (Figure 3). No IMCI-specific national or district planning or budgeting took place. Districts had no IMCI coordinators and IMCI ran side by side with vertical programmes such as those for diarrhoea, acute respiratory infections and others concerned with the same child health problems. The average annual number of supervisory visits was 0.19 per health facility, but the supply of drugs, vaccines and equipment was reportedly mostly adequate.
Summary of main findings, ecological analyses, 1996-2000
Ecological analyses were performed, combining combined the investigation of geographical and historical information for Perus 34 health districts (DISAs) and 24 departments (political divisions), for the period 1996 to 2001. Associations between IMCI implementation and impact variables (proportionate under-five mortality and height for age) and intermediate variables (utilization and coverage of health services) were evaluated, for the period 19962000. Implementation data obtained from the 34 health districts were converted into data for the 24 departments to match the geographical basis of the secondary data.
Mortality and nutritional status improved over time in most departments of Peru. One would expect Improvements in health care would be expected to show a negative association with the mortality ratio and slope variables that is, fewer under-five deaths relative to total deaths. Levels of training coverage were very low, however, and other variables related to accessibility of health facilities were not taken into account; the analyses are accordingly limited.
No significant associations were found between IMCI implementation and indicators of utilization, coverage and impact (Figure 4). The results did not change after controlling for contextual variables.
Summary discussion Lessons learned and challenges
Our findings have clear policy relevance to scaling up IMCI in Peru as well as in other countries. The main lessons learned include the following needs: to institutionalize IMCI at national and district level, with adequate planning and budgeting; to sustain training activities after the initial boost; to plan and implement supervisory activities; to coordinate training in clinical and community IMCI so that they occur in the same geographical areas. An important and complex issue that goes beyond IMCI programming is staff rotation; unless it is addressed the sustainability of most programmes cannot be ensured. Another important lesson has been that evaluation projects and implementation activities must be run as complementary and closely interdependent actions. This will assure an increased commitment of national and regional health authorities during evaluation activities and during post-evaluation corrective measures. Early findings from the MCE in several countries suggest that the problems identified in Peru are not unique. Further national-level evaluation of IMCI implementation should be encouraged.