REPORT
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITY lMCI
Convened by:
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Anti polo City, Philippines 29 January - l February 2002
(WP)/CHD/ICP/CHD/002-E
Report series number: RS/2002/GE/09(PHL) English only
REPORT
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITYIMCI Convened by:
WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC
Antipolo City, Philippines 29 January - l February 2002
Not for sale
Printed and distributed by:
World Health Organization Regional Office for the Western Pacific Manila, Philippines
March 2002
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REGIONAL NGO TECHNICAL CONSULTATION ON CO!vlMVNITY IMCI
NOTE
The views expressed in this report are those of the participants in the Regional NGO Technical Consultation on Community IMCI and do not necessarily reflect the policies of the Organization. This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Regional NGO Technical Consultation on Community IMCI, held in Antipolo City, Philippines, from 29 January to l February 2002.
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CONTENTS
SUMMARY .............................................................................................................................................. 5 1 INTRODUCTION........................................................................................................................................... 6 2 PROCEEDINGS .............................................................................................................................................. 7 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2. 9 2.10 2.11 2.12 2.13 2.14 2.15 Objectives .................................................................................................................................... Date and venue........................................................................................................................... Participants ................................................................................................................................. Opening ceremony ..................................................................................................................... Overview of the technical consultation .................................................................................... What is IMCI ............................................................................................................................... Presentation................................................................................................................................ The elements of the CORE framework ..................................................................................... Group discussions on the elements of IMCI and cross-cutting issues................................. Marketplace sessions ................................................................................................................ Presentation and plenary discussion on community IMCI planning ..................................... Discussion and small group work on developing and improving partnerships between NGOs and governments .................................................... Presentation of regional community IMCI framework and small group discussions............................................................................................................. Discussion of next steps ............................................................................................................ Closing ......................................................................................................................................... 7 7 7 8 8 8 8 8 9 15 15 16 18 19 20
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CONCLUSIONS ....................................................................................................................................... 21 ANNEXES : ANNEX 1 ANNEX 2 ANNEX 3 LIST OF PARTICIPANTS AND FACILITATORS ............................................................... 22 AGENDA ............................................................................................................................ 26 PRESENTATIONS: THE IMCI STRATEGY ...................................................................... - COMMUNITY IMCI PLANS AND ACTIVITIES .............................................................. - NGO CHILD HEALTH ACTIVITIES IN THE REGION ..................................................... - THE CORE FRAMEWORK FOR COMMUNITY IMCI ...................................................... 27 32 35 37
Key words: Child health services I Child welfare I Community health services I Delivery of health care, Integrated I Disease management I Non-governmental organizations I Philippines
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SUMMARY WHO has received numerous requests from governments in the Region for assistance and guidance on planning and implementing the community component of the Integrated Management of Childhood Illness (IMCI) strategy. It has become clear that governments need a framework to understand what types of issues and activities are included in community IMCI as well as a set of guidelines for planning such activities. Recognizing the wealth of experience that non-governmental organizations (NGOs) have gained through their activities in community child health, WHO invited representatives from 19 NGOs in the Western Pacific Region to participate in a regional consultation to share their experiences and assist in the formulation of a regional framework for community IMCI. The Regional NGO Technical Consultation on Community IMCI was conducted in Antipolo City, Philippines from 29 January to l February 2002. The technical consultation started with presentations on the IMCI strategy, community IMCI plans and activities, NGO child health activities in the Region, and the Child Survival Collaboration and Resources (CORE) framework for community IMCI. These were followed by two sets of small group discussions on a variety of issues related to community IMCI (e.g. communications strategies, partnerships between health facilities and communities, and sustainability). Next, discussions were held on the process of planning and strategy development for community IMCI and the issue of strengthening partnerships between NGOs and governments. The draft regional framework for community IMCI was then presented and participants were given a chance to discuss it in small groups. The consultation concluded with a discussion of next steps. Several key issues related to community IMCI emerged during the consultation. It was agreed that partnerships are required to make community IMCI a success. Partnerships can be developed through community IMCI working groups at various levels (e.g. district, province, national). The working groups have a major role to play in planning, coordinating, and implementing activities. A clear planning process for community IMCI is needed. During the planning process, existing activities should be reviewed and new or additional activities should be built upon them. Community members should be involved in the planning and implementation process, and community participation is considered to be a basic, underlying component of community IMCI. Government policies and laws may be needed to facilitate the implementation and to improve the sustainability of community IMCI activities. Regarding the regional community IMCI framework, the areas of community IMCI outlined in the framework are in line with the types of activities conducted by NGOs and cover many of the issues discussed during the technical consultation. However, it was felt that more details about the areas of the framework and how they are linked to one another would be needed to make it operational. The participants assisted in the development of a list of issues or topics to be included in the framework document. The framework document is currently under development. The draft framework will be distributed to technical consultation participants and other key agencies for comment in early 2002. It is hoped that a revised version of the framework will be presented to governments for their approval during a regional meeting tentatively planned for early in 2003.
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INTRODUCTION
The Integrated Management of Childhood Illness (IMCI) strategy was jointly developed by the United Nations Children's Fund (UNICEF) and WHO to improve child survival, growth, and development through the integration of programmes and activities that focus on the most common causes of death (acute respiratory infections, diarrhoeal disease, malaria, measles, malnutrition). The strategy is made up of three components which aim to improve health worker skills, to strengthen the health system, and to improve family and community practices. IMCI was introduced in the Western Pacific Region in the mid-1990s. To date, the IMCI strategy has been adopted by 12 countries in the Region. At country level, it is usually implemented in a phased manner: introduction; early implementation in a limited area to gain experience; and expansion. Four countries in the Region are now in the expansion phase, four countries are in the early implementation phase, and four countries are in the introduction phase. Experience in the Region has indicated that countries not only move through the overall phases of IMCI implementation, but they also tend to phase-in the three components of IMCI over time. Countries have usually begun implementation by adapting case management guidelines and training health workers (component 1). Strengthening of health worker skills has been followed by efforts to improve the health system to make it easier for health workers to provide care in an appropriate manner (component 2). The third component of IMCI, improving family and community practices, has been more difficult to implement and it has lagged behind that of the other two components in most countries. WHO has received numerous requests from governments in the Region for assistance and guidance on planning for and implementing the community component of IMCI. It has become clear that governments need a framework to understand what types of issues and activities are included in community IMCI as well as a set of guidelines for planning such activities. Recognizing the wealth of experience that NGOs have gained through their activities in community child health, WHO asked its country staff and contacts in Ministries of Health to identify the governments' strongest NGO partners in community IMCI. These NGOs were then invited to share their experiences and assist in the formulation of a regional framework for community IMCI during the Regional NGO Technical Consultation on Community IMCI in Anti polo City, Philippines from 29 January to 1 February 2002. The main product of the technical consultation is a draft regional framework for community IMCI that includes guidelines for planning. A document that elaborates the framework is currently under preparation, and it will be distributed to participants of the consultation for their comments in early 2002. The WHO Western Pacific Regional Office plans to share the revised framework with representatives of Ministries of Health at a regional meeting tentatively planned for early 2003. It is hoped that the framework will be endorsed by the governments currently implementing the IMCI strategy and used to guide planning and implementation of the community component starting in early 2003. It should be noted that the community IMCI framework produced by the Child Survival Collaboration
and Resources (CORE) group 1 was used as an important background document for planning the technical consultation and for developing the Western Pacific Region's framework for community IMCI . It was felt that the CORE framework could not be adopted for use by governments as the framework focuses on the strengths of NGOs and what NGOs can do to further the implementation of community IMCI. However, it was thought that the CORE framework and the framework developed for the Western Pacific Region could complement each other and co-exist as frameworks designed for two different groups of users.
1 Winch, P, LeBan, K, Kusha, B. Reaching Communities fo r Child Health and Nutrition: A Framework f or Hou sehold and Community IMCI, Child Survival Technical Support Project, Calverton, MD, April2001.
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2 The Regional NGO Technical Consultation on Community IMCI provided NGOs with an opportunity to share information about their community child health activities and to assist in the development of a regional community IMCI framework. It was also a chance to build and strengthen partnerships and to plan for next steps.
PROCEE DINGS
2.1 Objectives The objectives of the technical consultation were to: l. ensure a common understanding of the IMCI strategy and community IMCI;
2. share information about and discuss NGO experiences with community child health activities in order to identify potential approaches to promote community IMCI in the Region; 3. identify ways to strengthen collaboration between NGOs and governments for community IMCI implementation; and 4. discuss a draft framework for community IMCI in the Region.
2.2 Date and venue The Regional NGO Technical Consultation on Community IMCI was held from 29 January to l February 2002 at the Meralco-MML Development Center in Antipolo City, Philippines.
2.3 Participants Participants were representatives from NGOs with experience implementing community child health activities in six countries (Cambodia, China, Lao People's Democratic Republic, Mongolia, Philippines, and Viet Nam) in the Western Pacific Region. The Child Survival Collaboration and Resources (CORE) Group, the United States Agency for International Development (USAID), the Philippines Department of Health and WHO staff from country, Regional and Headquarters offices also participated in the technical consultation. The full list of participants and facilitators is included in Annex l.
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2.4 Opening ceremony Dr Shigeru Omi, Regional Director of the WHO Western Pacific Region, formally opened the technical consultation with a speech in which he discussed the importance of child health issues in the Region and the necessity for NGOs to be involved in community IMCI. The opening address was followed by the introduction of participants and the presentation of the objectives and agenda for the consultation. Officers for the consultation were named. Dr Ly Vanthy of World Vision in Cambodia was chosen as Chairman, Ms Eva Puertollano of Helen Keller International in the Philippines was appointed as Vice-chair, and Ms Isabelle Cazottes of Save the Children UK in Tibet, China was chosen as Rapporteur.
2.5 overview of the technical consultation The technical consultation started with four presentations, and continued with several small group sessions and discussions to get input from participants for the preparation of a draft regional framework for community IMCI. The draft framework was then presented and discussed, and next steps were identified. The agenda is included in Annex 2.
2.6 What is IMCI The consultation began with an activity to determine how much participants already knew about IMCI. Participants were asked to write down three things about IMCI. When these were read aloud to the group, it was clear that the majority of participants had a good understanding of the IMCI strategy and its three components.
2. 7 Presentations The initial activity was followed by presentations on (l) the IMCI strategy, (2) community IMCI plans and activities, (3) NGO child health activities in the Region, and (4) the CORE framework for community IMCI. Copies of the slides used for the presentations are found in Annex 3. The purpose of these presentations was to report back information about community IMCI activities collected from governments and NGOs and to make sure that all participants had the same level of knowledge of community IMCI and the CORE framework.
2.8 The elements of the CORE framework The framework developed by the CORE group of NGOs was used as the basis for small group discussions and as a background document for the development of the Western Pacific regional framework1. To ensure that participants understood fully the three elements of community IMCI as outlined in the CORE framework (l) partnerships between health facilities and the communities they serve, (2) appropriate and accessible care and information from community-based providers, and (3) integrated promotion of key family practices, participants conducted a sorting exercise of their main community child health activities. The discussions that followed indicated that the distinction between elements was not always clear. For example, elements 2 and 3 can overlap depending on how one defines the words "community-based 1 The CORE framework has three elements and the draft framework for the Western Pacific Region has four areas . The elements and areas of the two frameworks overlap, but are not equivalent REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITY IMCI
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providers" in element 2. If "community-based providers" includes community health workers (CHWs) and other health volunteers, then activities related to training CHWs or health education provided by them could be included under either element 2 or 3.
2.9 Group discussions on the elements of IMCI and cross-cutting issues Two sets of facilitated small group sessions were held to discuss issues related to the elements of the CORE framework and other issues that cut across the three elements of the CORE framework. These discussions served two main purposes. First, they provided participants with an opportunity to share information with each other regarding their work. Second, the discussions helped facilitators to obtain information about NGOs' activities and experiences for the development of the regional framework. Because the number of topics to be covered in each session was large, each small group discussed different issues and reported back on their discussions in a plenary session.
2.9.1 Elements of community IMCI The first set of discussions focused on topics related to the three elements of community IMCI outlined in the CORE framework. Tables l-3 summarize participants' practical experiences related to each topic discussed. Additional points from the discussions are included below each table. (a) Element 1: Partnerships between health facilities and the communities they serve
Table 1 outlines the main issues discussed with regard to building partnerships and creating linkages between health facilities and communities. Table 1. Discussions on Element 1 Topic: Partnerships between health facilities and the communit ies they serve Actors Activities Implemented • Health education • Community-based monitoring and evaluation • Participatory planning • Meetings that included community leaders and decision makers Results Achieved • Communities became more pro-active • Links between communities and health facilities facilitated community development Problems Encountered • Geographical inaccessibility of the population • Rapid health staff turnover • Political partisanship
• Community volunteers • Village groups • Teachers • Religious leaders • Health committees • Elected officials
In the plenary discussion, participants also underlined the importance of creating links between health facilities and communities in order to increase use of facilities. In the Philippines, use of health facilities has been increased through a programme (Sentrong Sigla) in which the government monitors the qual ity of health centres by checking on physical set up, service delivery, supplies and equipment, manpower, community involvement, links to government, etc. against set criteria. Health centres that achieve a certain level of quality are given a financial reward to further develop the services and a symbol to post on the wall. Thus, their quality services are better recognized by the community. REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITY IMCJ
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(b) Element 2: Appropriate and accessible care and information from community based providers Table 2 summarizes the discussions related to community-based health care providers and community drug supplies.
Table 2. Discussions on Element 2 Topic: Working with community-based providers and/or private providers Actors • Community health workers • Drug sellers • Midwives and traditional birth attendants • Pharmacists • Private clinics • Medical doctors • Teachers Activities Implemented • Advice and counselling • Referrals • Selling drugs (this varied from country to country and may depend on their level of training) Problems Encountered • Inadequate quality of care and counselling • Low motivation to provide appropriate services • Insufficient links to health facilities Suggested Solutions • Job aids • Training on counselling skills and on specific messages • Health education materials • Supplies and equipment (especially for midwives) • Supervision • Regular salaries • Awards and recognition • Exposure trips/cross visits • Inclusion in professional organizations • Links to the government system • Meetings between public and private providers • Links through referrals
Topic: Drugs and supplies at community level Actors • Community health workers • Drug sellers • Midwives and traditional birth attendants • Pharmacists • Private clinics • Medical doctors Activities Implemented • • • • Revolving drug funds Insurance schemes Community pharmacies Community drug boxes Problems Encountered • Labelling in a foreign language • Insufficient quantity • Not in appropriate form for children • High cost • Delayed delivery • Lack of capacity for drug management • Sustainability of drug provision schemes in communities Suggested Solutions • Use generic drugs • Strengthen community drug management • Develop adequate drug policies • Educate caregivers on appropriate drug use • Link community drug provision schemes to the government system
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Participants also discussed two other ways to improve the quality of care provided by community based providers. It was agreed that if normative roles for private providers could be created, then the quality of their work could be influenced by positive peer pressure. This was thought to be a good alternative in places where it is difficult to enforce laws or policies regarding the types and quality of care given by private providers. It may also be helpful if countries can officially recognize community-based providers, such as community health workers. This gives them legitimacy and helps ensure the quality of their activities. (c) Element 3: Integrated promotion of key family practices Table 3 outlines the discussions on three topics (working with community resource persons for health, communications strategies, and prioritizing key practices) related to the promotion of key family practices. Table 3: Discussions on Element 3 Topic: Working with community resource/persons for health Actors • Community health workers • Drug sellers • Midwives and traditional birth attendants • Pharmacists • Traditional healers • Community leaders Activities Implemented Problems Encountered Suggested Solutions • Motivating factors increased status in the community, monetary or other incentives, social and educational self-improvement • Advocate to donor agencies for longer funding cycles • Convince local government officials to include incentives for community resources persons for health in their annual budgets
• Counselling •Lack of motivation to • Health promotion continue working as • Referred community volunteers members to health facilities • Sustainability of using • Assisted with health facility community resource outreach activities person for health to • Data collection implement activities
Topic: Communications strategies Actors Methods/Activities Resu Its • Number of community health workers to train • Expense of training health workers and producing IEC materials • Lack of health worker time for activities • Unavailability of mothers Problems • Share costs with other groups (e.g. for training or health education materials production) • Advocate with the government to allocate funds for IMCI • Utilize mothers to educate their peers
For interpersonal • Interpersonal communication: communication • Community health workers • Massmedia • Drug sellers • Advocacy meetings • Midwives and traditional birth attendants • Pharmacists • Traditional healers • Community leaders
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Topic: Prioritizing key practices Actors Not applicable Activities Implemented Prioritized key family practices based on: • Severity of the problem • Feasibility of the intervention • Potential impact of the intervention Determined feasibility based on : • Consultations with communities • Availability of resources and political will Problems Encountered • Inability of community members to absorb multiple messages • Information overload Suggested Solutions • Involve communities in the selection of number and types of messages through a participatory process • Segment the target audience and provide specific messages to each segment • Integrate multiple messages into activities that require participants to put the messages into practice • Phase in messages overtime
Participants agreed that in their experience interpersonal communication is the most successful method for promoting key family practices, especially when supported by mass media. Interpersonal communication works best when it is participatory, based on the experiences of the learners, or transmitted from peer to peer. NGOs use a variety of types of IEC materials, ranging from counselling cards and flipcharts to radio messages and comics. At the moment, most countries do not have standard sets of messages for the key family practices. Standard messages are important for ensuring that the same ideas are heard in all parts of the country and that the same messages are transmitted by different people or channels (e.g. health workers and community volunteers). It was thought that the process of standardization could be led by one or two NGOs with approval or consistency checks being provided by the government. The group suggested that NGOs could advocate with donors to provide resources for one or two agencies to develop the IMCI communications strategies for a country.
2.9.2 cross cutting issues The second set of discussions focused on issues that cut across the main elements of community IMCI. These issues are listed below along with summaries of the discussions about each one.
2.9.2.1 Building ownership in the district and community NGOs have built ownership in communities through the use of participatory approaches, by developing mutual trust between communities and health providers, and by identifying credible and respected community members to promote ownership. Communities have been involved in planning, implementation, and monitoring of activities through their leaders or other community members who have been trained to undertake these tasks. At the district level, ownership of community child health activities has been created by sharing information about plans and activities with district officials and through district financing of community child health activities. The district, community, and NGOs can collaborate on developing a district plan for REGIONAL NCO TECHNICAL CONSULTATION ON CO!vlMUNITY JMCI
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community child health activities through meetings and correspondence. Some NGOs felt they might need to "train" district officials on the planning proce.ss. It is helpful if NGOs have a Memorandum of Agreement with the district that clearly outlines each group's role. The group identified the following constraints to building ownership: dominating district officials, limited budget at district level, lack of community participation in the process, and language barriers. It was thought that some of these issues could be overcome by building mutual trust between districts, communities, and NGOs. NGOs should involve the community and district in their projects from the beginning and should make sure to keep all their partners informed throughout the process. It may be necessary to raise awareness of the importance of child health activities at various levels (provincial, district, community) in order to create a desire for ownership. Following the presentation of this group's results, the issue of participatory approaches was discussed in the plenary. It was agreed that participatory approaches require a lot of commitment from stakeholders and NGOs, but that they are the best way to break dependency, promote empowerment, and create ownership. Community participation is a long struggle, but it is the price that must be paid for successful community activities. NGOs can promote the use of participatory approaches by advertising them as best practices.
2.9.2.2 Building capacity in the community and health facilities NGOs have used a number of strategies to build community capacity for planning, implementing, and monitoring child health activities. Some NGOs have increased community capacity by organizing and developing village health committees. Other NGOs have trained village health committees or other community resource persons for health to do community diagnosis using participatory processes. Still others have built capacity by training and monitoring village health workers and promoting village health workers as a link between communities and health facilities. Capacity building is often constrained by difficulties in scheduling training workshops and meetings and by lack of political commitment by local authorities. These types of problems can be overcome by setting up regular, periodic meetings, developing links between district planning and budget allocation, and by promoting community assertiveness to advocate for their own needs with local officials. To build capacity effectively, it is important to follow-up on activities once they are initiated.
2.9 . 2.3 Working with partners NGOs work on community child health issues with many kinds of partners, including governments at all levels, international organizations, other NGOs, and community groups. The activities of various partners in community child health are coordinated through inter-agency coordination meetings and technical working groups. Partnerships with government are best coordinated through regular meetings. NGOs' main roles as partners on community child health are to trigger innovation and to fill in gaps or complement existing activities and services. REGIONAL NCO TECHNICAL CONSULTATION ON COMMUNITY IMCI
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2.9.2.4 Delivery of interventions NGOs said that their two main approaches for the delivery of interventions are to use participatory methods at the community level and to utilize government structures to assist in implementation. They also felt that it is important to keep sustainability in mind from the start and to advocate for policies that could affect activities at the community level. As with choosing messages to focus on, choosing interventions or topic areas for community child health activities is done based on three main factors - community demand and input, health data, and the level of involvement and interest by local and national authorities. The most feasible interventions or activities are those that are the priority for the community, that use the government structures, that fit within the budget, and that can be adapted to local culture and beliefs. The group identified some important constraints to delivering interventions, such as lack of training materials for community health workers, lack of infrastructure, agricultural cycles and weather, war and political instability, and inadequate funding.
2.9.2.5 Strategies for integrating multiple interventions NGOs are able to implement activities on different topics by phasing them in over time or by linking their activities to the seasons. The number of topics or interventions that can be carried out at the same time depends on the community's ability to absorb new ideas. It is not feasible to have more than two or three activities at the same time. If a few or several partners are involved in the implementation of multiple interventions, their activities may be coordinated through meetings in which each organization agrees on its role and function or by following guidelines set by the government at the central level. It may be difficult to integrate multiple topics or interventions because the activities lack focus, there are language or cultural barriers, or the funding cycle is too short to implement different interventions. To sustain multiple interventions it is necessary for NGOs to work closely with their government counterparts. Multiple interventions are better integrated when activities are prioritized, there is an emphasis on behaviour change, activities are monitored regularly, and activities are coordinated through partnerships.
2.9.2.6 Strategies for promoting sustainability NGOs have tried to promote the sustainability of their community child health activities by integrating them into mainstream activities and by increasing ownership or stakeholdership. Sustainability can also be increased by building capacity at the local level and by creating a demand for services. NGOs can influence the sustainability of their activities by working on policies at all levels and advocating to funders. Some NGOs have increased sustainability by sharing results and lessons learned and by combining resources with other groups.
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2.9.2. 7 NCO contribution to scaling up
NGOs can contribute to scaling up of community child health activities through collaboration and capacity building with the Ministry of Health at all levels. NGOs can assist in standardizing activities and approaches across geographical areas by participating in coordinating committees, by using government technical guidelines and policies, and, in some countries, by following the existing hierarchical system. Task forces or coordinating committees are needed at all levels to make scaling up possible. NGOs can act as catalysts for the formation of task forces and can provide technical support to the task forces, if needed. NGOs can also introduce the importance of community participation to other task forces members. Finally, NGOs can advocate to the government for policies that make the implementation of community activities more efficient.
2.9.2.8 Monitoring and evaluation
NGOs select the indicators for their projects by identifying appropriate indicators already in use by the Ministry of Health or by coming to agreement on the indicators with representatives of the health services. Data is collected through household surveys, from health centres, and by health volunteers. Some projects use teams to make random checks in villages or the community may check on the progress of activities through a self-monitoring system. In general, NGOs said that their data collection systems were either closely linked to the government system or in the process of being linked. It is important to involve community members in data collection and analysis so that they can be motivated to take further action to change behaviours and so that they can monitor their own activities. Community-based data is also useful for health workers because it alerts them to problems and allows them to take action quickly.
2.1 o Marketplace sessions Participants from each NGO were asked to prepare a poster and bring informative materials to the technical consultation. The posters described the mission of the organizations and outlined what types of community child health and other activities they are implementing. They were displayed throughout the consultation. In addition, four sessions were held during which groups of NGOs had a chance to describe their activities and show in detail the materials they had brought. These sessions provided participants and facilitators with the opportunity to learn more about what each NGO is doing and to ask specific questions to the presenters.
2.11 Presentation and plenary discussion on community IMCI planning A presentation on the planning process for community IMCI, as conceptualized by the Interagency Working Group (IAWG) on Community IMCI, was presented to participants, and a number of issues regarding the process were discussed in the plenary. Through the discussion, it became evident that NGOs are focused on the concrete steps they can take to advocate for and implement community IMCI and are interested in the planning process at all levels and their role in it.
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Some of the highlights of the discussion are described here. One important issue was how NGOs can be involved in community IMCI planning and strategy development. It is necessary to have a strategy at national and district levels (and at provincial level, in some countries). The national strategy gives decisionmakers and partners a clear idea of how to conduct successful child health activities at the community level. The district strategy serves as a unifying document that is developed by all actors in a particular geographic area. All of the relevant existing activities should be included in strategies at all levels. This require NGOs (and other partners) to participate in a new planning process even if they have already done some of their own planning. Another issue was the importance of flexibility in planning for community IMCI. There is no rigid process for community IMCI planning and strategy development. Each country must decide if the planning starts from the Ministry of Health and goes down to the districts and communities or if it starts at the community and the community plans feed into the national plan. In either case, the endpoint must be a strategy where plans at different levels fit together. It is the role of the government to stimulate and oversee the planning process, but NGOs can also play an active and supportive role in driving the process forward. NGOs expressed some concern about how their community child health activities, which may not constitute "full-scale" community IMCI, can be integrated into official plans. They also stated that they may have other activities that address the needs of the community, but that do not fall within the scope of community IMCI. It was agreed that defining which activities should be included in community IMCI is a tricky issue, but that this can be determined in each country. The existing child health activities of NGOs, even if they are not "full-scale", should be included in official plans. Other activities that NGOs are doing may also continue, and can be very important, but may not be included in the community IMCI strategy.
2.12 Discussion and small group work on developing and improving partnerships between NGOs and governments The session on partnerships between NGOs and governments began with a role play by three participants that showed the types of relationships that can be formed between an NGO, a government ministry, and WHO. This was followed by a brief discussion in plenary in which participants stressed the importance of different actors talking and building relationships in order to make community IMCI implementation successful. It was also stated that identification and maximization of each actor's strengths is crucial to community IMCI implementation. In addition, collaboration and understanding of each other's motivations and discussions about how each group can complement the others is extremely helpful.
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Participants discussed the following: • strategies for forming links between NGOs and government at all levels; • • problems NGOs have overcome in the process of forming links; and how governments can help NGOs implement community IMCI.
The key points that emerged are as follows: Strategies for forming links between NGOs government • • • •
and
NGOs should consult or conduct meetings with government health officials at all levels An NGO coalition should be formed as a first step before consultations between NGOs and the government NGOs can participate in monthly district/provincial health meetings A neutral group (e.g. a UN agency) could serve as facilitator of meetings between NGOs and the government or could facilitate linkages, in general
Problems to overcome in the process of forming links • Lack of coordinated effort towards a common goal • • • • Lack of awareness of each other's activities Lack of communication or poor communication between the provincial and district levels of the government Vertical health programmes pull government health staff in too many directions and consume much of their time Change of government leadership (through election or appointment) makes it difficult to maintain links
How governments can help NGOs implement community IMCI • By sharing information on the latest developments related to community IMCI (e.g. policies, financing, implementation, monitoring and evaluation, national plans) • By coordinating the efforts of NGOs • • • • Through the formation of a community IMCI working group (including all types of partners) By including NGOs in existing health or nutrition committees at various levels By providing guidelines for community IMCI By facilitating implementation of activities through the establishment of policies or laws 17
RECIONAL NCO TECHNJC,\L CON.'il'LTATION ON COM.JI!('Nln' IMC/
2.13 Presentation of regional community IMCI framework and small group discussions An overview of the draft regional framework for community IMCI was presented to participants (see diagram below). During the brief discussion that followed the presentation, the context in which the framework was intended to be used was discussed. It was agreed that more details would be needed to understand the parts of the framework clearly and that these should be elaborated upon to make the framework useful. Community IMCI Framework Diagram 1 Component #1 : Improved Health Worker Skills
CHILD
t
Component #3: Improved
Family Practices
Partnerships and Linkages
Community mobilization .....1------l~~ and motivation
Health Health information ..,.,.._ _ _~.,.. Means and for improving practices promotion
Participants were then divided into small groups to discuss the framework diagram itself as well as some issues for the elaboration of the framework. Some important points emerged during the presentations by the small groups and the discussion that ensued. These points are described below.
2.13.1 Role of community health workers in community IMCI The role of community health workers varies by country. In general, community health workers conduct health education and prevention activities, make referrals for appropriate health care, mobilize the community, provide health commodities, record health statistics, and serve as a link between communities, health facilities, and NGOs. 1
The diagram included here is the version included in the draft framework document and is slightly different than the one presented during the technical consultation.
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REGIONAL NCO TECHNICAL CONSULTATION ON COMMUNITY IMCI
2.13.2 community IMCI planning and strategy development
The groups proposed a process for planning and strategy development. They suggested that there were some preconditions that should be met before community IMCI planning and implementation could take place. For example, the government must "buy-in" to or take ownership of community IMCI, and the other two components of IMCI should be underway. They also felt that partnerships should be formed and some financing for community IMCI should be available before starting the process. Once these conditions have been met, a situation analysis should be undertaken to review what exists in terms of community IMCI and to identify successes, gaps, and constraints. Using the results of the situation analysis, the key stakeholders can be identified and their roles defined, and priority interventions and strategies to implement them can be chosen. Issues such as the geographic scope of community IMCI and possibilities for scaling up should also be considered. In some cases, policies may be needed to make implementation easier or to facilitate access to the means for improving key family practices. These steps should be undertaken through a process of consultative meetings with partners and stakeholders at all levels, with each level developing its own plans that are linked to the strategies defined at higher levels.
2.13.3 Issues for inclusion in the framework
Based on the discussion of the framework, the following list of issues to include in the framework document was developed: • Definition of community IMCI • Definition and explanation of the parts of the framework and how they are linked • Description of the links between the community component and other components of IMCI • Role of various actors in community IMCI (community health workers, NGOs, health workers, private providers, UN agencies) • Guiding principles for community IMCI • Summary of the community IMCI planning process • Importance of partnerships and linkages • Strategies for sustainability and scaling up • Importance of policies for community IMCI implementation and sustainability
2.14 Discussion of next steps Following the discussion on the draft framework, the next steps for the development of the framework were summarized and an update on global activities related to community IMCI was reviewed. To plan for next steps after the technical consultation, participants were divided into small groups to discuss the following questions: How can we maintain the momentum generated at this meeting? • What kinds of communication mechanisms can we put into place to maintain the network? • Who will be responsible for doing this?
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITY IMCI
19
Pairs of groups merged their responses to the questions and wrote them on flipchart paper. A summary of the main points is provided below. How can we maintain the momentum? NGOs to: • • Create coalitions of NGOs at national/regional/district levels that hold consultations and meetings regularly. Maintain working groups in each country that include government, NGOs, bilaterals, UN agencies, and other partners. Organize a technical meeting for NGOs in the Western Pacific and Southeast Asian Regions following the next IMCI regional meeting. Internet listserves. Periodic meetings of NGOs at national and lower levels. Strengthen existing networks, such as Global Alliance to Improve Nutrition (GAIN) in the Philippines or Medicam in Cambodia. Inter-country visits between NGOs to learn best practices. From a regional coordinating organization made up of NGOs involved in IMCI. Quarterly newsletter sent out by email including updates on training courses, status of activities in different countries, etc. Coordinating organization made up of NGOs in the Region that are working on IMCI. WHO in collaboration with NGOs. Individual NGOs for coordinating meetings between NGOs within countries or in the Region. In some countries, the Ministry of Health could be responsible.
CORE to: •
What kinds of communication mechanisms can we put into place? • • • • • •
Who will be responsible? • • • •
2.15 Closing At the end of the consultation, the objectives were reviewed and the outputs discussed. It was agreed that the consultation provided an opportunity for open dialogue and for stronger collaboration between NGOs and WHO for the purpose supporting the efforts of the governments in the Region to improve child health in communities. The consultation concluded with speeches of thanks by staff from the WHO Regional Office for the Western Pacific, by elected official, and by several participants. Before departing, participants completed an evaluation form.
20
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITY IMCI
3
CONCLUSIONS
This technical consultation validated the importance of NGOs in the development of community IMCI in the Western Pacific Region. The posters prepared by NGOs and discussions during the consultation made it clear that NGOs are already doing many activities included in community IMCI. NGOs are in a unique position to be able to serve as catalysts for the process of community IMCI planning and implementation, and can provide examples of best practices. The willingness of NGOs to collaborate on implementation indicates that it is possible in each country to link activities conducted by many NGOs and other partners in order to take community IMCI to scale. Several key issues related to community IMCI emerged during the consultation. It was agreed that partnerships are required to make community IMCI a success. Partnerships can be developed through community IMCI working groups at various levels (e.g. district, province, national). The working groups have a major role to play in planning, coordinating and implementing activities. A clear planning process for community IMCI is needed. During the planning process, existing activities should be reviewed and new or additional activities should be built upon them. Community members should be involved in the planning and implementation process, and community participation is considered to be a basic, underlying component of community IMCI. Government policies and laws may be needed to facilitate the implementation and to improve the sustainability of community IMCI activities. Regarding the regional community IMCI framework, the areas of community IMCI outlined in the framework are in line with the types of activities conducted by NGOs and cover many of the issues discussed during the technical consultation. However, it was felt that more details about the areas of the framework and how they are linked to one another would be needed to make it operational. The participants assisted in the development of a list of issues or topics to be included in the framework document. The framework document is currently under development. The draft framework will be distributed to technical consultation participants and other key agencies for comments in early 2002. It is hoped that a revised version of the framework will be endorsed by governments during a regional meeting early in 2003.
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITY IMCI
21
ANNEx 1 Regional NGO Technical Consultation on community IMCI Antipolo, Philippines - January 29 to February 1, 2002 List of Participants and Facilitators
Country Cambodia
Organization Partners for Development
Name Ms. Michelle Lang Child Survival Coordinator
Address
Telephone
Fax 855-23-213-335
E-mail gfd.cambodia@ biggond.com.kh 012962859@ mobitel.com.kh
# 24, Street 294, P.O. Box 551, 855-23-213-335 Phnom Penh, Cambodia
PATH USA
Ms. Hara Srimuangboon Program Manager
National Center for Health Promotion, P.O. Box 1684, Phnom Penh, Cambodia #30, Street 9, P.O. Box 52, Phnom Penh, Cambodia P.O. Box 126, Phnom Penh, Cambodia #20, Street 71, P.O. Box 479, Phnom Penh, Cambodia
855-23-720-172 016-880-042 855-23-214-334
855-23-215-005
hsrimau@ gath.org
Save the Children- Dr. Reginald Xavier Australia Basic Health Services Project Manager World Relief Ms. Kay Hansen Director Child Survival Program World Vision Dr. Ly Vanthy Technical Administration Support for Health Coordinator WHO/Cambodia Dr. Severin von Xylander Medical Officer IMCI
855-23-363-433
scacmb@ biggond.com.kh scajo@biggond.com.kh kay@camnet.com.kh
855-23-214-085
855-23-216-052 012-983-703
vanthy ly@wvi.org
#120, Street 228 855 23 216610 San kat Chadomuk, Khan Daun Penh, Phnom Penh, Cambodia
xylanders@cam.wgro.who.int
China
Save the Children (UK)- Tibet Programme Swiss Red Cross
Ms. Isabelle Cazottes Room 307 - 311, Gang Jian 86-891-6334854 Community Health Advisor Lhasa Hotel, 81 Beijing East Road, Lhasa, Tibet, R.P. China 850000 Dr. Philippe Dufourg Medical Coordinator Shigtase 857000, Tibet, China 86-892-8822-148
86-891-6339700
scfuk@ gublic.ls.xz.cn
src@ gublic.ls.xz.cn
22
REGIONAL NCO TECHNICAL CONSULTATION ON CONfMUNITY IMCI
Annex 1 continued Country Lao PDR
Organization Enfants et Developpement Save the ChildrenFrance Adventist Development and Relief Agency ADRA Adventist Development and Relief Agency ADRA Norwegian Lutheran Mission in Mongolia -NLM World Vision Mongolia
Name Dr. Aeudom Silavong
Address Telephone Ban Phonxay Xay Setha District 856 21 414355 BP 2532, Vientiane, Lao PDR
Fax 856-21-415157
E-mail eedbkeo@ hotmail.com eedlaos@ laotel.com
Mongolia
Dr. Mitsuaki Toyoda Health Program Coordinator Dr. Tuvshinbayar Tuul Project Doctor Child Health Improvement Project Dr. Saran Batchuluun Health Education Officer Dr. Orosco Shijee Team Leader Bayankhoshuu Area Development Program
P.O. Box 1038, Ulaanbaatar210613, Mongolia
97611 95151253 976-11-326288
health@ adra.org.mn
P.O. Box 1038, Ulaanbaatar210613, Mongolia
976 11 95151253 976-11-326288
health@adra.org.mn
Building 20, Mangirt district, 3th 01372 23888 batalion, Darhan-Uul aimag Chingis Ave.II/I Central PO Box 976 11 306088 705, Ulaanbaatar 210613 99189628
01372 29536
ssaranbatchuluun@ hotmail.co m magnhild@ mongolnet.mn orosoo shijee@wvi.org shijee orosoo@wvm.org
976-1-328644
Philippines
Catholic Relief Services Catholic Relief Services Helen Keller International Helen Keller International PearlS. Buck International Inc. Plan Philippines
Ms. Melindi Malang 470 Gen. Luna St. lntramuros, Health Education Specialist Manila Mr. Eiler Fernandez OIC - Project Manager Ms. Eva Puertollano Communication Manager Ms. Dainah CasintahanFajardo IMCI Consultant Mr. Carlo Valiente Project Director Ms. Natividad Silorio Technical Officer (Health) or Health Coordinator
527 8331 to 35
527-4140
470 Gen. Luna St. lntramuros, 527 8331 to 35 Manila 704 Pablo Ocampo, Malate 1004, Manila 704 Pablo Ocampo, Malate 1004, Manila 28-A Eugenio Lopez Street, Barangay South Triangle, Quezon City 525 9457 525 9457
527-4140 525-9476 525-9476
crsmcsQ@ mozcom.com crs-vro@ sk~inet. net melindi@ mozcom.com ~Iarin @crs-org.Qh eilerf@mozcom.com concord@ hki.com.Qh docdai@ hki.com.Qh
925 5956
QSbioc@ ormocnet.net.Qh
6th floor, 1184 N & M Bldg., 897 1656 I 4042/ Chino Races Ave., Makati City 2745, 890 7589
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITY IMCI
23
Annex 1 continued
Country Philippines
Organization Save the Children/USA, Philippines Field Office Department of Health of the Philippines
Name Ms. Teresita Chua Team Leader, Integrated Family Health Services Dr. Juanita Basilio Medical Officer Center for Family and Environmental Health Dr. Marianna Trias Child and Adolescent Health and Development Dr. Rafael Lopez Child and Adolescent Health and Development
Address
Telephone
Fax 853-0215
E· mail babes chua@yahoo.com
1 Encarnacion cor Lapulapu 852 3059 I 5408 Sts., Magallanes Village, Makati City San Lazaro Compound, Santa Cruz, Manila 711 6130 918 9158215
711 7846
WHO/WPRO
WHO/WPRO P.O. Box 2932 1000 Manila, Philippines WHO/WPRO P.O. Box 2932 1000 Manila, Philippines
632 528 9868
triasm @w[)ro. who.int
WHO/WPRO
632 528 9868
lo[)ezra@ W[)ro.who.int
WHO/WPRO
Dr. Nguyen Tran Minh Child and Adolescent Health and Development
WHO/WPRO P.O. Box 2932 1000 Manila, Philippines
632 528 9868
tFanminhn @w[)ro.who.int
VietNam
Cooperation Dr. Dao Thi ToNga lnternationale pour Senior Project Officer le Developpement et Ia Solidarite- ClOSE Research and Training Centre for Community Development RTCCD The Centre for Public Health and Development
So 4 Duong So 6 Pho Nguyen Hong St., Khu A Nam Thanh Gong, Hanoi, Vietnam
84 4 8359939 84 903 255371
84-4-835-9928
ngadtt@cidse.org.vn dttnga@ hotmail.com
Dr. Nguyen Trong An 90 Pham Ngoc Thach Street Head of Community Heath Dong Da, Trung Tu, Hanoi, Unit and Community Vietnam Nutrition Dr. Nguyen Thi Bich Van Director 68 Thuy Khue Street, Tay Ho, Hanoi, Vietnam
84 4 572 6640
84-4-572 7012
rtccd@f[)t.vn
84 4 8472158 (tel/fax)
ttgdskcd @hn.vnn.vn
24
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNIJY IMCI
Annex 1 continued
Country USA
Organization CORE Group
Name Dr. Lynette D. Walker IMCI Coordinator Dr. Alfonso Rosales Co-Chair Ms. Maria Fransisco Technical Advisor Child Survival Division Ms. Cathy Wolfheim Child and Adolescent Health and Development Ms. Leda Nemer Child and Adolescent Health and Development Ms. Valerie Flax Consultant
Address 220 I Street, N.E., Suite 270, Washington D.C., 20002 220 I Street, N.E., Suite 270, Washington D.C., 20002 Ronald Reagan Building, Rm. 3.7-027 Washington, DC. 20523-3700 WHO-CAH Avenue Appia 20 1211 Geneva 27 Switzerland WHO-CAH Avenue Appia 20 1211 Geneva 27 Switzerland Pinninkatu 13 A 14 33100 Tampere, Finland
Telephone 1-202-608-1892
Fax 1-202-543-0121
E-mail Lwalker@worldvision.org
CORE-IMCI Working Group USAID, Bureau for Global Health
1-202-608·1892 1-202·712-5002
1-202-543-0121
ARosales@catholicrelief.org Mfransisco@ usaid.gov
Switzerland
WHO/HQ
41 22 791 2625
wolfheimc@who.int
WHO/HQ
41 22 791 2625
nemerl@who.int
Finland
WHOIWPRO
358 3 2122048
vflax@yahoo.com
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITY IMCI
25
ANNEX2 NCO Technical consultation on community IMCI Antipolo. Philippines - 29 January 29 to 1 February 2002 Agenda Tuesday, January 29 Wednesday, January Thursday, January 31 Friday, February 1
30 9:00 - 9:45 Opening 9:45-10:00 Presentation of objectives and agenda 10:00- 10:30 Coffee break and group photo 10:30- 10:45 Icebreaker 10:45-11:15 What do we know about IMCI? 11 :15-12:00 The IMCI strategy 12:00-13:30 Lunch 13:30-14:10 Community IMCI plans and activities 14:10-14:45 NGO child health activities in the Region 14:45- 15:30 The CORE framework for community IMCI 15:30- 15:45 Coffee break 15:45-16:15 NGOs' activities related to elements of community IMCI 16:15-17:15 Group discussions on three elements of community IMCI 17:15-17:30 Poster presentation set up REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNIT\' 1/v!Cf
8:00- 8:10 Summary of Day 1 8:10-9:40 Plenary session on elements of community IMCI 9:40 -10:10 Marketplace session #1 and coffee break 10:10-11:10 Group discussions on crosscutting issues related to community IMCI 11:10-12:00 Plenary session on cross-cutting issues 12:00- 13:30 Lunch 13:30- 14:30 Continuation of plenary session on cross-cutting issues 14:30- 15:30 Presentation and plenary discussion on the district and community level planning process for community IMCI 15:30 - 16:00 Marketplace session #2 and coffee break 16:00- 17:00 Continuation of plenary discussion on the district and community level planning process for community IMCI
8:00- 8:10 Summary of Day2 8:10 -10:10 Developing and improving partnerships between NGOs and governments 10:10-10:40 Marketplace session #3 and coffee break 10:40- 11 :00 Draft regional framework for community IMCI 11 :00- 12:00 Small group discussions on the draft regional framework 12:00- 13:30 Lunch 13:30 -14:30 Continuation of small group discussions on draft regional framework 14:30- 15:30 Plenary session on draft framework 15:30- 16:00 Marketplace session #4 and coffee break 16:00- 17:00 Continuation of plenary session on draft framework 17:00-17:15 Final poster evaluation by participants
8:00 - 8:10 Summary of Day3 8:10-9:00 Planning for next steps (country groups) 9:00- 9:30 Plenary session on planning for next steps 9:30- 9:45 Coffee break 9:45-10:15 Continuation of plenary on planning for next steps 10:15 - 11:00 Plenary session on regional next steps 11:00-11:15 Summary of workshop activities and accomplishments 11:15-11:30 Workshop evaluation 11:30- 12:00 Closing session and announcement of poster competition winners 12:00- 13:00 Closing lunch
26
The IMCI strategy
ANNEx 3
Global Oun it•\\ of the 1:\ICI
Stnttt·~~
Integrated Management of Childhood lllness - Rii'Jiollal NGO T«<ulical CobS111tadou • Andpolo Cit~, PbWppinn 29 JauUJ12002
• Global status of child health What is Integrated Management of Childhood Illness (llviCI) • Global status of llv1CI implementation
:\lain stmtegies in pn•gmm9·, cad) lift•, childhood and adokscencc ~?:~.::••4 _.,., IMPAC "=:.~nut•
I Ohjt•cth t•s of Child lll•alth l'n>gnmllllt' l To reduce significantly global mortality and morbidity associated with the major causes of deaths in children To contribute to healthy gro"'1h and development
:~::::::;~ec;n • C-••l'IIJlfi'OIMf,_w
o
Al!fwvQICM•
.=.-.,.~
..... l'lft.-...;.,.
. .-
:=:ollbaJ-- JMCI
o
l!rton~COUtS . . ftO'
Programming for adolescent healttl
• .ftlfollitolc•.lWrlilllldiJ ftflnhi'IIIWl.'IU'f
..
J
-· ·li'J11$S . ~.tor
............. ·(CUit.f/9
. & ..~
H..cy
I
- ~~ot
. m,..m•on ~-"'
~,...
of children
• ••r.v•Jaauc •~ fll lllll•l"' • t 411We«tltlftltfl~
~··t......,...ro:
~·
( 'ames uf 10.5 million deaths among ch ildren < 5 in dcveluping rountncs, 1999
l'l'llpurtion ol glohal burden nl ~rkrtrd diSeases horne b~ chiidn·n under 3 ~cars
One in every two
dlilddeltth$ In developing
are due lo just five infectious
countries
Dlanhoea
15°/o
diseases •nd maloocrition
Measles
8°/o
HN/AlDS Mal>rl~ JO/o 7(1./ o
=-~~t~~~IO.W tWi.
DISh ihutinn nl deaths among childnn < :; 199(1 and ro 'cl'tcd for 2()2() • Tite 5 main killet~: ARL dianhoea, measles,
In de\'l'Inping countries in
e\CI~'
I II children:
malaria and nwl.nutrition Perinatal COJLdihon.s • Other conumuticable disea::es
1111116 1111113
had fever/malaria
[iii Non·COJIUlntuicable di11ease:::
4 were low-height-for-age were low-weight-for-age
•lnjmle<
REGIONAL NCO TECHNICAL CONSULTATION ON COMMUNITY IMCI
27
Impm·tant Elements fm· lm l"n\·in Child Health
Principles of Integrated care for children
Improve case m<magement of sick cluldren l.mprO\·e nutrition Ensure innmmization Prevent mjuries Prevent other diseases l!npro\'e psychosocwl support and stimulation
.a. r.nm... . , ~.
·· ~·-~act.
tnl(tllrw
...... -':""1
Common problems that affect the quality of care
:\lajor clements in 1:\ICI clinical guidelines: Counselling
- incomplete cxmniu.1tiom and coumdli.ng- poor conumulic:1lion between health worker~ :md parents - irr:r.lioualnsc of dmgs
Admi.tll~tration antipyretic~.
of oral mechcations at home: anhmalarial':l. etc
antibiotic~.
Heakb S)'SIE"JD l'>slles: - location of health scn.·icc5 and 1cspo1L<:ibility -
(.::cutrnli~lllion)
Treatment of other problems: loc<Jhsed infection~. e::u utfections. tlu·oat pai.tt. etc Recommendation~
3\":'lilability of :~ppropriate dmgs and ,-acttnes ~upernsion I
for feeding: child when ~ick rmd when
-
dnisiou ofl::abo\11 ,· pmcti('E"S: scckiu~
01~:miz.11ion
ofworL:.
reco\"ered lnst:mction~ on when to 1ehun for foUow-np nnd when to come in immediatel) Care for mother'' health
Comm,wlly and
r~lmil~·
- dcl:l)td care
- poor kllowlcdgc of\\ilcn to rchunlo a hc:dlh facilit)• - seeking a~sistancc froiU u.nqu:~lificd Jlfo\'idcrs Jl(ltn'
, dttnmote ,..,. hcLlhh WUII:.t, -;19n.cc: mni rrutmtlll
Changes m \\ctght-for-:.lj:?,C (7..r-scorc) ofcluldrcn consultatiOn h~ health \\nrker
~tftcr
Too
man~·
diffe1·ent pieces ...
1rm 1t·~•
.....,....,_,.,.. . __ ...-.. ~-. ....;~
...
... .. •1
Pr
·-
~--------~-----------"
Dfl~«fl1r&m.-.,Clftrtttii'-V'ol-b-.ooJt•"'lll'lll,•~~~tti\JI~IJ~ EI1 lrHIIrll..,..,.,.~nurrao- ~nt "'~liU..,Iln1~i u.~~ IQirr~~""~'r~~~nlM~
~-
~-
1!Kf.l~oCi!Diht~'Wtl.lf~r.r-61c.&L'II:QII:.
lllol:n i i'III~._Rllllu~u ....
J:\ICI bl"ings them all togcthc1·
1:\ICI components
Ifunin pl:\nnin.e mana;:('mtu.t
~nd
.\l'lll !t,.hl• ~llii.P""Il"''"li:iu;
A'llih.bilitvuf!l\ICI Trllinincoff.uili~· · dl111.f
Nu11ir:ion n.~~~. ~r
bouPd put:.li~ I1Palth U1tpu,·idns
Qn:\liry imp1 o\"tmtJ.U a.ud~•lptn"i'"ionu
U!ol
~ 1\IOI••Ifi
hPalthfatilitiu· RPfl'lnlpathWi\)"S :uJd.ttn"itu· Jt .-,ili) 1 lzi!U11UI I m ~
maJL1ll'IRPJU & adhtl-.D.CPilJ 1n •mlllrn11 " '' 11 ~1111' llt
.
jl rrrllfP'.I"W\"I·~"n
Co1nmnnity
~aw"'n .. nt('of ro~~~.pet('IICPIImonJ
lln.. h'f-Mt"11J1111 bfo~la.Sf~'lr. t l.
mtin~d
htalrll
workPTs ~~lffi""~m-
sy& ttom
pfnn..11ine.& morurormc
~l.tl~~... l ~b·ll-,.T-:1(·1'~ H·181
28
REGIONAL NCO TECHNICAL CONSULTATION IJN COMMUNiTY llv1Cl
\\here Can lor Childn·n Is l'rm idcd'!
lmplt•nu•ntatiun nf 1\1('1
Earty 1996: 14 Counbies
Pl.mning and implcmcntmg I \I(' I in countncs
Implementation of IMCI Components 1 and 2 of the stnd:egy
(.luna 2001)•
} Acd\idU ad ll'Op11phJaal
121 0
18 months
Eqalllfon oCthe nua• of
> 5 years
uvena•
Quality of Clll"e imp•·oYes "ith int1·oduction ofll\ICI 00 Proportion or thU.Jnu r«-ri\inc:: 93
L\1('1 reduces antibiotic .tbusc rat<· in \lorocco 9S Proportion of sick children who received unneeded presalptlon of antibiotics:
80
•Hulth woden NOT nsinc 11\lC'I {a.:.:U!) Ill H•*la woa·ICPa· usiuc IMCI (n-..:l47J
0 Comp.-.henslve Nutritional evaluation Review of vaccination
assessment mBefore ( 1997) •Mer (1999) I)J"(r'bdf,~.wJII.t~w.
status
'IM'J~Qih .. tk1.1.'tml.fod\!Ja.1J.Ht.&~•
~!oth<.:IS km..: the: facdtl~ bdt..:I abk to can; lot th..:11 chdd '"ll!l'roii><>rlllon of mothers leaving helJith facility who reported correctly: 100
Global challenges to 1\1('1 impl<•m•·ntation
.. 60
70 (56/SOJ
20
How to gtve OJ;~ I m~k:lne5
At !.. : ut two «bnger signs
sBefore(1997) •.AJter{1999)
Increasing resources in countries to expru1d IMCI Expanding in scope and coverage without loss of quality • Strengthening the family and community component • Expanding the range of conditions to be covered by llv!CI (e g neonatal period) Adapting Th.JCI to areas of high IDVIAIDS prevalence Establishing and using links with Roll Back 1vlalaria to ma'(i,mize mutual benefit
... REGIONAL NCO TECHNICAL CONSULTATION ON COMJ\WNITY lMCl
29
\Yh~
1\ICI is a
pdodt~ '!
IMCiinWPR
Focuses on conunon setious he<~lth problems in children Responds to the needs and demands of populations Positively impacts child health and development Contributes to prevention as well as early diagnosis and treatment of illness at home and in the he<l!tlt facility Promotes cost-effective use of scarce resources Increases equity by improving healtlt services where tltey are needed most
,..
'V--~-
,
-~-. .. -- . .......;.
status of IMCIImplementation In the WHO Western Pacific Region by December 2001
1\ICI hdngs it all togcthct·
-::?" ·.'"--
............
'•
lmpnning Skills of Health \Ym·kct·s Integrated case management guidelines Adaptation ensures optimal fit to local sttuation DHF· Cambodia. Philippines. VietNam Rickets: lv!ongolia lviother·s care: Cambodia I 0-step checklist. PNG • Evidence-based. tmiform standards to care ··:rMCI is practical and useful for everyday work m1d everv child seen It increases confidence, respect ruld motivation " ~~..,.,.,;'~~a.11111ulh
lmpt·o,·ing Skills of Health \\'m·ket·s Trainmg and follow-up • Focus on ShiLLS acqutsition • Skills reinforcement m1d problem solving • .'\.lternative ways of trainmg In-sen· ice training course (8-11 days) On-the-job training (Philippines) Plans for telemedicine (1vialaysia) Pre-service educatiOn (Ftji, VietNam. Mongolia. Philippines)
Stt·cngthl•ning Health
S~·stcm
lmpt·o,ing
famil~·
ami
communi!~
pt·actices
• IlviCI as part of national health policv CAM. CHN''. MOG. PHI... VTN' Linked with health sector reforms CAM, ll·fOG, PNG. PHI... VTN Capacity building at district level • IMCI as catalyst for specific health sector tmprovements • Strengthened efforts to improve availability m1d rational use of drugs • Improved referral & referral care (VTN. MA'\)
• Locally adapted feeding r.:c m m~nd>l lll)t1.~ • Improved commumcation m1d co\U1Selli.ng on home care, care-seeku1g and preventton of illness • Mother's Card • Community-based actn•Ities
30
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITY IMCI
Lessons Lem·ncd • Th..!CI meets the child health needs in primary health care
' 1
·
Challenges
Substantml experience and techrucal capacity gained Interest and enthusiasm • Collaboration among programmes. partners and different levels of health system Evidence of (cost)-effectiveness <Uld 1mpact building up
Balanced implementation of all components Increasing coYerage + maintaining quality Building district le,·el ownership & capacity Incorporating child health in ongoing health sector reform efforts • Continuous building of partnerships • Demonstrating (cost)-effectiYeness and impact
• • • •
Thank You!
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITY IMCI
31
COMMUNITY IMCI PLANS AND ACTIVITIES
Background
Community IMCI Activities and Plans in the Western Pacific Region
• Countries have started some IMCI activities at community level. • A brief description of government's community IMCI activities and plans was prepared.
Jl ....... c-......... -
-·-~=r~' ll<'f:!/
IMCIImplementation Plan
WPRO Countries included
All seven countries include
Community IMCI as part of their nationaiiMCI implementation plan. ~1:\'!'~:5:1-"
d
...... _.M:.:-.=.7-=r
Cambodia's Community IMCI Activities Drafted and tested the IMCI mother's card. Breastfeeding counselling training being introduced. • Drafted a policy on infant feeding practices. • Conducted a mass media campaign on nutrition and breastfeeding. • Restructured national level community IMCI sub-group.
Cambodia's Activities (continued)
• In collaboration with PATH, carried out studies on health communication related to child health and strategies for working with private providers. • Task forces (that include NGOs) set up within the national sub-group on specific topics. • On-going collaboration with UNICEF and World Vision to implement community IMCI activities in two pilot districts.
Cambodia's Plans
China's Activities • Developed mother's card and used it for face-to-face education. • Developed training materials on counselling skills for community health workers. • Conducted community health education activities on child health, growth, and development. • Launched health education campaigns through mass media. • Initiated breastfeeding support groups. • Held well-baby care clinics.
Conduct mass media campaigns on ORS and ARI in collaboration with UNICEF. • Make contacts with NGOs and other partners for IMCI expansion. • Apply for UN Foundation funds to expand community IMCI. Collaboration with World Bank on community interventions on nutrition.
32
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITY IMCI
China's Plans • Continue with activities already initiated. • Develop stronger links between communi ties and health facilities.
Lao PDR Activities and Plans • Held preliminar y discussion s with major players in community child health. • Most current community activities conducted by NGOs and bilaterals. • Will develop more detailed plans as other componen ts of IMCI progress.
Mongolia's Activities • Developed a manual for caregiver training. • 1,250 mothers/car egivers were trained and followed up conducted one year later reinforcing good practices. • Held a summer camp for children 0-3 years old with feeding problem or rickets . • Produced radio and newspaper messages. • Community members of IMCI districts were trained in the PHAST initiative.
Mongolia's Activities (continued )
• Held celebration s for World Breastfeed ing Week and Internation al Children's Day. • Developed and distributed a child growth chart. • Conducted a nutritional survey in areas affect by disaster.
Mongolia 's Plans • Continue with existing activities . • Work more closely with communi ty-based volunteer s and communi ty health workers.
The Philippines ' Activities • In collaboratio n with HKI , held an orientation workshop for NGOs on community IMCI . • Trained trainers on Enhanced Child Growth. • Revised the ECG counselling cards to include IMCI concepts. • Conducted bi-annual national Pre.schoole r's Week. • Held a campaign against dengue and dengue hemorrhagi c fever.
The Philippine s' Activities (continued ) • UNICEF has established health and nutrition posts in hard-to-reac h areas. • Posts are run by BHWs, who conduct monthly growth monitoring sessions, cooking demonstrat ions, and mother' s classes. • Pearl S. Buck has provided supplement ary food for malnourishe d children and provided training to mother's support groups.
The Philippine s' Plans • Work closely with partners that are interested in communi ty IMCI. • Hold a national level meeting of local and internatio nal NGOs to plan communi ty IMCI activities .
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNIT Y IMCI
33
Vietnam's Activities • Developed mother's card for use by health facility staff and community health workers. • In collaboration with UNICEF and WHO, conducted quantitative and qualitative assessments of key family practices. • Trained 23 village health workers on communication skills and best family practices. • Village Health Workers conducted health education sessions for mothers.
Vietnam's Activities (continued) • One hospital is conducting biannual health education sessions for mother's groups in eight districts. • In collaboration with UNICEF, integrated health communication activities were introduced in two districts.
Vietnam's Plans • Hold a meeting to disseminate findings of qualitative study. • Develop plans for future community IMCI activities and collaborations. • Finalize training manual for village health workers.
Conclusions • Community component of IMCiis under development in most countries. • Activities implemented to date are appropriate, but mostly on a small scale. • Few countries have made clear plans for working with private providers on community IMCI. • other ministries and governmental bodies have community level structures or conduct activities that could be integrated into community IMCI.
Conclusions (continued) • In some countries community IMCI needs more support from planning at a national level. • Most countries could strengthen partnerships for the implementation of community child health activities.
34
REGIONAL NCO TECHNICAL CONSULTATION ON COMMUNITY IMCI
NCO CHILD HEALTH ACTIVITIES IN THE REGION
NGO Questionnai l·e NGO Child Health Activities in the Region • Completed by 22 NGOs and 1 bilateral • information obtained from NGOs in 6 countries
Taa·get Ga·oups ll!!!i !l! ll! iii l! ll! !I! II!
Health Pa·oblems Targeted Dia1Theal disease Nutrition and micronutrien ts Breastfeedin g Acute respiratory infection Safe mothed10od
91% 91'%
m
m:
87% 87% 78%
·~~~;ii!;@l="iii•wmz;;,,;".~.;;iii•;•iii•""'';.,;,"~:!!G~IM!•i•"L':"'" llmllil!llllll!
Key Are~ts of Inten·entio n Health promotion 100%
Community Resom·ces Pea·sons foa· Health and theil" Main Roles Couumulity health workers Health center UHumgement committee~
Preventive activities 91%
l'vfanagement of health systems 70%
Women's groups Traditional bil1h attendants Health and development conunittees Health education Reten·nls Mobilization Health center management
.,..._·-~I
r.!
i~~ --;.!).!
- .. . - ! ........:
Types of Health Education Activities
Ke~·
Family & Community Pa"llctices Pa·omoted 97% 91% 91%
Home care for illness Compkmentary foods Safe disposal of faeces Appropriate care-seeking :tv.!icronutrients Exclusive breastfeeding ImmunizHtion Antenatal care
91 o/o
87% 87%
83% 83%
REGIONAL NGO TECHNICAL CONSULTAT ION ON COMMUNIT Y IMCT
35
Training Provided to Community Resom·ce Persons for Health
Links Between Community Activities and the Health System HC and District: 96% 91% 87% 74% 70% • Train volunteers • Supervise volunteers • Assist with planning proJect actlntles • Monitor activities Communitv Volunteers: • Refer clients to health centers • Assist with outreach activities
"'
Use of health education materials Technical topics Communication skills Data collection Community mobilization techniques
Types of Private Pa·oviders and Activities Activities: • Provide training • Provide IEC materials
Collaboa·ation with Other Organizations 1vlinistry of Health (at various levels) 91% International NGOs 65%
'W1-IO UNICEF
llviCI 65'% I any topic 78% llvlCI 35% I any topic 78%
36
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITY IMCI
THE CORE FRAMEWORK FOR COMMUNITY IMCI .~:;.7~:~~~ ~: ; •'
The C/IMCI Timeline ·ct 0 • Househ old/Com munity- IMCJ Advanc ing a conceptual and operational Framework
_, 91
Oven;ievr ofthe Framework :; "C-IMCI is the optimization of a multisectoral platform for child health and nutrition that includes three linked requisite elements"
..,..,_.Ill..;..,.,.... . _ . .......... 4llllillll
...
~~
Examples ofconne cNons to MSP ·; Improved water and sanitation linked to promotion of handwashing · Income generation activities linked to promotion of bednets c Income generation for men linked to men's involvement in reproductive & child health
The 3 Linked Elements Element # 1: Partnerships between health facilities and the communities they serve <~Element #2: Appropriate & accessible care & information from community-based providers <~Element #3: Integrated Promotion of Key Family Practices critical for child health & nutrition *~
Elemen t One: Partnerships between health facilities and the communities they se1ve ~: Assumes:
Where Elemen t One is crucial Facilities and services have been improved, but utilization of child health services is still less than expected *:Commun ity Health Workers are linked to health facilities ~·: MOH or other organization having limited experience with community work *~
Facilities exist and are functional Communities have geographic and economic access to facilities ::.Ideally: Health workers trained in IMCI, systems improvements in place, quality of care meets standards
~ ~ Assumes :
REGIONAL NCO TECHNICA L CONSULTA TION ON COMMUN in' IJ'v!CI
37
_ .... ·E /·:::""'"""·
.. Element Two: Appropriate & accessible care & information from community-based providers {>Community Health Workers (CHWs) and other voluntary workers '} Private providers '>Traditional healers '>Traditional birth attendants '>Shopkeepers and pharmacists
How Element One may d~flerfi·om previous community-based programs to implementation of IMCI in facilities increasingly held accountable for quality of services they provide {>Community role in management and sustaining systems improvements that are part of IMCI Component II ~>Community role in maintaining quality of services ~>Facilities ~>Link
-
E lement Two: Activities related to community-based providers '>Improve treatment of sick children :-:Upgrade the skills of community-based practitioners :-:Simplified algorithms for case management ~:Improve
Element Two: Community Health Workers '>Backbone of many PVO programs ':Major challenge is finding appropriate incentives ::Cost-effectiveness of CHW programs, given high rates of attrition in some areas, needs to be assessed :: Role of CHWs vis-a-vis private providers is major issue
referral of sick children {>Decrease harmful practices (injections) '>Increase role of C-B providers in promoting preventive measures e.g. handwashing
Element Two: Referral ofsick children from community-based provider to 151 level facility ':Feedback from facility to provider '>Community-based emergency transport systems ':Community funds for health emergencies ~>Referral
Where Element Two is crucial ::Long distances and/or difficult terrain separate people from health facilities, particularly during rainy seasons. ::Traditional healers and private providers are major sources of care {>Concern about unsafe treatment practices in the community
Hou' Element Two may d(flerfi·om previous community-based programs ~:
Focus on private providers, not just CHWs {>Integration of training courses for community-based workers developed for ARI, malaria, diarrhea, nutrition etc. :->Adaptation of IMCI concepts and tools for use in home and community :-:Treatment of all conditions a child has :-:Algorithms for making decisions
-
E lement Three: Integrated promotion ofkeyfamily practices :: Take children as schedule to complete a full course of immunizations (BCG,DPT, OPV, and measles) before their first birthday :: Breastfeed infants exclusively for six months :: Starting at six months of age, feed children freshly prepared energy and nutrients rich complementary foods, while continuing to breastfeed up to two years or longer :: Ensure that children receive adequate amounts of micronutrients (Vitamin A, Iron, Zinc) o Dispose of faeces, including children's faeces, safely; and wash hands after defecation, before preparing meals, and before feeding children
38
REGIONAL NGO TECHNICAL CONSULTATION ON COMA1UN/TY fMC/
.emen
'!tree: Integrated
tlmen Three: ·~grated
i
promotion ofkeyfamily practices (Cant) • Protect children in Malaria-endemic areas, by ensuring they sleep under insecticide-treared bed nets e Continue to feed and offer more fluids, including breastmilk, to children when they are sick o Give sick children appropriate home treatment for infection e Recognize when sick children need treatment from outside the home and seek care from appropriate providers o Follow health worker's advice about treatment, follow up and referral
promotion ofkey.family practices (Cant) e Protect children in Malaria-endemic areas, by ensuring they sleep under insecticide-treated bed nets e Continue to feed and offer more fluids, including breastmilk, to children when they are sick tt Give sick children appropriate home treatment for infection o Recognize when sick children need treatment from outside the home and seek care from appropriate providers o Follow health worker's advice about treatment, follow up and referral
tlmen Three: Integrated
/
promotion ofkey family practices (Cant) o Promote mental and social development by responding to a chQ d's needs for care, and through talking, playing and providing a stimulating environment e Ensure that every pregnant woman has adequate antenatal care. This includes her having at least four antenatal visits with an appropriate health provider, and receiving the recommended doses of the tetanus toxoid vaccination.
How Element Three may di.fferfrom previous community-based programs e More systematic approach to integrated promotion of different behaviors e Better "support-vision" o Greater community input into selection of behaviors to be promoted cLink to IMCI implementation in facilities o Introduction of innovative strategies such as Positive Deviance
el
c~
.1';
Principles ofHHIC-IMCI e HH/C IMCI can be implemented at a national, district and/or community levels, as appropriate cHH/C-IMCI can be implemented by multiple actors or by a single organization
Principles ofHHIC-/MC/ (continued) o HH/C-IMCI recognizes the importance of curative and preventive interventions in the community for reducing child morbidity and mortality o HH/C IMCI can be implemented with or without components # 1 and #2 as feasible. cAll 3 elements are requisite for HH/C-IMCI (except element # 1 if facilities are inaccessible)
Principles ofHHIC-IMC / (continued) o Phased introduction of promotion of key family practices is acceptable o Phasing of introduction of the three elements is acceptable
Strengths of the Framework c Provides a common language for organizations working in communities o Moves C-IMCI closer to operational realities o Descriptive, not prescriptive o Adaptability to multiple child survival interventions
REGIONAL NGO TECHNICAL CONSULTATION ON COMMUNITY IMCI
39
Strengths of the Framework *>Highlights the community as the focal point e Emphasizes multi-sectoral involvement for health o Considers and builds on existing resources o Recognizes the importance of NGO community experience
Strengths of the Framework e Conceptualizes quality standards for CIMCI o Prioritizes operations research questions o Builds NGO organizational consensus on future community health strategies o Complies with WHO/UNICEF global standards
Strengths of the Framework o Provides a communication bridge to MOH and donors e Lends itself to multinational adaptation
-1 Bements ~lemems Element Three
.-:::«
~
.'
.,.. Bements
Who RHU pers.
Roles
Who IPHO
Roles LPgade sk~ of 8li1n on pr011'101h;;l, ~e:"ltlve m a.r~e CMe with emphasiS on th! feu
Element One CRS/IPHO
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PND:~ p.rnn;~
methods KKI CCU'tSdng
lmprovehtl!rperscnal~ skdls, n::rease comm.nty o..treach, a:i.lpt s:EJ"VU deVvery to
Element Two
KFI BHWs/CBHO LGUs Community CRS
'""""'"'"""' Faollta~
comnv..ntv org,riln;J 11anng lOr MV; commt.nty mobkzhg
KFI BHWs/CBHO
f1Vd.le l"'.rSe .n::l MV n
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-·
pro.]eo:t~
P.elliewrefeTalsvstem Devecp n:llm~ent q:propnate h:Entlves fer
Faall.am tranngonCOmi'I'IU'ltyMlb•z.Mr!n for
'""'" lTOuJClltr~trl't~."'('tl .rel!:S] .WOI';
servt:es by commt.tty members, devdcp comi'I'U"'tyb.lsec!MIS end 10g1Stlc.81 t"'llti.Rdecl!vltll!s
A~
for
nc:reasn;;~~:zatiOnofhealltl
cntJ-~. IR'\o~-t~"ebSO:~m Faoll~/~t~IDdevelcp~al
prOVIde to .....,""""", Pro:Mde StW7f to m commlllty· feecback
CRS
dwlge sb'"atEOes a"'d tranh;j on 1-t-1~-IMCI
RHJ
Pa1X~te n comnu.nty healtt'l a::llvllles, prOVllje teec1lad: on q.JUty he.Wth ~leeS
Stwcrt tr ant"YJ actMtJes rcr BHW!, prOVIde TA
e, Who IPHO/CRS/KFI Parents/Grand parents/other caretakers
Roles t:leveicp~ctw"'l9ecomfl'll..l'1catJaplcn; Ktenef'y mess.ages. fa' get .Lid ~«"~:;e. ch.rnels .rid
Activities tlllciilwldin~ ~
mab!11als to be us:e:l h promol:rlg key family
"""""
Erlt;)agecommtrltles nlheselectxlnofbehaVors Adopt pracUces to prevent dseases
PrCNideapJ:f"q:fiab!home::.n See:. CMe out5ide home when ~late
Pro mete Key ramtr Pracuoes th'Ot..Q"' IPHO f"~eld staff dlamels/methods based on ltle BCC ~ and BHWs
,......
'I'OT oa C-IMCl
• ........,Cionlnuaaaaa l'lln
frallllagor~ MV-.atiCiliHWalltprarnallllll "'"-' ~
JmplenwriUdlilllli:b<tllepaDOI!oaoner llmilr .,.._ ~~~~~~ Cllllllbanllolt1!11hlau.b"tllelii.... liWilillkili o1
CarldliCitCilllnlllllln CiitGIMCtiD.uall, ~
~-- I.GUJIDIIUJIIIIIItllil·i•lbollwu
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40
REGIONAL NCO TECHNICAL CONSULTATION ON COMMUNITY IMCI
e Tqot CcYegiver
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~if&~ OWnll R.adio.rd 1~1
CRS Philippines Behavior Communication Plan worn«>.rd m~ofO..S
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REGIONAL NGO TECHNICAL CONSULTATIO N ON COMMUNITY IMCI
41
REGIONAL NGO TECHNICAL CONSULTATION ON COMA1UNITY lAIC!
REGIONAL NCO T£CliNICAL CO/'lSlJLTATlON ON COMMUNITY IMCI
REGIONAL NCO TECHNICAL CONSULTATiON ON COMMUNITY 1;\-!CI