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Planning and implementation of the IMCI community childcare component in five countries of the Eastern Mediterranean Region. Report of an intercountry workshop, Cairo, Egypt, 29 June-4 July 2002

31 décembre 2003 Organisation mondiale de la santé

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WHO-EM/CAH/008/E/L Distribution: Limited

Planning and implementation of the IMCI community childcare component in five countries of the Eastern Mediterranean Region Report of an intercountry workshop Cairo, Egypt, 29 June–4 July 2002

World Health Organization Regional Office for the Eastern Mediterranean Cairo 2003

© World Health Organization 2003 This document is not issued to the general public and all rights are reserved by the World Health Organization (WHO). The document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written permission of WHO. No part of this document may be stored in a retrieval system or transmitted in any form or by any means—electronic, mechanical or other—without the prior written permission of WHO.

Printed by El-Zahraa for Arab Mass Media, Cairo, Egypt Document WHO-EM/CAH/008/E/L/01.03/500

Contents 1. 2. 3. 4. 5. Introduction ......................................................................................1 Workshop activities .........................................................................3 Progress of work of WHO on the IMCI community component at global level....................................................................................4 Community-based initiatives in the Eastern Mediterranean Region: the Basic Development Needs (BDN) project................6 Current status of the IMCI community component in five countries ............................................................................................8 5.1 Situation analysis .......................................................................8 5.2 Reviewing results with partners............................................16 5.3 Setting priorities.......................................................................17 5.4 Identifying potential interventions and approaches to community involvement.....................................................18 Planning: indicators and targets ..................................................18 Documenting progress ..................................................................19 Sustainability ..................................................................................20 8.1 Linking the community with the health system..................20 8.2 Linking the community with teaching institutions ............20 Plans of action.................................................................................21 9.1 Egypt…......................................................................................21 9.2 Morocco.....................................................................................22 9.3 Pakistan .....................................................................................23 9.4 Sudan ..23 9.5 Republic of Yemen.................................................................. 24 EMRO framework and guidelines for country progress reports..............................................................................24 11. 12. Conclusions.....................................................................................25 Recommendations..........................................................................27

6. 7. 8.

10.

Annexes 1. Agenda...................................................................................................29 2. Programme............................................................................................30 3. List of participants................................................................................33 4. Conclusions and recommendations of the Intercountry Meeting on Integrated Management of Childhood Illness (IMCI) Documentation and Community Component, Lattakia, Syrian Arab Republic, 7–11 October 2001................................................38 5. Introduction of the IMCI community component in countries with the IMCI strategy in the Eastern Mediterranean Region ..........41 6. Key family practices on childcare .....................................................42 7. The 10 steps of the planning process for the IMCI community component at national level ..........................................................44 8. Current status of the planning process for the IMCI community component in five countries in the Region .................................45

Introduction

The Regional Office for the Eastern Mediterranean (EMRO) of the World Health Organization (WHO) held an Intercountry Workshop on Planning and Implementation of the IMCI Community Childcare Component in Five IMCI Eastern Mediterranean Region (EMR) Member States at the EMRO premises in Cairo, from 29 June to 4 July 2002. The intercountry workshop had the following objectives: • To review the community component progress in five IMCI EMR member states, namely Egypt, Morocco, Pakistan, Sudan and Republic of Yemen; • To discuss the use of the EMR framework for the community component of the integrated childcare strategy, IMCI, as a practical tool to plan community interventions; • To identify common constraints and issues in planning and implementation of the IMCI community component; and • To prepare 12-month plans for the IMCI community component. A total of 26 participants attended the workshop, including 15 representatives of five countries, two observers from a sixth country (Syrian Arab Republic), four staff of UNICEF Middle East and North Africa Regional Office (MENARO) and country offices, and five staff from WHO headquarters, EMRO and country offices. The agenda and programme of the workshop are shown in Annexes 1 and 2, respectively; the list of participants is given in Annex 3. This workshop was a follow-up to the Intercountry Meeting on Integrated Management of Childhood Illness (IMCI) Documentation and Community Component, held in Lattakia, Syrian Arab Republic, 7-11 October 2001 (Annex 4). It was intended as the first of a series of similar workshops, designed to develop plans of action with small groups of countries. The countries selected in this first workshop were at an advanced stage of IMCI implementation, including all those already in the expansion phase.

Planning and implementation of IMCI community childcare component

The WHO/UNICEF strategy on IMCI was introduced in the Region in 1996 to reduce mortality and morbidity in children under five years old and improve children’s growth and development. Over the years, attention was increasingly given in the Region to the development of a strategy on integrated childcare, addressing not only the sick child but also the healthy child, in health facilities and in the home. While initial efforts focused on the delivery of integrated childcare services at health facilities, plans to develop interventions to promote key family practices on childcare as an integral part of the strategy (IMCI community component) lagged behind (Annex 5). To guide countries in planning and implementing the IMCI community component, EMRO developed a framework for the community component of the integrated childcare strategy in 20021. The strategy was based on recommendations made by the joint WHO/UNICEF IMCI Regional Consultation held in Alexandria, Egypt, in November 2000 and the intercountry meeting held in Lattakia. At the latter meeting, the draft strategy was thoroughly discussed and reviewed by participants. The document was then revised based on that review, sent to countries for additional comments and finalized in February 2002. Guidelines were developed and sent to the countries invited to the workshop for the preparation of country progress reports on the IMCI community component. The guidelines followed the planning steps outlined in the EMRO framework and aimed at guiding countries through each step of the planning process and collecting information to document progress on the IMCI community component in the Region. The first version of the country progress reports was reviewed at EMRO before the workshop, and comments and suggestions were sent to countries for revision and additional information, as appropriate. The information was then collated at EMRO before the workshop and summarized in tables.

Framework for the community component of the integrated childcare strategy, World Health Organization, Regional Office for the Eastern Mediterranean, 2002 (document WHOEM/CAH/003/E/G). 1

Planning and implementation of IMCI community childcare component

In a message to the meeting, Dr HA Gezairy, WHO Regional Director for the Eastern Mediterranean, described the rapid progress in IMCI implementation in the Region, with 15 out of the 23 countries of the Region having introduced the strategy and currently being at different stages of implementation, and four countries planning to introduce IMCI by the end of 2003. He appreciated the ability of the strategy to adapt to country needs and the health systems and socioeconomic situations in countries in the Region which differ so much from each other. Dr Gezairy pointed to the gradual shift of the strategy from an initial focus on illness to a broader scope on childcare in the Region, emphasizing the key and indispensable role that the family plays in caring for the child. He noted that this workshop was a follow-up to the recommendations of the previous intercountry meeting in Lattakia and represented an important step in accelerating the implementation of the IMCI community component in the participating countries.

Workshop activities

Unlike meetings where presentations are often used to encourage participants to share their experiences, this workshop made extensive use of small group work and discussions in plenary sessions, limiting formal presentations to a minimum and concentrating them in the morning of the first day. This was done in order to have as much interaction as possible within and among country teams, to revise country progress reports and prepare plans of action. For most sessions, participants were first divided into two groups. Group work was organized around main themes following the EMRO framework, including situation analysis, partnership, setting priorities, and identification of potential interventions, indicators and targets. This step-by-step approach facilitated focused discussions and the preparation of the action plan by country teams, building capacity for planning as the participants moved through the various steps of

Planning and implementation of IMCI community childcare component

the planning process. After group work, groups interacted with each other in plenary sessions, reviewing and commenting on the outputs of each country team. The workshop programme had originally been arranged to allow for flexibility, extending or reducing the time of sessions according to needs, and adapting to the pace of preparation of the action plans. Interaction among the various country teams was ensured both during group work and plenary sessions.

Progress of work of WHO on the IMCI community component at global level

Improving family and community practices involves initiating, reinforcing, and sustaining key family practices for child survival, growth, and development. The 12 key family practices are listed in Annex 6. WHO has established partnership with other interested agencies in this area and an Inter-Agency Working Group (IAWG) has been created, comprising UNICEF, the Child Survival Collaborations and Resources Group (CORE), the UK Department for International Development (DFID), the World Bank, and USAID. The IAWG secretariat is housed in UNICEF and funded by DFID. An advocacy brochure, ‘Improving child health in the community’2, supported by the IAWG, has just been developed and printed with the lead of the WHO Child and Adolescent Health and Development Department. At global level, WHO has been working in six main areas: i) Research on interventions to improve selected key family practices ii) Development of a planning/briefing package iii) Evidence for the 12 key family practices iv) Community health workers v) Indicators for monitoring and evaluation vi) Documentation of country experience

2 Improving child health in the community, Department of Child and Adolescent Health and Development, World Health Organization, 2002 (Document WHO/FCH/CAH/02.12).

Planning and implementation of IMCI community childcare component

ii)

iii)

iv)

Research has been conducted mainly in four intervention areas: a) Care-seeking, looking at the impact of counselling on careseeking behaviour in India, with results expected by the end of the year; b) Adherence to recommendations of health workers trained in IMCI on referral and follow-up in Sudan, that have yielded positive results; c) Using community health workers as a vehicle in Brazil; and d) Nutrition: reviewing community interventions to promote infant and young child feeding, and assessing guidelines for its promotion through peer counsellors; promoting key feeding practices at health facilities through IMCI counselling, studying large-scale community interventions linked with health facilities (India and Peru); and research on HIV and infant feeding. A planning/briefing package on the third component of the IMCI strategy has been developed, pre-tested in Benin in February 2002, and then field-tested in Senegal in May, while activities to increase its use have been conducted very recently. This guide is complementary to the EMRO framework on the IMCI community component. A draft paper has been prepared by the London School of Hygiene and Tropical Medicine, London, United Kingdom, describing scientific evidence for the 12 key family practices in detail. A second draft has been produced and ways to make the information it contains widely accessible are being explored. A number of countries have chosen community health workers as a means of implementing the IMCI community component and have developed training packages for them. WHO has completed a review of the existing materials for community health workers, to see how to advise countries in this area. Outcome indicators for monitoring and evaluation of interventions related to family childcare practices have been developed. Additional indicators related to the process are

Planning and implementation of IMCI community childcare component

vi)

under consideration by IAWG to be applied to the household and community IMCI (see below). There are plans to document country experiences globally in the area of the IMCI community component, as sufficient information becomes available.

Community-based initiatives in the Eastern Mediterranean Region: the Basic Development Needs (BDN) project

A number of community-based interventions are being implemented in the Region to address health, poverty and development, such as the Basic Development Needs (BDN) approach, healthy villages, healthy cities and women in health and development. The BDN approach, first implemented in the Region in Somalia in 1988, aims at achieving a better quality of life for people in a community by meeting their basic needs as identified by the community itself. The BDN concept looks to both health and development as two mutually interlinked aspects, whereby health contributes to development but also derives from it. Thus, BDN seeks to promote a comprehensive approach for development to meet community priority needs that might include not only health but also education, means of livelihood (e.g. income-generating activities), water supply, sanitation, improved roads, provision of electricity, etc. These components have synergistic effects on the quality of life of the individual. BDN recognizes the link between poverty and ill health: good health is regarded as a basic human need which helps reduce poverty, while any poverty alleviation strategy encourages better health. Attention is to be paid to the most needy in the community, to reduce not only poverty but also inequality within the community. The strategies of BDN include organizing the community, building its capacity and promoting self-reliance for its own development needs. Sustained socioeconomic development is to be achieved through a bottom-up approach, with community involvement, self-reliance and inter-sectoral collaboration. The BDN

Planning and implementation of IMCI community childcare component

approach, in which the health system should play a facilitating and supportive role, centres on ’people’ – a key element for change – helping communities to help themselves by assessing their needs and priorities. The establishment of links between the community on the one hand and health systems and other formal sectors on the other becomes essential. Examples of successful BDN from Somalia and Afghanistan have shown an improvement in key health indicators, such as a remarkable reduction in infant mortality and a significant improvement in children’s nutritional status, immunization coverage, and antenatal care in the communities involved. The link with IMCI then becomes obvious, as both the BDN approach and the IMCI strategy promote the active involvement of the community and see the community not as a passive recipientbeneficiary of an intervention but as both the means and main actor for effecting changes. Where BDN is in place, IMCI can build on the existing infrastructure and set-up created by the BDN approach for coordinated partnership, as well as economic and self-reliance schemes that should improve access to and use of health services. On the other hand, BDN can benefit from the IMCI strategy, including it in its essential health package together with safe motherhood, health education, nutrition, malaria control, tuberculosis control, availability of essential drugs, etc. BDN can build on a strengthened health system, improved health services, and the links between the health sector and the community created by the IMCI strategy, as well as the IMCI outcome-oriented focus. The BDN approach and IMCI strategy can therefore reinforce each other and be ‘partner approaches’ for sustainable development, as the promising experience in Dar Mali village in Sudan is already showing.

Planning and implementation of IMCI community childcare component

Current status of the IMCI community component in five countries Situation analysis

5.1

All countries participating in the workshop were at the planning stage – except for Morocco, which had already conducted some activities in the field – and had basically not gone beyond step 5 (Identification of potential interventions and approaches to community involvement) of the planning process proposed in the EMRO framework (Annex 7). Only steps 1 to 5 were therefore covered in detail in the workshop. Progress in those areas is described below. For the purpose of the workshop, the term ‘community health worker’ was used to refer to any person with some basic health background (‘trained’), who provides health or nutrition services (curative, preventive and/or promoting health) to the community, whether paid or not. This term therefore encompassed a wide range of definitions and tasks, varying from country to country and including for example lady health workers (LHWs), basic health workers, community health promoters, community health volunteers, cluster representatives, etc., serving as a bridge between the health system and the community. This section summarizes the information contained in the country progress reports, reviewed and updated during the workshop group sessions to analyse the situation. The information is presented in the tables in Annex 8. Situation analysis is an essential step in the planning process for the IMCI community component, to guide managers in the selection of effective interventions, building on the experience of existing community interventions. It helps identify areas where the need for more information is critical. Situation analysis is an ongoing process throughout planning and even after implementation may have started. Given its importance for planning and the fact that most of the participating countries were at the beginning of the planning process, the workshop largely focused on this step.

Planning and implementation of IMCI community childcare component

Partnership and the IMCI community component working group A strong and dynamic partnership is the foundation of the IMCI community component planning process. The partnership involves both relevant departments of the Ministry of Health and partners outside the Ministry, such as other ministries as appropriate, academic institutions, professional organizations, non-governmental organizations (NGOs), civil society, and private sector and international organizations. A key step is therefore the establishment of a functional structure that, within the national IMCI working group, is specifically responsible for planning and coordinating IMCI community component activities with all main partners. All the countries participating in the workshop had set up community component working groups at various stages of implementation of the IMCI strategy (Table 1, Annex 8), usually through formal endorsement by the Ministry of Health. These groups tended to have a broad base, including a representation of key programmes in the Ministry, as well as medical schools and NGOs among the partners outside the Ministry. The following points were emphasized in the discussion: • Partnership is the foundation of the IMCI community component: we do not work alone to implement communitybased interventions; • Knowing what partners’ interests and priorities are and what they are doing helps build common understanding and stronger partnerships; • Roles and responsibilities of partners in this joint venture should be clearly defined and agreed upon; • Partners may include not only those concerned with health but also those working in other development areas; and • There can be different partners at different levels in a country. b) Review of key family childcare practices This review aimed at describing what families are doing in relation to the 12 practices to care for both the healthy and sick child, identified by WHO and UNICEF as key to child survival, growth and

Planning and implementation of IMCI community childcare component

development (Annex 6). The review also sought to go beyond the description of the practices themselves (‘what people do’) and address the issue of why people do what they do. This workshop, through its guidelines for the preparation for the country progress reports and group work, was a stimulus for further analysis by the country teams and contributed to a revision of the reports themselves. Of the five countries, Egypt, Morocco and Sudan had conducted such reviews to various extents, Republic of Yemen had initially focused on the results of a community baseline survey, while Pakistan had originally planned for the review but had had to postpone it. The results of the reviews are shown in Tables 2a and 2b in Annex 8. Except for immunization, the desired childcare practices usually appeared to be followed only by a minority of caretakers in all countries. This was the case also for practices that had been promoted for many years by vertical programmes, such as the diarrhoeal disease and acute respiratory control programmes. In addition to reviewing ‘what’ families were doing in relation to the recommended childcare practices, it was therefore important to collect and analyse information on the determinants of caretaker behaviour related to those key practices as well, identifying factors influencing them positively (motivations, supports) and negatively (barriers). Participants recognized that such analysis, addressing the reasons why people do what they do, would help in the design of more focused and effective interventions. More information was needed on this. Results from follow-up visits to health facilities after IMCI training in Egypt and in the light of research data from Sudan suggested a moderate-to-good level of caretaker compliance with the advice received by an IMCI-trained health provider about treatment, follow-up and referral. Finally, the reviews from Egypt, Morocco and Sudan looked into the existence of differentials between population groups in the country, especially urban versus rural. Information of this type was considered important when selecting the communities to target.

Planning and implementation of IMCI community childcare component

Overall, participants appreciated the importance of a thorough review of family childcare practices as a fundamental aspect of the planning process. Interactive group work and plenary sessions stimulated further discussions on the reviews that had initially been carried out in preparation for the workshop and helped country teams identify areas where they would need to search for additional information on selected practices to strengthen their plans, regardless of the stage they had already reached in the planning process. Review of existing interventions at community level and lessons learnt Another important component of the situation analysis highlighted in the EMRO community framework is the review of existing interventions at community level, to draw on countryspecific lessons and build on them. It was emphasized that such a review would need to go beyond the simple listing of interventions, requiring the analysis of available documentation to establish objectively what can be learnt from each intervention (Table 3, Annex 8). The team from Egypt reviewed a number of community interventions, highlighting strengths and weaknesses, based on the information available. The team from Sudan limited its review to a description of some interventions, while the team from Pakistan focused its review on two initiatives, based on good data from external evaluations, especially on the LHW programme. Finally, the team form Morocco only listed few interventions and the team from Republic of Yemen had not yet made its review. A common finding, apart from Pakistan, was often the lack of structured assessments and data on the monitoring of interventions that could provide an objective analysis of the experience gained by the interventions. Most of the information reviewed was in fact only qualitative information, not validated by standard assessments or evaluations and solid documentation. It was suggested that this might have been the consequence of intervention plans lacking clear and measurable outcome indicators and targets, thorough monitoring c)

Planning and implementation of IMCI community childcare component

and evaluation, a clear definition of the roles and responsibilities of the various actors involved, and effective mechanisms for sharing information with other partners not directly involved in the projects. The LHW programme in Pakistan was the exception. It was a good model, with strong commitment from the government – including adequate funding and salaries – promising results and a goodquality, in-depth evaluation. In addition to the lack of evidence impeding the effectiveness of the community interventions listed or reviewed by the country teams, some other findings from the reviews shared by more than one country were that: partnership with, within and outside the community had been essential for planning and implementation; the community, through various structures including their leaders, had played a major role in facilitating and implementing the interventions; a high attrition rate of volunteers and lack of motivation had been serious challenges to the sustainability of the interventions, which had often been project-led and thus timelimited; and finally national legislation defining and supporting the roles and responsibilities of community health workers was needed. Review of existing health education and communication materials and activities All countries had adapted the IMCI mother counselling card to the local setting during the adaptation process of the IMCI strategy. Main child-related health education materials were also reviewed, to ensure consistency of messages. This aspect of the situation analysis, however, more specifically aimed to review experiences with health education and communication interventions in countries (Table 4, Annex 8). It emerged from the review that health communication activities or projects had usually not been evaluated in detail by the country teams and, except for an attempt in Morocco, comprehensive communication plans bringing together various partners’ efforts still had to be developed. This was an area needing further information and efforts. In fact, facilitating behavioural changes through effective communication interventions requires a thorough knowledge and d)

Planning and implementation of IMCI community childcare component

understanding of which communication channels and means are most effective in a community, based on a detailed review of welldocumented experiences in the country. e) Review of existing, successful approaches to involving communities Communities can be involved in an intervention in different ways, so as to become active participants in the process rather than passive recipients. This component of the situation analysis aimed at identifying and describing those approaches in countries that had been successful in involving communities fully in the intervention (from planning to evaluation of outcomes), making community resources available, attaining sustainability over time, and proving or being likely to prove replicable on a large scale (Table 5, Annex 8). The focus of the Pakistani team was also in this case mostly on the experience with the LHW programme, while the team from Sudan reviewed the promising experience of the BDN project and the potential use of the health area councils. The team from Egypt postulated the likely sustainability of community involvement in breastfeeding activities and support systems by NGOs, noting however the difficulty in accessing this type of information. In the examples from Pakistan and Sudan, communities were involved in planning, selection of the health workers or representatives based on set criteria, and forming health or development committees. f) Review of data on caretaker satisfaction As caretakers are ‘users’ of the services provided at health facilities, their positive perception of the quality of these services and of how their ‘felt needs’ are adequately addressed helps establish a relationship of trust between the community and the health system and set the ground for their possible involvement in childcare interventions in future. The objective of this review was to ascertain which health facility services communities value most and to meet their expectations (Table 6, Annex 8). For the review, follow-up visits after IMCI training represented a good source of information. Findings from Egypt, Morocco and Sudan showed that caretakers

Planning and implementation of IMCI community childcare component

using IMCI facilities were satisfied with the services provided, valuing the assessment of the health providers, their treatment of children and their attitude, including counselling. Interestingly, in Egypt a preference was expressed for the private sector in cases perceived as severe. The external evaluation of the LHW programme in Pakistan also showed that the community was satisfied with the services delivered by the LHWs, including an improvement in health, the receiving of more information, and increased immunization activities and health care. Review of information on health provider satisfaction Community interventions often involve health workers or volunteers. Satisfaction of health providers is key to their performance, in addition to skills and supplies. Although financial incentives and remuneration play an important role, it is critical to identify other motivational schemes which have been tried and succeeded in maintaining a certain enthusiasm, retaining the community health workers over time, based on other community experiences in the country (Table 7, Annex 8). Except for Pakistan, the country teams had difficulty reviewing this issue, possibly because of the scanty information available. Among factors cited as rewarding for community health workers were: • Receiving regular feedback on their performance from health facility staff; • Community recognition and respect for their work (also through awards); and • Refresher training. The LHWs in Pakistan were also paid by the government. h) Identification of existing or potential community structures and channels to link the community and the health system It is fundamental to identify those structures and channels in an existing community that are fully functional and can be used to promote childcare practices and support interventions. Some examples cited by the country teams included health committees, g)

Planning and implementation of IMCI community childcare component

village committees, health facility boards with community representatives, women’s clubs and chambers of commerce (Table 8, Annex 8). As stressed during the discussions, an important element of the IMCI community component is the establishment of strong and effective links between community intervention and the health system, also between the structures described above. Examples may go beyond the health sector and include other development aspects, as in some of the cases reviewed by the teams from Egypt and Sudan. Links were viewed as critical by the participants, as community health workers should not work in isolation but be an integral part of the public health system. They could be seen as a bridge, or even an extension of the primary health care facility into the community but also of the community into the health system. Health facility staff would play a guiding role for the community health workers, providing continuous feedback, support, encouragement, and supervision. Health facility staff should be aware of what is going on in the community and trained to meet community demand for services and to address issues. Also, they should ensure that community health workers have supplies of the communication tools required (e.g. the IMCI mother counselling card) and any other materials and drugs they need (e.g. oral rehydration salts, iron preparations, and other selected drugs in some cases). It is because of the need for this strong link and the meeting of demands that all participants felt that the community component should be implemented together with the other two components of the integrated childcare strategy, as part of the whole IMCI strategy and not in isolation from the health system component. There should also be a simple reporting and feedback mechanism from/to the community health worker, with regular meetings, which would serve as a valid opportunity for community health workers to reinforce and update their knowledge and skills and see their work recognized and appreciated. On the other hand, these meetings would also enable health facility staff to know about what is going on in the community. As seen in 5.1g) above, feedback and updates act as a powerful motivation for community health

Planning and implementation of IMCI community childcare component

workers. Health facility staff should be involved in all phases of community intervention, starting with planning and then continuing with the essential task of supervision, and supporting the relationship between the community health workers and the community. These links between the community and the health system should also include community structures and partners, to keep everybody involved and generate and maintain the needed support. One of the main challenges, as seen by the participants, was making these links active and functional in the long run. i) Identification of information gaps The review of the information available on the items described above also has the objective of identifying those areas where additional search for, or collection of, information may be needed, if this is vital for decision-making and planning at this stage. Only the team from Egypt looked at information gaps and identified areas where additional information should be gathered (Table 9, Annex 8). These areas concerned the determinants of family behaviour related to childcare, in order to identify supporting elements for and barriers to the desired practices, as well as designing more targeted and effective interventions. Another area was psychosocial development, which all country teams had difficulty finding information about. 5.2 Reviewing results with partners

As noted in 5.1a) above, a strong partnership is the foundation of the IMCI community component. Partners should be involved in all steps of the planning process, implementation, monitoring, and evaluation. A key step in the situation analysis is reviewing results with partners before priority areas for interventions are identified and selected. In the same way as all countries had set up working groups with representation of key partners, all the countries that carried out the situation analysis shared and discussed the results with key partners (Table 10, Annex 8). This was often done in the form of workshops or meetings, with participation of different ministries, international multilateral and bilateral organizations,

Planning and implementation of IMCI community childcare component

NGOs, different levels of the health system and the community. The outcome of these meetings was usually a draft plan on the community component with some proposed activities. Thus, partners were involved to various degrees during this step of the planning process. 5.3 Setting priorities

The situation analysis and review of results with partners should assist in prioritizing the recommended family practices according to priority needs, agreed criteria and the country situation. ‘Prioritization’ is the selection of a few practices on which to focus initially. It was considered ‘essential’, so as to concentrate rather than dilute efforts and resources and increase the chances of achieving the desired outcomes. It was felt that without initial focus it would be very difficult to effect changes in behaviour that would also require additional efforts to be sustained over time. The teams from Egypt, Morocco, and Pakistan set selection criteria for prioritizing the key family practices and ranking them in a certain order (Table 11, Annex 8). The criteria used were similar and related to each other, and included: • ‘Importance’ of the practice to promote, in terms of likely impact on child mortality, morbidity, and development if adequately adopted by the community; • Acceptability of the practice by the community; • Current level of the practice, i.e. extent to which it is adopted in the community; • ‘Feasibility’; • Likelihood of change; • Availability of experience in the countries on promotion of the desired practice; and • Resources needed and available to promote and sustain the practice and interest of partners.

Planning and implementation of IMCI community childcare component

The ‘feasibility’ criterion was considered a broad one, as it included some of the other criteria listed above. It was felt that criteria should be clear, very specific and well defined, and reflect consensus of the parties involved in the process. In Sudan, the review at central level had had the main purpose of establishing which family practices were most relevant to the country, leaving the question of prioritization mostly to the state level. It was concluded that priorities should be set at national level as a focus for the initial phase, based on the situation analysis and selection criteria. Among those priorities, a few would then be selected at community level, according to the situation at that level and local needs and criteria. 5.4 Identifying potential interventions and approaches to community involvement

After reviewing information on existing, successful country approaches to involving communities actively in 5.1e) above, it should be possible to identify those community structures and interventions that are most promising and on which the IMCI community component can build. Table 12 (Annex 8) shows some of these structures and interventions. Strengthening of the childcare component was seen as an important added value of IMCI in relation to existing interventions, such as the LHWs (Pakistan) and basic development needs (Sudan).

Planning: indicators and targets

Any plan should include clear, measurable indicators and set quantitative targets so as to enable regular monitoring of what has been done (‘process’) and what this has led to (‘outcome’). None of the countries had yet reached this stage and therefore examples were provided in this session of outcome indicators that could be used at community level. A list was distributed of indicators for IMCI at household level, developed by WHO in collaboration with the IAWG on IMCI Monitoring and Evaluation. It was emphasized that, when

Planning and implementation of IMCI community childcare component

selecting indicators, attention should be paid to which monitoring instruments would be used to follow up progress of implementation, identify constraints and address them accordingly. Monitoring methodology had to be developed locally and be simple, inexpensive and integrated in existing monitoring systems wherever these existed, to avoid creating new vertical projects. As much as possible, monitoring had to allow for the collection of information on both process and outcomes and help link activities with results. Thus, each country had first to set its own indicators, based on the key family practices and community interventions it had selected, and available monitoring tools. This session proved very useful as it enabled some country teams to start identifying certain indicators for which targets would later be set and include some examples in their plan of action. It was understood that the final list of indicators would be prepared after the community intervention for childcare had eventually been selected and final plans prepared accordingly.

Documenting progress

Documentation of inputs (resources made available for the intervention), outputs of activities, experience with implementation and outcomes of the intervention are all necessary to identify strengths and weaknesses and describe lessons learnt, as well as for advocacy. The situation analysis carried out by the five countries participating in the workshop clearly showed that the community interventions reviewed were often poorly or incompletely documented, limiting the value of their experience. This made it difficult to learn from them and make reliable conclusions. On the other hand, the LHW programme in Pakistan had shown the importance and value of a thorough documentation, to provide effective feedback to those concerned, reinforce programme components and continue to receive the required political and financial support.

Planning and implementation of IMCI community childcare component

8. 8.1

Sustainability Linking the community with the health system

The community component of the integrated childcare strategy is potentially seen as one of the key answers to the issue of sustaining over time the achievements made by the whole strategy. However, mechanisms should clearly be devised to ensure that the community interventions themselves and the improvement of childcare practices accomplished through them are sustainable over time. These mechanisms should rely on full involvement of the community in the intervention and strong links between the community and the health systems in 5.1h) above. 8.2 Linking the community with teaching institutions

The establishment of close links between the community and teaching institutions was identified by participants as vital for ensuring sustainability in the long term and was discussed in detail in a session devoted to links with the community. In many countries in the Region, medical graduates should serve in rural areas before working with the Ministry of Health. In some other countries, service in rural areas was a pre-requisite for registration with the medical council and enrolment in postgraduate studies (e.g., Sudan, Republic of Yemen). This rural service was seen as a good opportunity for doctors to understand the reality in the field and the importance of community work. Even before then, while at university, medical students would often be exposed to the community through outreach field visits during the community medicine, family medicine and paediatrics rotations. They would also collect data from the community for operational research, be involved in educating the community on health topics and assist it in addressing health issues. Thus, a good and useful link could be set up between the community and teaching institutions. To formalize the approach, there would be a need to orient teaching staff of community medicine, family medicine and paediatrics departments to the integrated childcare strategy and its

Planning and implementation of IMCI community childcare component

community component, and include them in community working groups at various levels. The staff would have to participate in planning, implementation, monitoring, and evaluation of community activities. Results of evaluations and operational community research conducted by the medical schools could be presented in medical conferences and meetings of professional societies, to promote the importance of public health work and its relationship with everyday medical practice. The discussion was kept relatively broad as the topic of medical education and child health was going to be reviewed in detail in a regional consultation planned by EMRO for September.

Plans of action

A major objective of the workshop was the preparation of a 12month plan of action for the IMCI community component by each country team. It was understood that these plans would represent an outline and would need to be finalized and approved by the responsible authorities in the country after the workshop. The plans were drafted by each country team separately, then presented and discussed in a plenary session with all the other participants. The timetable provided in the plans would allow for their implementation. 9.1 Egypt

The team from Egypt prepared a document describing the rationale and main strategic directions guiding their plan of action, covering a 12-month period until July 2003. A number of partners at national and local levels were identified, whose role and responsibility for the plan would be discussed and agreed with them after the workshop. The plan aimed to cover at least one community in each of seven districts, in which all the three components of the IMCI strategy would be implemented. The first step involved strengthening the management and planning structures for the community component at national and governorate levels and additional situation analysis. The team chose to prioritize six

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practices at national level (Table 11, Annex 8) and promote them through a communications strategy, mostly relying on training of community-based workers in communications skills, providing them with health education materials to be developed for this purpose, and mobilizing the community. The plan clearly indicated orientation and planning meetings with all the actors involved at different levels of implementation and included information on the remaining five steps of the planning process. It suggested five areas for which intermediate outcome indicators may be developed, broadly delineated plans to develop integrated supervisory tools and proposed criteria for the selection of priority communities. 9.2 Morocco

Since the early implementation of the IMCI strategy, Morocco had conducted some activities for the community component of the strategy. Criteria had been set for the selection of communities, including the presence of a low level of health indicators, landlocked areas and a poor infrastructure. A guide on the IMCI community component – all key family practices and communications skills – had been developed; five sites had been selected in the IMCI early implementation districts in two provinces and community workers in those sites had been trained using the guide. A workshop was finally conducted in 2001 to review the experience and the approach adopted. Since the members of the Morocco team at the workshop were not directly responsible for planning for IMCI, the plan that they developed listed a few specific activities and a timeframe to be proposed to the national IMCI working group. The activities included gathering information needed for the situation analysis, development of monitoring and evaluation tools to document experience in the selected sites, and reviewing the experience within six months.

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9.3

Pakistan

The plan prepared by the team from Pakistan focused on the LHW programme. The LHW job description was applied to all 12 community and family practices recommended for IMCI. During the early ICMI implementation phase, the presence of an LHW attached to a facility was one of the criteria for the selection of a facility for IMCI, in order to exploit the link between the health system and the community since the implementation of ICMI began. The plan of action for the IMCI community component included as a first step after this workshop a review of the key family childcare practices in the country. This was originally planned for last year but had to be postponed. The plan also included activities to: identify a few indicators to be used by the LHWs at community level as part of their existing management and information system; assess the quality and effectiveness of the current Ministry of Health mass media campaign related to the family practices; strengthen LHWs’ training in child health and training of master trainers; and develop monitoring tools to monitor progress of the community component. 9.4 Sudan

The first steps of the Sudanese team’s plan of action included the setting up of sub-committees for the IMCI community component in all the states – only three of the 11 states implementing IMCI already had them – and the conducting of baseline and need assessment surveys in 14 communities to be selected for the first phase of implementation of the community component. The plan concentrated on fostering partnership with medical schools, strengthening the links between the health system and the community, and developing monitoring tools. The aim of the partnership with medical schools was to introduce the key family practices and related topics in their basic teaching programme. As for links between the health system and the community, two categories of health workers would be used to educate and counsel families on the priority family practices: the community health workers and

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health facility supportive staff (nutritional educators, vaccinators, nurses). 9.5 Republic of Yemen

Improvement in six of the 12 recommended family childcare practices was the objective of the plan of action. The plan included activities to strengthen partnership at national and sub-national levels and for the development of plans, with involvement in the districts of the district health management team and existing community structures. The intervention would be first implemented in the districts where the IMCI strategy was currently being implemented, then assessed before being expanded to other districts together with the other two components of the IMCI strategy. Community-based workers (‘local communicators’) would be the channel to provide health education to the community, after being equipped with the required communications skills by training and with support in their education efforts by dissemination of messages via the mass media. A system would also be developed to monitor implementation.

10. EMRO framework and guidelines for country progress reports Participants much appreciated the EMRO framework for the community component of the integrated childcare strategy, as a comprehensive guide for the development of country strategies for the IMCI community component. The ‘Planning: indicators and targets’ section was considered very clear and useful. There was a demand for expanding the other sections of the framework, basically transforming it from a framework into a practical tool such as a planning guide. The guidelines developed for the preparation of the country progress reports for this workshop could well serve this purpose. The participants found them very clear, helpful, comprehensive and consistent with the 10 planning steps illustrated in the framework. They stated that the guidelines facilitated the

Planning and implementation of IMCI community childcare component

preparation of the progress reports and offered a standardised approach to the exchange of information among the country teams at the workshop. The examples provided in the annexes were found to be relevant and helpful. It was recommended that the guidelines should include an annex with definitions to be sent out well in advance of the workshop.

11.

Conclusions

The workshop was a valid opportunity to exchange experiences, review country progress and develop an outline of country plans of action. Thanks to the methodology used, it stimulated interactive debate involving all country teams and drew attention to key aspects of the community component and planning process, helping clarify issues and address questions in a practical way. The EMRO framework and the guidelines developed for the workshop were seen to be very clear, useful and of practical value. Participants also felt the need for materials for training in management, planning and coordination, and negotiation skills, to strengthen links with partners. Participants agreed that information on community experiences and work with partners was available in countries and just had to be looked for more carefully. They also recognized that the added value of IMCI to existing community interventions should be clearly identified and described, to clarify the role of childcare strategy. Detailed conclusions were made for each session of the workshop and are described in the related sections of this report. The main conclusions, that are in line with the conclusions and recommendations of the intercountry meeting held in Lattakia in 2001 (Annex 4) and expand on them, can be summarized as follows: 1. Strategy on childcare: The IMCI strategy is not a vertical project but a comprehensive strategy; the emphasis has in recent years switched from illness to childcare, although IMCI has been retained as a ‘logo’;

Planning and implementation of IMCI community childcare component

2. Implementation of the community component: The community component should be implemented together with the other two components of the integrated childcare strategy, as part of the whole IMCI strategy and not in isolation from the health system components; 3. Partnership: A strong partnership is the foundation of the IMCI community component. Defining and agreeing on the role and responsibilities of partners at different levels for the whole process is very important; 4. Situation analysis: This is an essential and crucial step in the planning process, which may continue also during implementation, for filling in information gaps as they are identified. Much information is often available in countries but needs to be looked for. Understanding why people do what they do helps with the design of effective interventions; 5. Review of existing interventions: There is often a lack of standard methods to show that interventions – including health education and communications initiatives – work and that lessons have been learnt. Thorough documentation of the experience and structured monitoring and evaluation of the IMCI community component are indispensable; 6. Building on existing experience: IMCI is a strategy that maximizes child health care efforts through a coordinated and standardized approach, building on existing, local community experiences and structures. It is also cost-effective; 7. Links: The establishment of functional, effective links between the health system and the community is essential and a key to longterm sustainability. Community health workers should not work in isolation. Setting up links between teaching institutions and the community offers additional strength to the IMCI community component; and 8. Prioritization: Another key aspect of the IMCI community component is the need to be selective and focus-oriented, initially prioritizing only the promotion of a few family practices to

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concentrate rather than dilute efforts, in order to increase chances of achieving and sustaining the desired outcome.

12.

Recommendations

Participants made a number of important recommendations during the various sessions, among which the following are worth emphasizing. To the country teams 1. The outline of the country plan of action should be finalized by the national IMCI community working group – including identification of resources needed, indicators and targets, and monitoring tools – and formally endorsed by the Ministry of Health; 2. The plan of action should be integrated in the national plan for the IMCI strategy, to generate one well-coordinated plan for all the three components; 3. The country progress report should be revised according to what was discussed in the workshop, to serve as a key background document on the planning process for the IMCI community component in the country; 4. The composition of the national IMCI community working group should be reviewed in light of the concept of partnership discussed and agreed in the workshop; 5. All planning and implementation steps should be well documented; and 6. Country reports on progress in planning and implementation of the community component should be submitted to EMRO every four months through the WHO country representative offices.

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To WHO 7. WHO should continue to organize theme-focused workshops such as this one with a limited number of countries, to facilitate more interaction and generate quality output; 8. WHO should, through any opportunities and follow-up visits in countries, continue to provide technical support and guidance in this area, including operational research; 9. WHO should collate the information received from countries, prepare an annual summary report and share it with countries; 10. WHO should promote exchange of experiences between countries, including field visits as appropriate, and identify resources for this purpose; 11. WHO should send the guidelines for country progress reports to countries much earlier before future workshops and develop guidelines for documentation of planning and implementation; 12. WHO should coordinate an informal e-mail discussion group on the IMCI community component for those participants who have expressed an interest; and 13. WHO should continue providing an overview and update of progress of, and developmental work on, all the three components of the child health strategy in the Region for IMCIrelated events, irrespective of the specific activity.

Planning and implementation of IMCI community childcare component

Annex 1

Agenda 1. 2. 3. 4. 5. 6. Inauguration of the intercountry workshop and selfintroduction of participants Introduction of the workshop objectives Status of implementation of the community component of the integrated childcare strategy in the five participating countries Community component implementation status at the global level Community-based interventions in EMR; Basic Development Needs project Planning for the community component: − Situation analysis and partnership: introduction, review of country work, discussion and points for action − Setting priorities: introduction, review of country work, discussion and points for action − Identification of potential interventions: introduction, review of country work, discussion and points for action − Indicators and targets: introduction, review of country work, discussion and points for action − Follow up: introduction, review of country work, discussion and points for action Development, presentation and discussion of 12-month plan of action with the five participating countries Documentation and monitoring of the implementation of the developed plan of action: process and available tools Reporting to EMRO and expected technical support during implementation: process and available tools

7. 8. 9.

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Annex 2

Programme Saturday, 29 June 2002 08:00–08:30 Registration 08:30–09:30 Opening session 09:30–10:30 Introduction of the workshop objectives and summary of the progress status of the IMCI community component in the five participating countries Dr Suzanne Farhoud, WHO/EMRO 10:30–10:45 Presentation on the progress status of IMCI community component implementation at the global level Dr Samira Aboubaker, WHO headquarters 10:45–11:00 Presentation on Basic Development Needs project: community-based interventions Dr Mubashar Sheikh, WHO/EMRO 11:00–11:30 Discussion 11:30–12:00 Presentation of the planning process of the IMCI community component: Situation analysis and partnership Dr Sergio Pièche, WHO/EMRO 12:00–14:30 Group work on the situation analysis and partnership 14:30–18:00 Development of the 12-month plan of action with Egyptian team following the EMRO framework on community component Sunday, 30 June 2002 08:00–09:30 Group work on situation analysis and partnership (continuation) 09:30–10:00 Presentation on the planning process of the IMCI community component: Setting priorities Dr Suzanne Farhoud, WHO/EMRO

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10:00–10:30 10:30–14:30 14:30–18:00

Discussion Group work on setting priorities Development of the 12-month plan of action with the Moroccan team following the EMRO framework on community component

Monday, 1 July 2002 08:00–09:30 Presentation on the planning process of the IMCI community component: Identification of potential interventions Dr Suzanne Farhoud, WHO/EMRO 09:30–10:00 Discussion 10:00–14:30 Group work on potential interventions 14:30–18:00 Development of the 12-month plan of action with the Pakistani team following the EMRO framework on community component Tuesday, 2 July 2002 08:00–09:30 Presentation on the planning process of the IMCI community component: Setting indicators and targets Dr Sergio Pièche, WHO/EMRO 09:30–10:00 Discussion 10:00–14:30 Group work on indicators and targets 14:30–18:00 Development of the 12-month plan of action with the Sudanese team following the EMRO framework on community component Wednesday, 3 July 2002 08:00–09:30 Presentation of the 12-month plan of action of Egypt, Egyptian team 09:30–10:30 Discussion 10:30–11:30 Presentation of the 12-month plan of action of Morocco, Moroccan team 11:30–12:30 Discussion

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12:30–13:00 13:00–14:30 14:30–18:00

Presentation of the 12-month plan of action of Pakistan, Pakistani team Discussion and revision of the plans of action of the three countries Development of the 12-month plan of action with the Yemeni team following the EMRO framework on community component

Thursday, 4 July 2002 08:00–09:30 Presentation of the 12-month plan of action of Sudan, Sudanese team 09:30–10:30 Discussion 10:30–11:30 Presentation of the 12-month plan of action of Republic of Yemen, Yemeni team 11:30–12:30 Discussion and revision of the plans of action of the two countries 12:30–13:00 Round table on documentation and monitoring of the implementation of the developed plans of action 13:00–14:30 Discussion 14:30–16:30 Round table on the process of reporting on implementation to EMRO and expected technical support

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Annex 3

List of participants EGYPT Dr Azza Ahmed Abou Zeid Focal Point for IMCI Community Component Health Directorate Alexandria Dr Nagwa Khallaf Focal Point for IMCI Community Component ARI Programme Manager Healthy Mother / Healthy Child Project In cooperation with USAID Ministry of Health and Population Cairo Dr Said Madkour National IMCI Coordinator Ministry of Health and Population Cairo MOROCCO Dr Lalla Aicha Lamrani Membre du Comité technique national de la Stratégie PCIME et Cadre du Service de Protection de la Santé infantile Direction de la Population Rabat Dr Karima Gholbzouri Chef de Service de la Couverture sanitaire et de l’Intégration des Activités Direction des Hôpitaux at des Soins ambulatoires Rabat

Planning and implementation of IMCI community childcare component

Dr Abdelkrim Meziane Bellefquih Délégué provincial de la Santé Province d’Ouarzazate Rabat PAKISTAN Dr Zahid Larik Deputy Director General PHC National Coordinator National Programme for Family Planning and Primary Health Care / IMCI Ministry of Health Islamabad Dr Fazal Mahmood Khan Executive District Officer for Health Multan Dr Shabina Raza Provincial Focal Point for IMCI Deputy Director, Reproductive Health/ Nutrition Health Directorate Northern Western Frontier Province Peshawar SUDAN Dr Igbal Ahmed Bashir Coordinator of the IMCI Community Component Federal Ministry of Health Khartoum PHC Department Khartoum

Planning and implementation of IMCI community childcare component

Dr Salah Ahmed El Badawi Communications Person for Basic Development Needs (BDN) Project Federal Ministry of Health Khartoum Dr Samia Mohamed El Hassan IMCI Coordinator Federal Ministry of Health Khartoum SYRIAN ARAB REPUBLIC Dr Sahar Mosleh Head of IMCI Project Ministry of Health Damascus REPUBLIC OF YEMEN Dr Khadija Mohamed Al-Dumini National IMCI Focal Point Ministry of Public Health and Population Sana’a Dr Kariman Mansour Ali Rageh Member of IMCI Community Working Group Ministry of Public Health and Population Sana’a Dr Khalid Ghilan Saeed Chairperson of the IMCI Community Working Group Ministry of Public Health and Population Sana’a

Planning and implementation of IMCI community childcare component

Other organizations UNICEF/MENARO Dr Qussay Al-Nahi Regional Health Adviser Amman UNICEF/SUDAN Dr Abdel Halim El Tahir Project Officer (Health Sector) Khartoum UNICEF/REPUBLIC OF YEMEN Dr Magdi Bayoumi Programme Officer Health and Nutrition Sana’a Dr Hisham Osman Health Programme Consultant Sana’a Observers EGYPT Dr El Sayed Nouh IMCI National Team Ministry of Health and Population Cairo Dr Mona Rakha IMCI National Team Ministry of Health and Population Cairo

Planning and implementation of IMCI community childcare component

WHO secretariat Dr Mohamed Jama, Assistant Regional Director, WHO/EMRO Dr Kunal Bagchi, Acting Director, Health, Protection and Promotion, and Regional Adviser, Nutrition, WHO/EMRO Dr Suzanne Farhoud, Regional Adviser, Child and Adolescent Health and Development, WHO/EMRO Dr Sergio Pièche, Medical Officer, Child and Adolescent Health and Development, WHO/EMRO Dr Mubashar Sheikh, Regional Adviser, Community-based Initiatives, WHO/EMRO Dr Samira Aboubaker, Medical Officer, Child and Adolescent Health and Development, WHO/Headquarters, Geneva Dr Ahmed Nagaty, IMCI Officer, WHO/Egypt Dr Sumaia Al Fadil, Programme Officer, WHO/Sudan Dr Maher Abou Mayala, Temporary Adviser, WHO/EMRO Ms Ingi El-Manasterly, Secretary, Child and Adolescent Health and Development, WHO/EMRO

Planning and implementation of IMCI community childcare component

Annex 4

Conclusions and recommendations of the Intercountry Meeting on Integrated Management of Childhood Illness (IMCI) Documentation and Community Component, Lattakia, Syrian Arab Republic, 7–11 October 2001

Conclusions 1. Most of the focus of IMCI planning and implementation has to date been directed towards sick child management, where there has been some documented progress. Evidence that IMCI works is accumulating from the Eastern Mediterranean Region, showing improvement of health providers’ skills, health system support, family knowledge and caretaker satisfaction. The community component is crucial for successful and sustainable IMCI implementation. The draft regional framework on integrated childcare at community level is a welcome development and will provide a useful and practical guide for planning for the IMCI community component. Communities’ problems should be solved with the community, not for them. Field visits during intercountry meetings have proven to be a valuable tool to share field experience, to promote interaction between country representatives and to stimulate new ideas. Systematic collection of data on the process and outcome indicators is important for advocacy, planning, and problem solving. New adaptation areas for the clinical guidelines in different EMR Member States are being developed to suit countryspecific needs.

3. 4.

5. 6.

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9. 10.

The creativity experience is a valuable one but should take place earlier in a meeting. Useful operational research addressing IMCI implementation issues has taken place in some countries of the Region with very positive results.

Recommendations To countries 1. Partnership at all levels and sectors should be established and maintained as IMCI is a multi-sectoral strategy and not just a vertical health programme. The comprehensive plan and indicators for the community component should be based on the results of a thorough situation analysis, giving emphasis to developing and strengthening of linkages between the health system and the community and to making use of existing interventions. Indicators should be simple and therefore manageable. Capacity-building at district level should be part of the planning process as it is essential for planning and implementation at the district and community levels. Field visits should be part of future meetings as they provide rich and fertile experiences for the participants. Tools for data collection and data management should be developed, and staff at all levels should be trained in their use. These tools should be compatible with the existing HIS. More research should be encouraged on the implementation and achievement of IMCI. Countries should submit annual progress reports sharing development work to the WHO Regional Office for the Eastern Mediterranean to be collated and published.

4. 5.

6. 7.

To WHO 8. The Community and Adolescent Health unit in the WHO Regional Office for the Eastern Mediterranean should finalize

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11.

the framework on community childcare based on the comments in the meeting and share it with the IMCI team in the countries. Strategy, planning and implementation should change focus from management of sick children only to integrated childcare, including well childcare, e.g psychosocial development, feeding recommendations and growth monitoring, etc. When developing national plans, countries should include all the three components of IMCI with equal emphasis.

Planning and implementation of IMCI community childcare component

Annex 5

Introduction of the IMCI community component in countries with the IMCI strategy in the Eastern Mediterranean Region Country Year when IMCI strategy introduced Year when IMCI community component was introduced by IMCI phase (characterized by the formation of a working group on the community component) Introduction Early implementation phase Expansion

Sudan Morocco Egypt Pakistan Iran, Islamic Republic of Yemen Tunisia Iraq Oman Syrian Arab Republic Palestine Saudi Arabia Afghanistan Djibouti Libyan Arab Jamahiriya NA: not available

2000 1997 1999 1999 2002 1998 NA 2001 1999 1999 1999 2001 2000 2000 IMCI strategy just introduced in the country or under development: community component not yet elaborated

2000

2001

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Annex 6

Key family practices on childcare 3 1. Exclusive breastfeeding Breastfeed infants exclusively for up to age 6 months 2. Complementary feeding Starting at about 6 months of age, feed children freshly prepared energy- and nutrient-rich complementary foods while continuing to breastfeed up to 2 years or longer 3. Micronutrients Ensure that children receive adequate amounts of micronutrients (vitamin A and iron in particular) either in their diet or through supplementation 4. Hygiene Dispose of faeces, including children’s faeces, safely, and wash hands after defecation before preparing meals and before feeding children 5. Immunization Take children as scheduled to complete a full course of immunizations (BCG, DPT, OPV, and measles) before their first birthday 6. Malaria: use of bednets Protect children in malaria-endemic areas by ensuring that they sleep under insecticide-treated bednets 7. Psychosocial development Promote mental and social development by responding to a child’s needs for care and through talking, playing, and providing a stimulating environment 8. Homecare for illness Continue to feed and offer more fluids including breast milk to children when they are sick

3 Improving family and community practices – A component of the IMCI strategy. Geneva, World Health Organization, 1998 (Dcoument WHO/CAH/98.2).

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9. Infections Give sick children appropriate home treatment for infections 10. Care-seeking Recognize when sick children need treatment outside the home and seek care from appropriate providers 11. Compliance with advice Follow the health worker’s advice about treatment, follow-up and referral 12. Antenatal care Ensure that every pregnant woman has adequate antenatal care (This includes having at least four antenatal visits with an appropriate health care provider and receiving the recommended doses of tetanus toxoid vaccination. The mother also needs support from her family and community in seeking care at the time of delivery and during the post-partum and lactation period)

Planning and implementation of IMCI community childcare component

Annex 7

The 10 steps of the planning process for the IMCI community component at national level National level 1. Gather existing information ⇓ 2. Perform situation analysis (collect additional information if needed) ⇓ 3. Review results with partners ⇓ 4. Set country priorities (needs and family practices) ⇓ 5. Identify potential interventions and approaches to community involvement ⇓ 6. Define indicators with targets and integrated monitoring tools ⇓ 7. Identify tools for integrated supervision ⇓ 8. Identify resources ⇓ 9. Define criteria for selecting priority communities ⇓ 10. Develop a strategic plan within national integrated childcare strategy

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Annex 8

Current status of the planning process for the IMCI community component in five countries in the Region Table 1. IMCI working group on the community component Working group Established EGYPT Formally established MOROCCO Established PAKISTAN Formally established 2002 SUDAN Formally established Jan 2000 (similar subcommittees established in three states) Representatives of various programmes, state IMCI coordinators YEMEN Established, Feb 2001

Composition Within MOH

PHC, MCH, health education

National IMCI coordinator, representatives from directorate of hospitals, PHC, BDN and population dept

IMCI coordinator and adaptation focal point, FP/PHC, CDD/ARI, EPI, BF, provincial IMCI focal points NGOs (SCF, AKHSP), WHO, UNICEF

Staff of PHC departments (child health/ nutrition, health education, community participation)

Outside MOH

NGOs (Egyptian Women Physicians’ Association, Community Medicine Association, academia, Ministries of Information, Education, Social Affairs, Environment , UNICEF

NGOs, WHO, UNICEF

Universities – community depts (chair of group)

MOH: Ministry of Health; MCH: Mother and child health; FP/PHC: Family planning/primary health care; CDD/ARI: Control of diarrhoeal diseases and acute respiratory infections programmes; EPI: Expanded programme on immunization; BF: Breastfeeding; NGOs: non-governmental organizations; SCF: Save the Children Fund (US); AKHSP: Aga Khan Health Services Project; WHO: World Health Organization

Table 2a. Review of available information on key family childcare practices: sources of information (1) EGYPT Review Carried out MOROCCO Carried out PAKISTAN Planned for 2001 but postponed SUDAN Carried out YEMEN Not yet fully carried out. Decision made first to conduct community baseline and morbidity survey IMCI community baseline survey in selected areas, 2001 (BS2001); 2week morbidity survey; Demographic and Health Survey, 1997 (DHS97)

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Sources of information (mentioned in the country reports)

Practice 1, 2, 3: IMCI community baseline survey in 3 early implementation phase districts, 1999 (BS99); Demographic and Health Survey, 1995, 2000 (DHS2000); surveys on breastfeeding, Aswan, 1998 (BF98); national survey on iron deficiency anaemia, 1995 (IDA95); national survey on vitamin A deficiency, 1994 (VAD94); assessment of VAD and IDA in Alexandria governorate, 1998; national survey on iodine deficiency, 1989 Practice 4, 5: BS99; DHS2000; IMCI community assessment survey, 2001 (CAS2001) Practice 8, 9: BS99, DHS2000; follow-up after IMCI training, 1999-2001 (FU2001); IMCI health facility survey in 10 governorates

Practice 1, 2: Pan-Arab Project for Child Development survey, 1997 (PAP97); IMCI food box adaptation: improved practices attempts, 1997 (IPA97); Practice 3: national survey on iodine deficiency, 1994; national survey on iron deficiency, 1995; regional survey on vitamin A deficiency, 1996; national survey on iron deficiency, use of iodised salt and vitamin A supplementation, 2000. Practice 4, 5: PAP97; national survey on causes and circumstances of infant and child deaths, 1998 (SCD98); Demographic and Health

Practice 1: Baby Friendly Hospital Initiative evaluation, 1994 (BFHI94); Multiple Indicators Cluster Survey, 2000 (MICS2000) Practice 2: MICS2000 Practice 3: Nutrition surveys, 1996-98 (NS98); MICS2000 Practice 4: Knowledge, attitude and practices survey, 1992 (KAP92); MICS2000 Practice 5:

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Table 2a. Review of available information on key family childcare practices: sources of information (1) EGYPT facility survey in 10 governorates, 2002 (HFS2002) Practice 10, 11: BS99; DHS2000; caretaker compliance with followup for pneumonia, 3 EIP governorates, ARI 1998 (ARI98) Practice 12: national statistics, 2001; BS99; DHS2000 MOROCCO Demographic and Health Survey (DHS), 1992 Practice 8: PAP97; IPA97 Practice 9: Health facility survey on quality of management of sick children in Meknes and Agadir provinces, 1997; findings of follow-up after IMCI training in 2 IMCI provinces (Meknes and Agadir) compared with 2 non-IMCI provinces (Larache and Tetouan) Practice 10: IMCI community baseline study in Meknes and Agadir provinces, 1997; childhood illness: practical representation and careseeking, 1999; SCD98 Practice 12: PAP97 PAKISTAN SUDAN MICS2000 Practice 6: MICS2000 Practice 8,9: CDD/ARI household survey, 1995 (HHS95); Practice 10: HHS95; assessment survey (NAS); Qualitative study in Gezira, 1999 (QSG99) Practice 11: QSG99; Study on compliance with referral and followup advice, Gezira 2000-01 (Gezira2000) Practice 12: HHS88; Safe motherhood survey, 1999 (SMS99) (1)

YEMEN

Available here refers to information contained in the country progress reports prepared for and reviewed during the workshop. ‘Poor’, ‘low’, ‘moderate’ and ‘good’ in

these tables refer to the degree the practice is followed (e.g., a very low exclusive breastfeeding rate would be referred to in this table as ‘poor’ exclusive breastfeeding practice). These judgements are just indicative, to give an idea across the table at a glance. When available, the figures on which they are based are shown in brackets.

Table 2b. Review of available information on key family childcare practices: findings Key childcare practice EGYPT MOROCCO PAKISTAN SUDAN YEMEN

(Review not carried out yet) Moderate (EB 68% for children < 4 months, then down to 28% in 4-6 months group; breastfeeding started within 1 hour of delivery in 75% of newborns; only a minority excl. BF throughout the first 6 months of life) Low (15% of children 7-9 months still exclusively BF; type of complementary food inadequate, DHS2000). Low (EB 46% for children <4 months; breastfeeding started late after birth; 47% children 2-3 months bottle-fed, PAP97) To be reviewed Poor (19%R-23%U of children under 4 months old, MICS2000)

(Partial review)

1. Exclusive breastfeeding

Low (40% < 6 months) [good knowledge level about when to start breastfeeding and frequency]; 38% of caretakers advised to feed formula (BS2001) Level of practice not mentioned in report

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2. Complementar y feeding

Poor (solid food introduced early in 12% of infants < 3 months; 47% (?) of children 12 months old given only breastmilk) Low for vitamin A supplementation (41% of children receive 1 dose of vitamin A); iron n.a.

To be reviewed

Poor (41%-52% of children 6-9 months introduced solid food in diet, MICS2000)

3. Micronutrients

Low for iron (health facility iron supplementation policy implemented in many but not all governorates; bread fortification with iron still being debated; 29.7% of children 6-59 months old anaemic at Hb <11 g/dl, DHS2000)

To be reviewed

Low-moderate for vitamin A (over 40% of children 5-59 months had not received vitamin A supplementation in the past 6 months, MICS2000) Poor for iron? (high prevalence of anaemia

Low for vitamin A (36% of < 5 years old given vitamin A during polio campaigns; 9% > 2 years old have night blindness – BS2001)

Planning and implementation of IMCI community childcare component

Table 2b. Review of available information on key family childcare practices: findings Key childcare practice EGYPT MOROCCO PAKISTAN SUDAN YEMEN

(Review not carried out yet) in children less than 5, NS98)

(Partial review)

4. Hygiene: a. handwashing

Low (handwashing with soap claimed in 75% of cases before cooking, 68% after using toilet, and 54% after disposing of child stools) Low (safe disposal of child stool in toilet claimed in 54% of cases in BS99 but much lower in CAS2001) Good (91% children 12-23 months old fully immunized)

Low? (diarrhoea still a leading cause of mortality and morbidity in under-fives) n.a.

To be reviewed

b. safe disposal of faeces

To be reviewed

Poor? (18% of mothers would practice hygiene as recommended – data before promotional activities, KAP92)

Low (58% of child caretakers ‘claiming’ proper handwashing with soap – BS2001) Poor (BS2001)

5. Immunization

Good (81% children fully immunized by age 1)

To be reviewed

Low (20%R-33%U of children 12-23 months old fully immunized)

Low-intermediate (among those with vaccination cards; measles: 43%; DPT3/OPV3: 72% – BS2001) Poor (2.8% of children sleeping under mosquito net; 90% of fathers not concerned about it – BS2001) Low (93% caretakers recognize importance of talking to child but

6. Malaria: use of bed-nets

Not relevant

To be reviewed

Low (15%N-25%S of children under-5 sleeping under insecticide-treated mosquito bednet) Level of practice not reported

7. Psychosocial development

Not mentioned in report

Not reviewed

To be reviewed

Table 2b. Review of available information on key family childcare practices: findings Key childcare practice EGYPT MOROCCO PAKISTAN SUDAN YEMEN

(Review not carried out yet)

(Partial review)

Planning and implementation of IMCI community childcare component

playing not mentioned; 80% fathers involved in caring for child – BS2001) 8. Home care for illness Poor (29% continued feeding during illness in BS99; 27% in DHS2000; 17% increased fluids during diarrhoea in DHS2000) Low (27% of children with diarrhoea given increased fluids; 69% continued feeding; food energy and nutrients usually inadequate during illness) Low To be reviewed Poor (18% of children with diarrhoea given increased fluids and continued feeding, HHS95) Poor? (BS2001)

9. Appropriate home treatment for infections 10. Careseeking

Low (BS99)

To be reviewed

Moderate (32% of children with diarrhoea given ORS) Poor? (24% of caretakers mentioned difficult breathing and 10% fast breathing as signs to seek care, but 80% mentioned ‘pneumonia’ – NAS) Moderate (33% of cases referred reached referral site on same day; 44% of those due

Poor/low (BS2001)

Poor (low level of knowledge about when to seek care; physicians major source of care in BS99; 1/3 of those seeking care did so on 1st day in BS99)

Low (median duration of care-seeking 4 days; advice usually sought from traditional providers)

To be reviewed

Level of practice not mentioned in report

11. Compliance with advice

Good (of those advised on follow-up, 70% in BS99 and 72% in ARI98 complied; 17 of 18 cases advised on referral

Not mentioned in report

To be reviewed

Level of practice not mentioned in report

Planning and implementation of IMCI community childcare component

Table 2b. Review of available information on key family childcare practices: findings Key childcare practice EGYPT MOROCCO PAKISTAN SUDAN YEMEN

(Review not carried out yet) complied with advice) to follow-up complied, Gezira2000) Low (more than 40% of mothers received no antenatal care) To be reviewed Low? (29% of mothers received no antenatal care; the rest received sub-optimal care, SMS99) Disparity between rural (R) and urban areas (U): better practices in U for: 1,2,3,5 and in south vs north for 6) Use of iodised salt; growth monitoring; detection and elimination of anopheles larvae at household level; rational use of drugs

(Partial review)

12. Antenatal care

Low (37% of women who delivered had paid 4 or more antenatal care visits and 53% received some kind of care, DHS2000; 73% of women received tetanus toxoid) Disparity between rural (R) and urban areas (U), and Lower (L) and Upper (Up) Egypt: better practices in U-Up for 1,2,3,4)

Level of practice not mentioned in report

Differentials

Disparity between rural (R) and urban areas (U): better practices in R for: 2, and in U for: 3, 5, 12

To be reviewed

Not mentioned in report

Other practices identified locally for promotion

Not chewing kat; prevention of home accidents

N = north; S = south R = rural; U = urban; ? = more information needed or information needs to be checked

Table 3. Review of existing interventions at community level and lessons learnt EGYPT Review Carried out MOROCCO Partially carried out (some interventions briefly described, but not reviewed – no remarks on lessons learnt) Not identified PAKISTAN Carried out, with focus on two initiatives (LHWs and HHCGs) SUDAN Carried out YEMEN Not carried out yet

Planning and implementation of IMCI community childcare component

Source of information

Not identified

External evaluation (Oxford Policy Management – OPM) LHWs and HHCGs

Not clearly identified (volunteers’ project evaluation in 2000 and BDN evaluation in 2001) Volunteers’ project; BDN – N; child-friendly communities#; community-based nutrition surveillance in Kassal and Sennar; schools of farmers and their wives in the agricultural scheme in Gezira; school gardening in Gezira; school health program in Gezira; health facility supportive staff for health education sessions in the community Volunteers’ project:

Interventions

‘Raidat refiyyat’ – female CHWs-N; ‘Daya’ – TBA-N; female health promoters in Qena, Aswan, Fayoum; CHW ‘depot holders’ in CDD project; Shorouq project – N; BDN; women’s clubs; mother-to-mother support groups, Aswan

Agricultural promoters – N; boy scouts for CDD – N; Development community workers – N; school teachers as ‘health auxiliaries’

Review findings

Volunteers mainly

No info

LHWs effective in

Planning and implementation of IMCI community childcare component

Table 3. Review of existing interventions at community level and lessons learnt EGYPT female; high turnover and lack of financial incentives a constraint for volunteer-based initiatives; project-led initiatives unsustainable; lack of partnership; influential and facilitating role of community leaders MOROCCO PAKISTAN providing and promoting use of services (antenatal, birth, EPI, family planning) and improving household health indicators (health knowledge, hygiene, diarrhoea prevalence, breastfeeding) SUDAN partnership essential; trainers should be from health cadres; high turnover of volunteers and lack of financial incentives adversely affected project sustainability. BDN: community well involved in project activities and happy about project and outcomes YEMEN

N = nationwide; CHW = community health worker; TBA = traditional birth attendant; CDD = control of diarrhoeal diseases; EPI = expanded program on immunization; LHWs = lady health workers; HHCGs = home health care guidelines; BDN = basic development needs #

Not included in the country progress report but mentioned in the group discussion with the country team

Table 4. Review of existing health education and communication materials and activities EGYPT Review Source of information Review findings Carried out National IMCI community group Messages usually consistent but not widely disseminated; incomplete messages on care-seeking and full antibiotic treatment; info gap on micronutrients; valuable experience with mass media, esp. TV IMCI mother counselling card adapted Guide for communitybased workers developed No comprehensive communication plan developed yet MOROCCO Carried out National IMCI community group Not described in report PAKISTAN Carried out Progress report Need to revise the LHW curriculum to include all key IMCI family practices SUDAN Not mentioned in progress report YEMEN Started Progress report Not available yet

Planning and implementation of IMCI community childcare component

Actions resulting from review

IMCI mother counselling card adapted Communication plan developed to bring together partners’ communication efforts

LHW curriculum and materials revised MCI mother counselling card adapted Mother and child health card for HHCGs developed incorporating messages on key IMCI key family practices

IMCI mother counselling card adapted

Planning and implementation of IMCI community childcare component

Table 5. Review of existing, successful approaches to involving communities EGYPT Review Not carried out yet MOROCCO Not carried out (activities of BDN approach listed) Progress report PAKISTAN Carried out, with focus on two initiatives – LHWs and HHCGs External evaluation (OPM) SUDAN Carried out, with focus on BDN YEMEN Not carried out yet

Source of information Review findings

Progress report

Progress report on evaluation of BDN (March 2001) and review of Health Area Council (HAC) BDN: community electing its representatives, village development committees established and involved in BDN (plans to integrate activities between BDN and IMCI) HAC: multidisciplinary body representing formal and informal sectors, involved in planning, implementation and evaluation of health activities; it has much potential but not fully used in all health areas.

Small-scale approaches such as ‘BF Friends Association’ and ‘Patients’ Friends Society’ considered sustainable

Community represented and involved in planning, selecting LHWs and forming health committee and women’s group; positive perception of LHWs’ work and project

BDN = basic development needs

Table 6. Review of data on caretaker satisfaction EGYPT Review Source of information Carried out Follow-up visits to health facilities after IMCI training IMCI pre- and postintervention assessment Review findings Satisfaction with IMCI services due to child examination, treatment given, counselling Otherwise, preference for private sector, especially for perceived severe cases MOROCCO Carried out Follow-up visits to health facilities after IMCI training IMCI evaluation survey Satisfaction with IMCI services due to health provider’s attitude, time spent, counselling Satisfaction due to improved health in community, more health education, more EPI visits and health care available, better household hygiene More than 80% caretakers satisfied PAKISTAN Carried out External evaluation of LHWs by OPM SUDAN Carried out Follow-up visit to health facilities after IMCI training YEMEN Not carried out

56 Planning and implementation of IMCI community childcare component

Planning and implementation of IMCI community childcare component

Table 7. Review of information on health provider satisfaction EGYPT Review Not carried out (remarks in progress report) Progress report Limited feedback on performance may contribute to lack of motivation NGOs’ motivational schemes for CHWs thought successful in maintaining low turnover of CHWs LHWs paid by the government, motivated also through the respect accorded by the community, additional training received, certificates/awards , supervision by lady health supervisors MOROCCO Not reported PAKISTAN Carried out SUDAN Not carried out because of lack of data (remarks in progress report) Progress report YEMEN Not carried out

Source of information Review findings (motivation)

External evaluation of LHWs by OPM Community health providers may develop self-esteem when serving their community and given recognition by it. Refresher training of cluster representatives in BDN may be appreciated by them.

Table 8. Identification of existing or potential community structures and channels to link the community and the health system EGYPT Review Source of information Review findings Carried out IMCI community assessment Women’s clubs, ‘raidat refiyyat’ and FP educators, health facility board, boards on community development interventions, community-based board of ‘community development society’ (an NGO under village or town council or the council’s health and environmental committee), local administration councils MOROCCO Not reviewed Progress report Two community structures set up for IMCI: ‘action’ (provincial level) and ‘local’ (community level) community committees PAKISTAN Carried out Progress report LHWs, TBAs, health committees, women’s health committees Health area council, community structures under the BDN approach, volunteers’ project SUDAN Carried out REPUBLIC OF YEMEN Not carried out

Planning and implementation of IMCI community childcare component

Table 9. Identification of information gaps EGYPT Identification of gaps Information gaps Identified MOROCCO Not identified PAKISTAN Not identified, as review of information on practices not yet carried out SUDAN Not identified REPUBLIC OF YEMEN Not identified

Practices related to psychosocial development Determinants of behaviour related to childcare (understanding reasons for poor practices)

Table 10. Review with partners EGYPT Review of results How Done Seminars MOROCCO Done Meeting PAKISTAN Done IMCI community preplanning and orientation workshop SUDAN Done National workshop on the IMCI community component Workshop on IMCI and school health programme When March 2000 (results of IMCI community baseline survey) February 2002 (results of IMCI community assessment) Partners present WHO, UNICEF, USAID, NGOs, universities and professional associations, MOH departments, governorates and districts Development of plan for IMCI community component, in cooperation with active Presentation of results of IMCI community assessment and planning to the community March 2002 October 2000 (community) 2001 (school health) REPUBLIC OF YEMEN

Planning and implementation of IMCI community childcare component

Not yet done

MOH staff, representatives of different ministries (education, agriculture, interior, etc.) and local communities, NGOs

MOH (malaria, EPI/CDD, ARI), academia, provinces and districts, SCF-US, AKHSP, WHO, UNICEF, World Bank

IMCI community workshop: federal and state MOH departments, academia, WHO, UNICEF, UNFPA, NGOs School health: federal MOH and Ministry of Education IMCI community workshop: agreed community-, facility- and school-based

Outcome of review

Agreement to form a partnership on childcare

Outline of activities needed to promote selected family practices as a basis to

Planning and implementation of IMCI community childcare component

Table 10. Review with partners EGYPT NGOs, focused on orienting to it various sectors (also at district level), training volunteers in health education, strengthening teaching of communication skills at medical and nursing schools MOROCCO PAKISTAN develop the plan for the IMCI community component SUDAN interventions and development of plan of action for 2000-2001 School health: schoolbased activities proposed to improve childcare community practices REPUBLIC OF YEMEN

Table 11. Setting priorities EGYPT Priorities (in the order ranked by countries)* Exclusive breastfeeding Complementary feeding Care-seeking Compliance with provider advice Home care Home treatment for infection Handwashing MOROCCO Exclusive breastfeeding Home care Hygiene Correct use of treatment Care-seeking Antenatal care PAKISTAN Immunization Home treatment for infections Exclusive breastfeeding Antenatal care Complementary feeding Home care Care-seeking Hygiene Micronutrients Compliance with provider advice Contribution to mortality and morbidity Susceptibility to change Acceptability by community Present in LHW curriculum Available experience SUDAN All key family practices + 4 additional practices (see Table 2d) [9 of them likely to be proposed as priorities for the 1st phase, to be endorsed at national level] REPUBLIC OF YEMEN Priorities not set yet. All the 12 WHO-recommended practices found suitable to the country situation + 2 additional practices (see Table 2d) [6 practices emphasized in the plan of action developed during this intercountry workshop: Nos. 1, 2, 3, 5, 8 and 10]

Planning and implementation of IMCI community childcare component

Selection criteria adopted

Importance of practice (likely impact on mortality) Prevalence of practice Likelihood of change

Importance of practice (likely impact on mortality) Likelihood of change Availability of resources for implementation

All practices relevant to Sudan

Note: practices are listed in the ranking order set by each country.

Planning and implementation of IMCI community childcare component

Table 12. Identification of potential interventions and approaches to the community involvement EGYPT Existing structures Women’s clubs, literacy classes, religious meetings, youth clubs Identification of CHWs (See Table 8 for existing structures which team plans to select from) Training of CHWs using newly developed materials Improving link between community and health system More ‘dynamism’ Strengthened childcare aspects Childcare component Training and social mobilization, illiteracy fighting and water supply (BDN) FP-PHC programme BDN MOROCCO PAKISTAN LHWs, TBAs, health committees, women’s groups SUDAN Health area council, community structures under BDN approach, volunteers YEMEN Not yet reviewed

New structures Existing interventions

New interventions

‘Added value’

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Meeting reports

Date d'adoption 31 décembre 2003

Source Organisation mondiale de la santé