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Joint MOPH/UNICEF/WHO Review and Planning of CDD Training in Yunnan Province, People's Republic of China, 16-27 February 1993 : report

31 декабря 1993 г. Всемирная организация здравоохранения

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(WP)CDS(K)/ICP/CDD/001-E Report series no.:

English only

RS/93/PR/01(CHN)

~DINT

MDPH/UNICEF/WHD REVIEW AND PLANNING OF GDD TRAINING IN YUNNAN PROVINCE, PEOPLE'S REPUBLIC OF CHINA 16-27 February 1993

Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippi~s June 1993 FfH()IWN?n LTBRAR:I

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09 DEC 1993

NOTE

The views expressed in this joint report are those of the CDD Programme review and planning team and do not necessarily reflect the policies of the World Health Organization.

This joint report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for the People's Republic of China.

EXECUTIVE SUMMARY

Diarrhoeal diseases remain a major cause of childhood morbidity in China; and although childhood mortality due to diarrhoea is declining it is still a significant contributor to deaths in children under five in some counties. Having regard to the active provincial diarrhoeal diseases control programme organized by the epidemic prevention station network (EPS) and to the Maternal and Child Health (MCH) project in 20 counties, as well as the potential for good collaboration at provincial level between the three departments of EPS, MCH and Medical Administration, and also with the All China Women's Federation (ACWF), Yunnan was selected for a joint review and planning activity. The aim was to strengthen diarrhoeal diseases control and to maximize the effect of the input of the different departments. The recommendations of the previous evaluation and review activities indicated that well-coordinated efforts - in particular, in training - would help to ensure better quality of care at household and health facility levels and therefore lead to a reduction in diarrhoea-associated morbidity and mortality. The aim was also to identify other factors influencing quality of care, such as communication activities to influence the care-takers, high-level policy decisions that needed to be made to ensure that activities carried out by different departments would be complementary. and according to uniform national case management and prevention guidelines, and regulatory as well as health financing issues. The joint review and planning of Diarrhoeal Diseases Control, carried out from 16 to 27 February 1993, was a first step towards defining the roles and complementarity of the different departments and ACWF, in achieving the national and provincial goals specified in the National Plan of Action goals, the health for all by the year 2000/Primary Health Care goals, the Maternal and Child Health targets for child health, and the COD programme targets for morbidity and mortality reduction of the Ministry of Public Health. All aim to reach the child morbidity and mortality reduction goals through improved preventive interventions and quality of care at community and health facility levels. The methods used to assess the implementation of training activities included reviews of the records and reports of training courses carried out. The quality of case management at health facilities, and the practices of trained and non-trained health workers had been surveyed prior to the joint review; the results and recommendations of the CDD health facility survey (1992), household survey (1989) and comprehensive review (1990), and the MCH baseline survey findings (1989) were reviewed. The review team visited health facilities and used checklists, structured interviews and observation forms to interview the heads of health services and health workers responsible for the management of diarrhoea cases, and to observe the facilities; no cases were available for observation of case management. The major achievements noted were the increase in awareness of case management among health workers, the improvement of CDD managerial and supervisory skills, increase in availability of oral rehydration salts (ORS), the infrastructure and the threelevel approach to increasing the coverage of services, and the potential for Kunming First Hospital to establish a diarrhoeal training unit.

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RECOMMENDATIONS

The problems discovered by the team were related to doctors' attitudes, beliefs and practices; the costing and financing of drugs; the communities' perceptions and practices; the current training design and foUow-up; the Emited effect of past training activities on the quality of care; the lack of a strong communication component; and the management and coordination of CDD activities. On the basis of the review findings the review team recommend that, in order to further strengthen diarrhoeal diseases control: The draft workplans prepared by MCH, EPS, medical administration (1) departments and ACWF during the planning phase of the review, should be finalized in a coordinated manner by the relevant departments as soon as possible, taking into account the roles, responsibilities, and the complementarity of the departments involved. The availability of skilled manpower and resources, quality of training, gradual expansion of coverage and prioritization of activities should be considered in the finalizations of the plans. UNICEF and WHO could participate in finalization of the plans, upon request by the Ministry of Public Health. (2) Considering the unique opportunity for coordinated CDD efforts provided in Yunnan Province, UNICEF and WHO should facilitate financial and technical resource mobilization to support the implementation of the revised plans. (3) The provincial CDD activities need to be supported by the foUowing activities organized at Ministry of Public Health nationalfcentrallevel, with the participation of selected provinces, including Yunnan: the development of a national policy on case management, endorsed by aU concerned departments and national experts; the preparation and implementation of a workshop to enhance the teaching in medical schools, including the revision of medical textbooks; a meeting of aU concerned departments to agree on one set of CDD monitoring indicators to be used in aU systems; the development of a strategy for ORS marketing and pricing; support for these activities by UNICEF/WHO within the agreed framework of assistance, if requested. (4) The First Hospital of Kunming Medical CoUege should be strengthened as a centre for diarrhoea case-management training. The diarrhoea training unit should focus on the training of trainers and medical students. To enable the Kunming diarrhoea training unit to serve as a centre of exceUence, to develop into a fuUy functional unit, the following actions are recommended: A team of clinicians from the hospital directly involved in the casemanagement training and representatives from MCH, EPS and Medical Administration should participate in a study tour to a diarrhoea training unit with (i) long experience in the training of trainers, and (ii) weU established case-management practices.

- iii A training of trainers course using the new guidelines for training at small hospitals and health centres should be conducted. A system for monitoring case-management practices in the hospital should be established. UNICEF/WHO technical and financial support for these activities should be considered. (5) Emphasis should be given to a more comprehensive case management in all COO training and educational activities, instead of the current narrow focus on ORS. The definitions are: Home case management: increased fluid (ORS and/or home-available fluid), continued feeding and knowledge of when to seek care. Case management at health facilities: correct assessment, rehydration using 0 RS for some dehydration and intravenous fluids for severely dehydrated cases, the selective use of antibiotics for dysentery (blood in stool), the non-use of antidiarrhoeal drugs, and advice on home case management of diarrhoea. (6) Linkages and mechanisms for continued close collaboration and coordination of COO activities need to be ensured: a core of trained trainers; standardized content of training and educational materials; common COO monitoring indicators. The preventive component of diarrhoeal diseases control needs to be (7) emphasized, especially the promotion of exclusive breast-feeding, improved weaning practices and handwashing; and also the educational aspects of safe water and latrine use. The communication component of diarrhoeal diseases control needs to be (8) strengthened, with emphasis given to interpersonal communication skills training. (9) The key roles of the provincial EPS include coordination of the technical clearing house, organization of the training of trainers courses in case-management skills, conducting the programme managers and supervisory skills courses, and evaluating programme progress in the province as a whole. (10) MCH is encouraged to continue to strengthen its COO and ARI activities in priority counties, as proposed in their plan, through reinforced ARI and COO casemanagement training - including first referral case-management training - revision of the record system, use of data for management, and strengthened health education. MCH should also continue to gradually expand its coverage to other counties in a phased manner. (11) The Medical Administration should increase its involvement by incorporating relevant priority COO and ARI activities into the PHC programme. Medical Administration should also provide support to quality of care in health facilities through treatment guidelines, and monitoring in hospitals. (12) ACWF should be fully involved in mobilizing the local leaders and the community in the prevention and home case management of diarrhoeal diseases. ACWF should ensure technical consistency with standard messages in their training and educational activities through close collaboration and coordination with EPS/MCH.

CONTENTS ~

1. 2.

INTRODUCTION ................................................................................................................ 1 BACKGROUND ................................................................................................................... 1 2.1 2.2 2.3 2.4 The provincial CD D programme ..................................................•............................ The MCH county project............................................................................................. Medical Administration............................................................................................... The All China Women's Federation (ACWF) ........................................................ 1 1 2 2

3. 4. 5. 6. 7. 8. 9.

RATIONALE FOR A JOINT REVIEW AND PLANNING EXERCISE IN YUNNAN PROVINCE................................................... 2 SPECIFIC OBJECTIVES OF THE REVIEW OF TRAINING AND PLANNING ................................................................................... 3 METHODS............................................................................................................................. 3 OVERVIEW OF ORGANIZATIONAL STRUCTURE .............................................. 5 TRAINING STATUS AND COVERAGE ...................................................................... 6 TRAINING MATERIALS .................................................................................................. 7 RESULTS OF EVALUATION ACTIVITIES IN YUNNAN PROVINCE.................................................................................................. 8

10. FIELD VISIT FINDINGS .................................................................................................. 10 10.1 Health worker interviews ........................................................................................... 10 10.2 Review of facility set-up and management .......................................................................................................... 11 10.3 Assessment of First Hospital of Kunming Medical College ..................................................................................... 11 11. DISCUSSION ........................................................................................................................ 12 12. PROPOSAL FOR A COMPREHENSIVE APPROACH TO CDD ....................................................................................................... 14 12.1 12.2 12.3 12.4 Rationale ...................................................................................................................... Overall objectives ......................................................................................................... Strategies ....................................................................................................................... Activities ........................................................................................................................ 14 14 14 14

13. RECOMMENDATIONS OF THE REVIEW TEAM.................................................. 18

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ANNEXES: ANNEX 1 ANNEX 2 ANNEX 3 ANNEX 4 ANNEX 5 ANNEX 6 ANNEX 7 ANNEX 8 LIST OF PARTICIPANTS...................................................................... 21 SCHEDULE OF ACTIVrnES .............................................................. 23 BASEUNE DATA FOR 1989 ................................................................ 25 CDD TRAINING COURSES HELD IN YUNNAN PROVINCE FROM 1989-1992 .......................................... 29 LIST OF REFERENCES ........................................................................ 33 TRAINING PLANS .................................................................................. 35 COMMENTS AND GUIDEUNES FOR DEVELOPMENTOFWORKPLANS 1993-1996 .............................. 39 DRAFT OUTLINES OF WORKPLANS ............................................ 53

I. INTRODUCIlON

Diarrhoeal diseases remain a major cause of childhood morbidity in China; and although childhood mortality due to diarrhoea is declining. it is still a significant contributor to deaths in children under five years in economically less developed counties. In Yunnan, the annual incidence of diarrhoea is 2.7 episodes per child. The provincial health bureau is addressing this problem, and the Maternal and Child Health (MCH) office is collaborating with UNICEF in 20 counties in the province to strengthen maternal and child health services. The provincial diarrhoeal diseases control (COD) programme, organized by the epidemic prevention station (EPS) network, has been operational since 1990. There is also a Primary Health Care (PHC) project of Medical Administration which exists in 18 counties. In view of the good collaboration between these three departments at provincial level, and also with the All China Women's Federation (ACWF), Yunnan was selected for a joint review and planning activity with the aim of strengthening diarrhoeal diseases control and maximizing the effect of the input of the different departments. Previous evaluation and review activities have indicated that well coordinated efforts - in particular in training - would help to ensure better quality of care at household and health facility levels and therefore lead to a reduction in morbidity and mortality in children.

2. BACKGROUND

2.1

The provincial CDD programme

The control of diarrhoeal diseases (CDD) programme, coordinated by the Epidemic Prevention Department was initiated in 1986 in Yunnan. It became operational in 1990 when the five-year provincial plan for 1990-1994 was formulated. Yunnan Province has carried out many CDD training courses and evaluation activities, and ORS production has been established. Out of the 17 prefectures, six have conducted training of managers courses and five prefectures have prepared CDD plans. The objectives of CDD are the reduction of mortality and morbidity in children under five years of age through the strategies of improved management and supervision, effective case management at all levels of the health care services, and implementation of preventive interventions. The evaluation activities, a household survey in 1989, followed by a comprehensive review in 1990, a cost-effectiveness study in 1991 and a health facility survey in 1992, have provided the provincial CDD programme with information on the quality of care and the practices at household levels. The major findings have been low ORS/ORT use rates and high IV fluid and drug use rates. The national CDD programme provides technical support and guidance to the provincial programme. 2.2 The MCH county project

Strengthening the maternal and child health - family planning services at the grassroots level is a project implemented by the Maternal and Child Health Department of the Ministry of Public Health in 20 poor, remote and minority counties of Yunnan, with support from UNICEF and UNFPA. The broad objective of the project is to reduce infant, under five, and maternal mortality by strengthening the health services delivery

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system at the county, township and village levels. The selection of counties was based on the infant mortality rate (IMR) > 50 per 1000 live births, crude birth rate (CBR) > 25 per 1000, and income per capita < 300 yuan per year. The activities in Yunnan include the strengthening of the three-level MCH networks, leadership and technical groups at different levels, implementation of base-line survey, improvement of services and management including supervision and monitoring, in-service training of MCH staff, and provision of essential equipment. Two rounds of training have been implemented; the second was expanded to non-project counties, e.g., areas of integrated training have included diarrhoeal and acute respiratory diseases, breast-feeding, postpartum hemorrhage and family planning. 2.3 Medical Administration

The Medical Administration Department is responsible for the medical management of hospitals and provides treatment guidelines. Out of the 76 diseases covered in the national guidelines, Yunnan Province has issued guidelines on 12 specific diseases. The department is also involved in the monitoring of hospital management; evaluations of hospitals cover such aspects as quality of care, cost, techniques, logistics, nursing, administration and attitudes of the doctors. Records are reviewed during these evaluation activities. A Primary Health Care project has been carried out by the Medical Administration of the Ministry of Public Health since 1988; it includes among its components the reduction in child mortality through maternal and child health. Diarrhoeal Diseases Control and Acute Respiratory Infections have not been emphasized, but there is an interest in strengthening these primary health care components in the project. In Yunnan, 18 counties have been selected for PHC project activities; only one overlaps with the MCH priority counties. 2.4 The All China Women's Federation (ACWF)

ACWF has a wide network through which it addresses health issues. The Yunnan Province Child Development Centre, with 24 persons, has been responsible for various health issues, including the production of materials and training. Health education is carried out through prefectures (7-8 staff), counties (5-6), townships (one focal point) and village cadres (one in each village). The Association would like to be more involved in CDD activities by promoting CDD as a priority issue among leaders, involving media, promoting preventive approaches and case management at home.

3. RATIONALE FOR A JOINT REVIEW AND PLANNING EXERCISE IN YUNNAN PROVINCE

To maximize the effects and impact of future CDD activities in the province, a review and planning exercise was organized with the participation of WHO and UNICEF to prepare a proposal for a comprehensive approach to diarrhoeal diseases control with workplans to be implemented by the EPS, MCH and Medical Administration Departments and ACWF. The aim was also to improve the effect of training on health workers and caretakers performance and to identify other factors influencing quality of care, such as communication activities to influence the caretakers; high-level policy decisions that need

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to be made to ensure that activities carried out by different departments are complementary and according to uniform national case management and prevention guidelines; financing and monitoring. It was felt that a joint review and planning of CDD activities could promote a fruitful exchange of ideas between the different departments involved. It could help to define their respective roles and complementarity in achieving the national and provincial goals as spelt out in: the National Plan of Action (NPA) goals; the health for all by the year 2000/PHC goals; the MCH targets for child health; and the CDD programme targets for morbidity and mortality reduction. It is hoped that the experience of planning and implementation a comprehensive CDD programme that involves all departments related to control of diarrhoeal diseases in one province, Yunnan, could be used as a model for other provinces. It is also hoped that a well functioning diarrhoea training unit (DTU) in Kunming would serve as a centre of excellence for diarrhoea case management. The review and planning exercise was conducted from 16 to 27 February, with the participation of UNICEF country and headquarters staff and WHO regional and headquarters staff. The list of participants is to be found in Annex 1 and the Schedule of Activities in Annex 2.

4. SPECIFIC OBJECTIVES OF THE REVIEW OF TRAINING AND PLANNING

Specific objectives of the review were agreed on as follows: to assess the implementation and effect of past and current training activities in diarrhoeal diseases control; to prepare a comprehensive approach to training with workplans to improve diarrhoeal diseases case management and prevention; and to include activities that would influence other factors determining quality of care at household and health facility levels.

5. METHODS

To assess the implementation of training activities, the team reviewed the records and reports of training courses on CDD programme management, supervisory skills and case management carried out by EPS, and the training activities of the MCH Department. The quality of case management at health facilities, and the practices of trained and non-

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trained health workers had been surveyed prior to the joint review; the results and recommendations of the COD health facility survey (1992), household survey (1989) and comprehensive review (1990), and the MCH baseline survey fmdings (1989) were reviewed (see Annex 3). The review team visited health facilities and used checklists, structured interview and observation forms to interview heads of health services and health workers responsible for the management of diarrhoea cases, and to observe the facilities; only one case of diarrhoea was available for observation of case management. Discussions between the team members, representing the different departments from national and provincial levels, provided valuable information for the recommendations of the whole team. Initial steps towards the development of detailed workplans for the different parties were made. The plans were discussed and recommendations for their finalization and for future collaboration were made.

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6. OVERVIEW OF ORGANIZATIONAL STRUcruRE

The organizational structure is shown in the following figure.

HEALTH ADMINISTRATION STRUCTURE

fprOVince health bureau

I I EPS (1)

. I 14tH (2)

I HOSP IT AL ADM

(6)j

IPrefecture

1 I EPS (17)

14tH (17)

HOSP IT AL AD~I ( )

Itount y

I I EPS ( 127)

14tH (127)

HOSPITAL ADM (

)

TOWNSHIP HOSPITAL

r lePS.14tH

(1103)

HOSPITAL

VI LLAGE DOCTOR (17482)

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7. TRAINING STATUS AND COVERAGE

The provincial COO programme of the EPS Department in Yunnan has been designated by the national COO programme, to prepare COO training materials and to organize training courses in the province. A diarrhoea training unit (OTU) was established in 1989 at the Kunming Red Cross Hospital and courses on case management were conducted annually. This unit is no longer operational, partly owing to lack of patients for hands-on practice, and the First Hospital at the Kunming Medical College has been selected as the new site for a unit to start in 1993. The new site was selected based on availability of patients. its training function (medical students are trained there) and the availability of trainers trained in diarrhoea case management. The Medical College also provides technical support to the MCH Institute. The number of staff already trained in COO programme management, supervisory skills training. and case management is given in Annex 4; a total of 174 staff were trained in the programme management course, 696 in supervisory skills training and 2482 in case management during the period 1989-1992. The WHO COD training materials were translated for these courses, and technical support was provided for training of trainers courses in 1991 and 1992. The case management training has targeted provincial, county level and township health workers, including participants from MCH, epidemic control stations and hospitals. The COO programme of EPS has a plan of action for 1992-1994, which includes targets for training: 100% of programme managers will be trained by 1994; 60% of supervisors will be trained; 20% of county level doctors or nurses will be trained in case management. The training coverage was estimated in 1992 to be 70% of supervisors trained in supervisory skills in 14 prefectures, and a 6% case management coverage, based on training records. The objectives of the training are to improve effective case management and supervisory and managerial skills of different managers. EPS has singled out the following issues as major constraints: lack of involvement of the hospital administration in the support to training; deficiency in the quality and quantity of trainers; large numbers of doctors needing training; need for a well-functioning diarrhoea training unit. The Health Bureau has provided most of the funds for COO training activities. However. limited funds have been a major constraint on the further acceleration of training for township and village-level health workers.

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As part of the UNICEF/UNFPA-supported MCH project, Yunnan MCH conducted a total of two rounds of training during 1991-1992. The training covered the following five topics: safe motherhood/preventing deaths due to postpartum haemorrhage, breastfeeding, family planning, case management of diarrhoea and ARI. The training modules were adapted for the training of in-service staff at township and village level. MCH workers at provincial, prefecture and county levels were also trained as trainers with added emphasis on new training methodologies, interpersonal communication skills and on how best to deliver the essential MCH knowledge and skills to grassroots workers. The training has gradually expanded to non-project counties; to 26 new counties in Yunnan in 1992. Five medical universities provide staff to form regional expert groups responsible for training provincial staff and for monitoring the training in their region. The training output is measured in person time; figures on numbers trained are not available and it is difficult to estimate these as there were also refresher training courses. The duration of case management training was 1.5 to 2 days for diarrhoeal disease. First-level referral case management training is planned for the future.

8. TRAINING MATERIALS

The WHO COO programme managers training course and supervisory skills training course have been translated into Chinese. WHO staff participated in the initial training courses using the English version together with the Chinese version during the training of facilitators. The WHO OTU training package has also been translated, and the updated short course "Guidelines for case-management training at small hospitals and health centres" is being translated but is not yet available for training. Other case-management guidelines have been translated and modified; the major difference from the standard WHO materials is the emphasis given to the etiology of diarrhoea, with extensive information on causative agents and other aspects of diarrhoea case management. The WHO emphasis on clinical skills assessment is given less prominence in these recently translated materials. The Notes for Trainers have not yet been translated. The training module on acute diarrhoea (1.5 - 2 days) used by the MCH department in the integrated training for village doctors and township doctors has been modified from the WHO supervisory skills module on diarrhoea treatment and from the WHO publication on "The treatment and prevention of acute diarrhoea - practical guidelines·. The module is targeted at village doctors to teach them how to advise mothers on home case management, and for township doctors to assess and treat, advise and refer correctly. The textbook used in the medical education on paediatrics has a section on diarrhoeal disease, with the main emphasis on etiology/causative agents. It includes different intravenous formulas for rehydration of dehydration due to diarrhoea. The national COO programme treatment chart is not incorporated, and oral rehydration therapy for patients with some dehydration is not yet included in the textbook. Interpersonal communication skills are included in a module of the MCH training course, but are not incorporated into the current COO case-management training. The preventive messages are consistent in all training materials produced by EPS and MCH, except in the current materials used by the Women's Association, which have

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not been updated; the rest are in accordance with the WHO and UNICEF preventive priorities.

9. RESULTS OF EVALUATION ACTIVITIES IN YUNNAN PROVINCE

The scope and volume of evaluation activities carried out in Yunnan Province are impressive. The surveys have provided important baseline data on major programme indicators and good opportunities to train provincial health workers on the conduct of various surveys. The key findings from the household case-management survey, health facility survey, cost-effectiveness study and programme review are summarized below. (1) Household case-management survey

A diarrhoea morbidity and household case-management survey was conducted in Yunnan Province (three counties) in 1990. The major findings indicated an estimated annual incidence of 2.7 diarrhoea episodes per child, with a variation from 2.7 to 3.8 episodes per child per year. The survey indicated a low oral rehydration salts solution (ORS) use rate of 1.5% and a high drug use rate of 68.5%. Intravenous (IV) fluid use rate varied from 0.7% to 4.7%. Almost all mothers continued breast-feeding during diarrhoea; most mothers (46.3% - 73.6%) continued feeding, but only about 15% (4.9 - 9.0%) gave increased amount of fluids. Most commonly given fluids during diarrhoea were water, soup and sugar water. (2) Programme review

Following the CDD household case management survey in 1990, a provincial programme review was carried out. The review included visits to health facilities, analysis of the household survey results, and review of programme organization, management and implementation at various levels of the health delivery system. Review of diarrhoea in-patient records showed that 83% of diarrhoea patients at health facilities were given intravenous fluids, 36% were given ORS and 95% received antibiotics. Six percent of children with diarrhoea were given anti-diarrhoeal drugs. From the results it was evident that almost all diarrhoea patients received IV fluids irrespective of their dehydration status. The most commonly used IV fluids were normal saline in 5% or 10% dextrose. Interviews of 36 health workers indicated that 40% had acceptable or good knowledge on assessment of cases, 20% would select appropriate treatment, 60% would prepare ORS correctly and 60% would advise the mother correctly. The survey team indicated that diarrhoea case fatality rates in Yunnan Province were relatively low. This was assumed to be the result of a good nutritional status, almost universal access to health facilities, and a liberal use of IV fluids for treatment of any form of dehydration. However, the review of records in a low-income rural area indicated a

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higher hospital case fatality rate, as 7% of diarrhoea in-patients (28% of admissions) with diarrhoea had died. (3) Cost-effectiveness study

A cost-effectiveness study was carried out in 1991. Surveys were conducted within five townships in Jiang Chuan County. In each township six villages were selected. Owing to the records being insufficiently detailed to aUow retrospective review, three archetypical cases were described to the doctor in each hospital. The key findings of the survey indicated that the health workers performed best in the assessment of dehydration. Eighty-two percent of the health workers scored satisfactorily in the physical examination task, and 94% came to the right conclusion about the degree of dehydration. The survey also illustrated how the hospitals depend on profits from drug and service sales not only to maintain supplies, but also to meet other expenses, including salaries and staff bonuses. At aU levels of the study, the cost per treatment of current practice was found to be higher than the ideal for C<lse management and economicaUy wasteful. The cost of the insufficiency of current case management is borne by the families who consequently receive no treatment, by the families who pay unnecessarily large amounts for treatment, and by the public sector capital account. (4) Health facility survey

A health facility survey was carried out in Yunnan Province in AugustSeptember 1992 in coUaboration with the Ministry of Public Health and WHO. The survey was carried out in 25 major hospitals, including four diarrhoea training units in four prefectures of the province where training had taken place. The surveyors reviewed 938 inpatient records and observed the management of 34 diarrhoea cases. In addition, 127 doctors and 135 mothers were interviewed. The key findings of the survey indicated that the health workers performed best in the assessment of dehydration. Eighty-two per cent of the health workers scored satisfactorily in the physical examination task, and 94% came to the right conclusion about the degree of dehydration. On the basis of the WHO and national CDD programme criteria for correct treatment, it was found that none of the cases were correctly rehydrated. Doctors did not administer ORS at the health facility to treat cases with some dehydration. When ORS is used it is mainly given out for mothers to be used at home to prevent dehydration. With respect to health workers' knowledge of rehydrating some and severe dehydration, it was found to be inappropriate for both trained and untrained health workers. On the basis of the criteria for advice given to caretakers, it was found that 38% of the caretakers were given correct advice. The trained health workers seemed to score better than untrained health workers (50% versus 33%). Of the 34 cases observed during the survey, four cases were diagnosed as dysentery. On the basis of the WHO/CDD programme recommendations, none of the cases were treated correctly. Antibiotics such Gentamycin and Norfloxacin were prescribed. A positive finding was that 71 % of the doctors interviewed knew that antibiotic use was not appropriate for treatment for non-dysentery diarrhoea.

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The review of 938 hospital records indicated an overall ORS use rate of 27% and IV use rate of 94%. Data analysis indicated that IV use was also very high in diarrhoea training units (86%) as in other hospitals (96%). A further 86% cases were given antibiotics, 45% anti-diarrhoeal drugs and 18% traditional Chinese medicine. About 25% of cases received four types of drugs at a time. The results of the MCH baseline survey 1989 are found in Annex 3. In the 20 MCH project counties in Yunnan, the IMR was 72 per 1000 and the under five mortality rate 87 per 1000. Pneumonia ranked first (32%) among the major causes of infant deaths, and diarrhoea (18%); in the 1-4 age group, diarrhoea was the major cause of death (34%) and pneumonia the second (27%).

10. FIELD VISIT FINDINGS

The review team visited health facilities and village doctors, (see Annex 2 for the schedule of activities). At each facility the team divided into three groups, each interviewing the health workers managing cases at the time or the head of diarrhoea services (the director of paediatrics or the hospital director), or observing the facility. The impressions of the team were in accordance with the findings of the health facility and costeffectivenes.~ studies. 10.1 Health worker interviews Fourteen health professionals, either directly responsible for case management or the supervisors of the services, were interviewed. Six out of 14 reported that they had been trained in the treatment of diarrhoea; four at a course conducted in a hotel (one of them mentioned visits to Kunming Hospital during training); almost aU were lecture-based teaching, and two trained by MCH. Only one reported that the training included hands-on practice and none had taken care of a severely dehydrated case or patients with complications during their training. Two trained health workers had prepared plans during training, but no supervisor reported seeing the plan of trained staff. All health workers have someone with whom to discuss complicated cases, although only two reported that the supervisor observed him/her treat cases. All who mentioned supervision from outside the facility (9) referred to the visits of EPS mainly for investigation of outbreaks and to take preventive measures, e.g., a visit last year in response to dysentery cases among neonates. No reference was made to supervision or monitoring by other departments. One township hospital director explained that the hospital functions as a "closed enterprise". All health workers reported having received information on CDD (main source EPS); this may be partly due to the pre-review visits by EPS as reported by two of the interviewed health staff. The knowledge varied among the health workers and no staff referred to the treatment chart for assessment and decision. The main areas which differed from correct case management were the indications for intravenous fluids and antibiotics, what fluid volumes to give and advice on the use of 0 RS. One health professional at the Children's Hospital trained in 1992 (WHO-supported training) explained the risk of using Ringers Lactate solution for rehydration of children with diarrhoea due to the liver function and another senior trainer reported that indications for intravenous fluids depend on [blood] pressure. Preventive messages were more consistent. The most frequent (8) obstacles to correct case management mentioned by the interviewees were mothers' expectations (they want IV therapy and antibiotics) and lack of health education on case management. Doctors' lack of conviction was another factor. It

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~ well illust~ated by the d~iption by one untrained village health doctor who reported: I manage diarrhoea cases with a [acupuncture1needle In the centre of the abdomen antibiotics and advise mothers not to feed their childfe~ during diarrhoea.. ' 10.2 Review of facility set-up and management !he ~eam reviewe~ health facility set-up and management in the provincial capital of Kunmmg. ~ the township of Shalang and the counties of Yuxi and Xundian. Visits ranged from the highest referral hospitals to MCH hospitals, district, county township hospitals and village clinics. ' Major fmdings of the visits indicate that more than half of the units visited had established an oral rehydration therapy (ORT) area. Most commonly this was located in a general treatment area, where ORS and utensils for ORTwere available. However in most health facilities there was not adequate space for (at least 4) mothers and children to stay for ORT. Diarrhoea treatment wall charts (both MCH and EPS charts) were commonly display~d in the assessment areas at all major hospitals visited at prefecture, county and township levels. In most of the facilities equipment for ORT (cups, spoons and containers) was commonly available. However, equipment to demonstrate ORS mixing to mothers varied from IV bottles (500ml), beer bottles (700ml) to jugs of different volumes. Most facilities were equipped with functioning toilets and adequate water supplies. ORS was usually properly stored at the hospital pharmacy. The number of ORS packets in store varied from over 1500 in a district hospital to about 20-50 in a village clinic. Most commonly available intravenous solutions included Ringers Lactate (in district and county hospitals) and normal saline in 5% or 10% glucose. Intravenous fluid sets were found in all facilities visited. Most commonly found antibiotics in the hospital pharmacies included cotrimoxazole, ampicillin, tetracycline and metronidazole. Nalidixic acid was not found in any of the hospital pharmacies visited. Other drugs available and commonly prescribed for the treatment of diarrhoea included a number of traditional Chinese medicines, digestives, vitamins, charcoal, berberin, lactobasillus and loperamide. Review of prescription pads in the facility pharmacies indicated that the use of ORS, particularly in the facility, is still not common. In cases when ORS was found to be described, it was often an addition to multiple drug therapy of antibiotics, traditional Chinese medicine, vitamins and digestives. 10.3 Assessment of First Hospital of Kunming Medical College The First Hospital of Kunming Medical College has been selected for the development of a diarrhoea training unit. Regarding its potential for development into a fully functional unit, the following observations were made. The training course agenda used in the current in-service (on-the-job) training is based on the WHO DTU course (the "Guidelines for training at small hospitals and health centres" are not yet available). However, the medical textbook used in the teaching of medical students is different with diagnosis made on the basis of etiology and identification of causative agent, and with more complicated intravenous fluid guidelines. In the current

- 12-

ORT unit (a new locality within the flIcility is being prepared), diarrhoea treatment charts are displayed; there is an opportunity for 24 hour "rooming-in" and lectures and group sessions can be held next to the diarrhoea training unit. Adequate supplies and equipment for training exist, as well as the supplies for the ORT area and ward. The average number of diarrhoea patients seen during the peak season from May to July is 40 (around 20 dehydrated cases) per day. The diarrhoea training unit is not yet operational, and a model course needs to be conducted in the hospital for facility staff followed by the ftrst training of trainers using the new guidelines, emphasizing assessment and treatment based on clinical skills, and deemphasizing laboratory technology, etiology, and complicated intravenous regimes. This course should be carefuUy monitored, and the diarrhoea training unit assessed during training as this will be an essential step in the establishment of quality training of trainers' routines. A system to monitor the routine diarrhoea case management of the hospital should be established.

II. DISCUSSION

The list of achievements and problems specified by the whole review team were related to doctors' attitudes, beliefs and practices; the pricing of drugs and health financing; the communities' perceptions and practices; the current training design and follow-up; the lack of a strong communication component; and the management and coordination of CDD activities. The achievements and problems identified by the team are listed below, but in no order of priority. Acruevements

Increase in ORS availability

con training has improved knowledge on case management among health workers ORT is less costly for Nral inhabitants

There is an improvement in managerial skill among managers Many facilities have treatment charts Some doctors are giving up some aspects of traditional practices Three-level MCHjEPS approach has increased training coverage

Government support has helped to achieve current results Recording system established Good infrastructure with broad access to services ORT use seems to be increasing Baseline data are available Increased awareness of ORSjORT Targets are set for morbidity and monality reduction

- 13-

Problems

Doctors believe Ihal IV rehydrales fasler Ihan ORS

ORS is perceived as a fluid, nOI a drug Doctors rely on Ihe sales of drugs Health education methods are oUldaled and skills are lacking There are still dealhs among cases not seen by health workers Emphasis on ORS, not ORT Gap berween knowledge aod practice

Treatment charts are not used to assess and treat Old concepts and methods of case management remain

Lack of follow-up of Iraining Training not adapted to different levels MOlhers believe thaI only IV is good trealment

Lack of involvement ofwomen's cadres in eno promotion Importanl key people are not involved in the planning/delivery of ORT

Lack of good monitoring system with use of data Poor selection of target groups for training Pre.service training content and methods differ (rom in-service Little hands-on practice for training of village heallh doctors Lack of a comprehensive approach Confusion in advice on preparation of ORS - hot water preferred for drinking Little emphasis on home fluids in teaching and health education

Lack of health education tools for demonstration Data are not analysed for use Poor people cannot afford treatment The relationship between prevention and treatment is not clear Lack of communication skllls in CDD programme Lack of planning and implementation of effective preventive interventions.

- 14-

12. PROPOSAL FOR A COMPREHENSIVE APPROACH TO COD

12.1

Rationale

The purpose of a comprehensive approach to COD in Yunnan is to benefit from the input of the different departments involved. This is necessary in order to achieve an . impact on quality of care at health facilities and at home. As the departments have different target groups among the health professionals, and may operate at different levels of the system and in different geographical areas of the province, effective coverage could be significantly increased through coordinated efforts. It is also expected that a consensus on standardized messages and guidelines for case management, adapted for different audiences, would enhance diarrhoeal diseases control efforts. This was a first attempt at clarifying responsibilities and roles, and defining the main tasks of each department to avoid duplication of efforts and inconsistencies. It was proposed that the coordinating function should be the responsibility of the Health Bureau of Yunnan Province; even though each department and ACWF report and operate through their respective systems. 12.2 Overall objectives To reduce diarrhoeal 12.3 Strategies To improve qual ity of care at health facilities and case management at household levels. To implement etfective preventive interventions with emphasis on breast-feeding promotion, improved weaning practices and hand washing. 12.4 Activities The proposed activities of EPS, MCH, Medical Administration and ACWF are outlined below. Worksheets for planning the training activities are found in Annex 6. The first draft workplans prepared during the meeting are being revised. They will be finalized on the basis of the comments of the review team and, in particular, considering the financial framework and the different roles and responsibilities of each department. The external reviewers' comments on the drafts are found in Annex 7, and the first draft outlines prepared during the review meeting are given in Annex 8. Below are the proposed roles, responsibilities and activities of each participating department, together with a description of their current strengths and functions. 12.4.1 The provincial COD programme, EPS disea~es

morbidity and mortality.

The provincial COD programme is the only unit which has COD activities as its sole function; it is already designated by the Ministry of Public Health as a technical centre for case management. The current strategy of the programme is to improve the quality and cost-effectiveness of case management. It has trained provincial surveyors in the WHO methodologies for health facility and household surveys. The provincial COD programme has mainly focused on province, prefecture and county levels in its training efforts; surveillance mainly focuses on reporting of notifiable diseases and outbreak investigation with emphasis on preventive measures.

- 15 -

12.4.1.1 (1)

Main roles and activities for 1993-1995

Development of a provincial diarrhoea training unit

The development of a functional diarrhoea training unit is an essential activity in order to improve the quality of case-management training. There is a need for a unit that routinely practises correct case management in the province, and where there are skilled trainers fully dedicated to the methodologies of hands-on supervised practice during training, and convinced of ORT and the other principles of case management. EPS can collaborate with the First Hospital of Kunming Medical College in setting up this unit in 1993. A diarrhoea training unit is also a prerequisite for enhancing medical education, which is in the plan of the national CDD programme. This would be an ideal site. (2) Training of trainers in case management

There is a need for a core team of trainers, from EPS, MCH and Medical Administration, to be trained in a training of trainers course. It may be a refresher training for some, while it would be the first course for others. The selection of these trainers will be crucial and their role will be to train others within the different programmes/projects. These training of trainers courses should be situated in health facilities that can provide hands-on, supervised practice, and practise correct case management. The treatment chart would be used in the training and interpersonal communication skills. EPS is already in the process of printing the new guidelines for training at small hospitals and health centres. There can only be 15-20 trainers trained at each course. If training could be expanded to three more DTU sites in 1994 with a total of four by 1995, and if each site conducted four courses during the diarrhoea peak season, the result would be 180 trained trainers in the province by 1995. This would be a significant achievement. (3) Follow-up support to trained trainers

The provincial CDD programme keeps records and photos of all staff trained at each course. This provides an excellent possibility for follow-up activities: monitoring visits assessing quality of care, dissemination of information (e.g. diarrhoea dialogue, survey results); and sharing the list of trainees with the other departments for them to also followup and monitor participants after training. Ensuring that all participants receive supplies, ORT equipment and charts during training and that they write training plans of actions (copies kept by course organizers for follow-up) are other methods to be tried in 19931995. Funds will also be needed for the training activities that follow after the training of trainers courses. (4) Evaluation and monitoring of programme progress

The provincial CDD programme should, in collaboration with the other departments, evaluate progress through a household and health facility survey at the end of 1995, when some significant changes should be expected. It is proposed that more emphasis on routine monitoring be planned and implemented, by developing a simple questionnaire for mothers to be used in appropriate situations such as during visits to health facilities or communities and a checklist for monitoring/supervisory visits (these should be the same as those used by other departments to allow for exchange of information and comparability).

- 16 -

(5)

Preventive interventions

EPS witt select priority preventive interventions (access to clean water. handwashing and breast-feeding) to be emphasized and implemented through school education and the mass media. These have not yet been well defined. (6) Technical clearing house

One of the important collaborative functions in the province witt be to coordinate a clearing house to check the technical content in all materials developed by the different departments and organizations to ensure consistency in messages/content. 12.4.2 Maternal and Child Health (MCH)

The MCH project target groups are women and children under five. Training has mainly targeted health workers at county, township and village doctor levels. The MCH project is expanding county by county, conducting integrated training including COO and ARI training of managers and supervisors implementing ARt and COO routine recording systems, promoting breast-feeding and the baby-friendly hospital initiative. How to use data from routine reponing to improve training and management and to reinforce COO and ARt training by conducting tirst-Ievel referral hospital case-management training are the main responsibilities of MCH. MCH is also intending to strengthen its function as a provincial programme, with responsibilities for the coordination of MCH activities beyond the project areas. 12.4.2.1 (I) Main roles and activities 1993-1995

Provincial MCH programme

The provincial MCH programme plans to strengthen its organization and management as a provincial programme and also to improve coordination through the coordination group at provincial level. (2) ARt and CDO case-management training

The current integrated training should gradually expand to be used in the whole province. For tirst-Ievel referral units the new CDO guidelines for conducting training at small hospitals and health centres, together with the ARI case management guidelines for outpatients, are planned to be used to strengthen case management at that level within the priority counties. The development of this clinical skitts package witt be carried out by MCH/Ministry of Public Health for use in the MCH pilot project counties. Collaboration with EPS in the training of trainers should be sought. Managerial and supervisory skills training for the different levels will continue and expand to other countries in the region. (3) Health education

The promotion of exclusive breast-feeding and the baby-friendly hospital initiative will be a priority in the MCH preventive activities. (4) Supervision and monitoring

MCH plans to continue its revision of the ARt and COD record system and to define ways of better using the data to improve management and training efforts. The

- 17-

development of a common set of monitoring indicators, foUowing the MCH approach, would be an important coUaborative effort in 1993. 12.4.3 Medical Administration

The Medical Administration can play an important role in support of COO in two ways: fIrstly, by strengthening the quality of care in hospitals, through guidelines and monitoring, and secondly, by building on the PHC initiative and strengthening the COO component in Primary Health Care. The PHC programme of the Ministry of Public Health and four other ministries includes 13 items, of which the goal to reduce child deaths will require incorporation of COO and ARI activities. PHC leader groups and offices have already been established in 26 provinces and 18 counties have been selected for Primary Health Care in Yunnan Province. The emphasis of PHC would be to improve home casemanagement "self-care", reducing payments for drugs among rural poor. To address the problem of doctors' prescribing patterns, monitoring and supervision by Medical Administration could be implemented as a foUow-up to training, to enhance its effect. The Medical Administration proposes to use existing materials to implement activities in different counties from MCH. 12.4.2.1 (1) Main roles and activities in 1993-1995

Case-management policy

A uniform case-management policy could be reinforced by the Medical Administration in its hospital policies. Guidelines will have to be developed based on this case-management policy (yet to be agreed on). The standard ORT equipment and charts should be included in the hospital guidelines. (2) Monitoring of hospitals

COO and ARI could be included in the monitoring and routine supervision of hospitals, by the use of standard checklists. (3) Health education

Through the PHC initiative, emphasis on health education on prevention and home case management, according to agreed standard messages, will be an important activity to accelerate diarrhoeal diseases control. (4)· Case-management training

The main target groups for Primary Health Care are doctors at township health centres and village health stations. Training these target groups, foUowing the training of trainers courses organized by EPS, and adapting existing materials to this level, would help to increase the training coverage significantly. 12.4.4 AU China Women's Federation

The main objective of the involvement of ACWF would be to change the concept of home case management (promote ORT and ORS use) and prevention, among people in remote and impoverished areas. The main target groups for training would be cadres at different levels, who would educate caretakers. ACWF's role will be to organize and mobilize the local government leaders and cadres, and to use mass media for communication.

- 18 -

12.4.4.1 (1)

Main roles and activities 1993-1995

COD advocacy and mobilization

ACWF can advocate increased attention to COD among government officials and achieve broad mobilization. (2) IEC/mass media

ACWF plans to train cadres on health education and communication, with interpersonal skills and face-to-face communication as one important topic. The target groups for health education would be caretakers, school teachers and activities would include development of posters, leaflets, tape records and videos. The IEC efforts will be evaluated as to the impact on behaviour change. (3) School health education

A campaign to mobilize school children in the prevention of diarrhoea and in the use of ORT and feed ing is planned. 12.5 Funding mechanism The participants in the review from EPS, MCH, Medical Administration and ACWF have prepared preliminary draft workplans as outlined above. The first draft will be finalized following review and comments, and submitted for funding. Two funding mechanisms were discussed during the review and planning exercise. One alternative is that each department submit a separate plan of action for funding and that funds be provided through the usual mechanisms, from national to provincial levels. The other alternative is for the provincial Health Bureau of Yunnan to prepare a joint proposal, including the activities of the participating departments and ACWF, and that funds be provided to Yunnan Province and allocated to each department according to the plan. Whichever mechanism is chosen, it will be important for the Health Bureau of Yunnan to playa coordinating role in its implementation.

13. RECOMMENDATIONS OF THE REVIEW TEAM

- 19 -

and WHO could participate in the finalization of the plans, upon request by the Ministry of Public Health. (2) Consid~ring the unique opportunity for coordinated COO efforts provided in Yunnan ·Provmce, UNICEF and WHO should facilitate financial and technical resource mobilization to support the implementation of ;he revised plans. (3) The provincial COD activities need to be supported by the following activities organized at Ministry of Public Health national/central level, with the participation of selected provinces, including Yunnan: the development of a national policy on case management, endorsed by all concerned departments and national experts; the preparation and implementation of a workshop to enhance the teaching in medical schools, including the revision of medical textbooks; a meeting of all concerned departments to agree on one set of COD monitoring indicators to be used in all systems; the development of a strategy for ORS marketing and pricing; support for these activities from UNICEF/WHO within the agreed framework of cooperation, if requested. (4) The First Hospital of Kunming Medical College should be strengthened as a centre for diarrhoea case-management training. The diarrhoea training unit should focus on the training of trainers and medical students. To enable the Kunming diarrhoea training unit to serve as a centre of excellence. to develop into a fully fUnctionalllnit, the following actions are recommended: A team of clinicians from the hospital directly involved in the casemanagement training and representatives from MCH. EPS and Medical Administration should participate in training at a diarrhoea training unit with (i) long experience in the training of trainers, and (ii) well-established case-management practices. A training of trainers course using the new guidelines for training at small hospitals and health centres should be conducted. A system for monitoring case-management practices in the hospital should be established. UNICEF/WHO technical and financial support for these activities should be considered. (5) Emphasis should be given to a more comprehensive case management in all COD training and educational activities, instead of the current narrow focus on 0 RS. The definitions are: Home case management: increased fluid (ORS and/or home-available fluid), continued feeding and knowledge of when to seek care. Case management at health facilities: correct assessment, rehydration using ORS for some dehydration and intravenous fluids for severely dehydrated cases, the

- 20-

selective use of antibiotics for dysentery (blood in stool), the non-use of antidiarrhoeal drugs, and advice on home case management of diarrhoea. (6) Linkages and mechanisms for continued close collaboration and coordination of COO activities need to be ensured: a core of trained trainers; standardized content of training and educational materials; common COO monitoring indicators. (7) The preventive component of diarrhoeal diseases control needs to be emphasized, especially the promotion of exclusive breast-feeding. improved weaning practices and handwashing; and also the educational aspects of safe water and latrine use. (8) The communication component of diarrhoeal diseases control needs to be strengthened, with emphasis given to interpersonal communication skills training. (9) The key roles of the provincial EPS include coordination of the technical clearing house, organization of the training of trainers courses in case management skills, conducting the programme managers and supervisory skills courses, and evaluating programme progress in the province as a whole. (10) MCH is encouraged to continue to strengthen its COO and ARI activities in priority counties, as proposed in their plan, through reinforced ARI and COO case-management training - including first referral case-management training - revision of the record system, use of data for management, and strengthened health education. MCH should also continue to gradually expand its coverage to other counties in a phased manner. (11) The Medical Administration should increase its involvement by incorporating relevant priority COO and ARI activities into the PHC programme. Medical Administration should also provide support to quality of care in health facilities through treatment guidelines, and monitoring in hospitals. (12) ACWF should be fully involved in mobilizing the local leaders and the community in the prevention and home case management of diarrhoeal diseases. ACWF should ensure technical consistency with standard messages in their training and educational activities through close collaboration and coordination with EPS/MCH.

- 21 •

ANNEX 1

LIST OF PARTICIPANTS Dr Zhan Wen tao Dr Chen Hong Dr Du Kel1n Dr Huang Qiyu Dr Zhao Shangde Dr Xie Lichun Dr Ren Lijuan Dr Wei Wei Dr Liu Fengying Dr Hu Meiying Dr Chen Li Dr Yin Canze Dr Yang Liging Dr Zhao Bing Dr Wang Yang Dr Wang Wenjie Dr Zheng Qingsi Dr Niu Shengli Dr Fang Hesong Dr Monica Sharma Dr Suomi Sakai Dr Pang Ruyan Dr Mariam Claeson Dr Seppo Suomela Vice-Director, Health Bureau, Yunnan Deputy Chief, Division of Epidemic Prevention, Health Bureau, Yunnan Chief, MCH Division, Health Bureau, Yunnan Deputy Chief, Division of Medical Administration, Health Bureau, Yunnan Director, provincial EPS Doctor in charge (CDD) , EPS, Yunnan Doctor in charge (CDD) , EPS, Yunnan Doctor, provincial EPS, Yunnan Director, provincial MCH, Yunnan

Chief, provincial MCH, Yunnan Deputy chief, provincial MCH, Yunnan Vice-Director, provincial Women's Federation Chief, provincial Centre for Children and Children Development MCH officer, Department of MCH, MOPH Medical Officer, Department of Medical Administration, MOPH Medical Officer, Department of Epidemic Prevention, MOPH (NCDDP) Professor, Institute of Epidemiology and Microbiology, CAPM (NCDDP) Department of Foreign Affairs, MOPH Professor, Capital Institute of Paediatrics Senior ARI/CDD Adviser, UNICEF/HQ Programme Officer, UNICEF, Beijing MCH officer, UNICEF, Beijing CDD Programme Manager, WHO/HQ Medical Officer, CDD, WHO/WPRO

- 23 -

ANNEX 2

SCHEDULE OF ACTIVITIES

16 February 1993 11 February 1993 18 February 1993

Arrival of teal Discussion and finalization of schedule Review of provincial COD progra..e Review of HCH 300 county project Visit to Pang long District Hospital Visit to Children's Hospital Visit to First Hospital of Hedical College Visit to Shalang Tonwship Hospital Visit to two village clinics (Saturday) (Sunday) Visit to Xundian county, Hospital and town clinic ~CH

19 February 1993 20 February 1993 21 February 1993 22 February 1993 23 February 1993 24 February 1993 25 February 1993 26 February 1993

Hospital, Township ~CH

Visit to Y~li Prefecture Hospital, village clinic

Hospital and

Discussions on review findings Prepration of plans Presentation of plans Discussions on other i.portant activities Finalization of plans Preparation of review report Recouendations Departure of tea.

21 February 1993

- 25 -

ANNEX 3

BASELIXE 1989 DATA FROM ALL JOO 'ICH PROJECT ~O~STIES r~ ~HI\A CO'IPAREO IdTH THE ~O ~tCH PROJECT CO~\TIE~ IS Y~:>INA\ 300 CODITIES

ISFANT ~ORTALITY (~) ! /l000) CACSE (%) Pneumonia Diarrhea Birth Trauma \eonatal Tetanus Prematurity

53,793 68.0 "2~.~

3,496 j 2. j 32.4 9. l 1.9 9.6 14.3 3.0 i.e I ~ . :

8.5 1.8 8.8 ! -+ ..1

Congenital Anomalv ~ccident

n.1i .; . I

'eonataL Asphv~,~ ~ 5 . 4 Other :3.2 PLACE OF DEATH 1%) ~O.5 County hospltal Township health center a.5 Homelon .... ay al.o ~ED. ATTESTIO\ BEFORE DEATH ( !:. ) :; 3.7 Did not seek attentl~n HosPltal 28.5 Village 17 . 9 SEOSATAL ~ORTALITY (/I0001 ~ 5.3 CE\OER DISTRIBUTIO~ 1%1 ~ale 52.7 Female 4i.3 1-4 CHILO ~ORTAL[TY I~) 12,941 (/10001 --I. i

11.0 .1. ·.l 7.~

83.7 64.~

24. 8 10.8 49.~ 56.~ ~3.6

710

4.5 :; 1 .4 ~8.6

GEXDER DISTRIBUTION 1%) ~ale

Female CAUSE (X) Pneumonia Diarrhea Infection Accident Othe rs ACCIDENT/CAUSE OF DEATH 1%) Drowning Traffic Poisoning Others PLACE OF DEATH (X) County hospital Township HC Home/on way ~ED. ATTENTION BEFORE DEATH Did nct seek a~tcnti~~ Hospital Village

51.3 ~ 8.7 2~.7

26.6 33.7 7.9 1 "' . ~ 17. 4

22.5 11.8 22. ~ 18.6 55.8

6.4 9.8 28. I 12.7 12.0 75.3 (% )

42. ~ 5.9 11.8 40.2

9.6 8.5

82.0 ~5.8

36.1 ~3.5 20.~

31.0 11. 2

•

- 26 -

Annex 3

300 COCSTIES CNDER 5 ~ORTALITY

YL'NNAS ('OCSTl ES ~.206

1=) I /l000)

66,i3~ 8~.~

87.::

CAUSE 1%) Pneumonla Diarrhea ~ATERSAL ~ORTALITY

~~.5

11.2

1=) 1/(0000)

H8; 20.2 14.9 7. 1

Jl . -I 13 . ~ 202 15 . 1 H.D 2.0 10 . oJ 17 . J 0;.. I • .:..

CACSE 1%) Hemorrha,!e Toxemla Puerperal Infection ~ed. Complication Others PLACE OF DEATH 1%) l-:-ount:: hOSPlt.:ll

9.8 21. ::! li.O 19. J

I ·, -

1~ • 0 Township healcn Center \'illage health station 0.8 52. "7 Home On \;ay 13.2 ~ED. ATTEST lOS BEFORE DEATH ( ~, ) Did not seek attent,on H.8 Co. hosp. or ~bove 20.8 Township health center 20.~ Village health station H.O 791,002 BIRTHS 1=) (/l000) 24.2 PERINATAL CARE 1%) Antenatal Visit 36.9 Antenatal Vislt>-3 times 20.8 Postnatal \'isit 28.0 PLACE OF DELIVERY I¥l Hospital/HC H.3 85.7 V illa'!e/Home CHILD CARE CHILDREN CNDER 3 (X) Growth ~onitorln! 0.2 "~-2-1" Well Child Visits 2.5 CHILDREN UNDER 7 IXl Routine Physical Exam 1·t. 2 ~ANPOWER

1 6 .. , n ..3 58. ~ ~

.. .

1 . .}

59.9 13.9 19. J 6.9 48,21~

22. ;

3 -I. 8 16.9 16.3 23.6 76 . -I 0.3 I .5 6.2

VILLAGE DOCTORS/VILLAGE HEALTH ASSIST./VILLAGE TRAINED BIRTH ATTESD./VILLAGE VILLAGES WITH HEALTH STATIONS AV. HEALTH PERS./TOWNSHlP COUNTY-HEALTH PERS./1000 POP. Med. College Grad./Co. Tech. Sch. Grad./Co. POPULATION PER COUNTY INCOME PER CAPITA SAFE WATER SUPPLY (% OF POP. ) ILLITERACY RATE (%) CHILDREN IN SCHOOL (%l

0.9

0.5 0.6 70.2 12.6 0.7 9.2 23.9 401, ·148 374 38.6 18. 1 94.7

0.3 0.2 0.4 20.3 11. 5 0.6 3.6

25.1 352,98. 399 17.6 23.5 97.1

- 27 -

Annex 3

1987 est.: ~.----~----------'--~ '"' t.: JIANSKUI . 65.20." .'

'P "! I ~ A t ! f!.

~.J:..~t:~:

J.. O!l!:t=·

~J.. l1~~jo.. j 'i pr.,~,c.I:.""4I

, 17.11 18.02 304! 208.9

.+I:!'~~.

5"3

53.,/.

[j~

SKIPING

• 68.84

;

1H•• , h

S'I

"fO.").

~~S ____ ~~.~i_K~0~U~D~IN_G__~_4_8_._32 ______ 17_._3_5____~30~6~__.

Ch.1"'·" C~W

56.79 is

17.40 16.42

304 300.7 244

,1.", 5'3 i60

XIANGYUII KIDU 62.81

Val; 1),/: D~/;

14.40

i;f ~.1

•.• ~EISIIAN 58.25 19.01 205 r------~~~~--~~~--~~~----~--XINPING 105.86 18.68 304

!J7 71 i:J.

,.1 , • ;

~ ~

:::

YUANJIANG LUQUAN WALONG

67.01 79.43 64.44 60.04

16.81 15.59 14.56 16.94 19.7Z 18.82 24.01 21.46 18.07

306 288 301 201 309 302 258

\"" ,,; \-' ~ ... : kl.4lt "';,,~

1°7.: 13.~

'7 6'1 S''f 7S'

60SI

Q"j:", Gwj: •.,

'7s.z,'

:lC-;

XUIIDIAN CIIANGNING JINGSU LANCANG

----~------------------------

95.54 94.80

B•• s~." $.' "",.0 I

60.<;" I:. 7.:;, bl.'j

! z, , '" ;ttl

/'9 12'1

172.06 88.42 70.20

1/6. (. 62..71

FENGSING

)05 208 245

70 100

-----------------------------v:. ZHENXIONG 56.8

GUANGIIAN

{'3. I;

22.97

# ..tr,t'CI< 'r'ltnn;ut

l'r'!lw<J C" .... ~,e.! ~

1'1: ~. und i an *Midu ..t Vuani i ang ;Ie Laxi If Luquan

~iil lr.~ jC;J.

.&.0 &Z. 8 &1. 0

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Yun n:lJ1. province

- 29 ANNEX 4

CDD TRAINING COURSES HELD IN YUNNAN PROVINCE FROK 1'8'-1"2 CASE MANAGEMENT Place level time num. Kunming p 89.7 20 Kunming p 91.7 25 Honghe c 91.12 24 Gujin c 91.5 45 Yuxi c 92.6 20 Honghe t 91.10 40 Heoin t 91.7 33 Jinpin t 91.10 35 Menzi t 91.7 28 Kaiyuan t 91.10 33 Pinbian t 91.9 37 Ship in t 91.6 51 Jianshui t 91.6 36 Qujin t 91.6 50 Xuanwei t 91.5 57 Chenjian t 91.5 50 Yumen t 91.8 44 Xundian t 91.10 46 Hekou t 92.3 24 Yunlong t 92.3 39 Qiubei t 92.4 41 Guannan t 92.4 52 Xichou t 92.6 48 Weixi t 92.9 43 Xinpin t 92.7 46 Luquan t 92.8 56 Eryuan t 92.6 39 Jianchuan t 92.5 39 Zhongdian t 92.8 40 subtotal 101(p); 175(C); 1942(t) PROGRAMME MANAGEMENT Place level time Gejiu p 89.10 subtotal 72(p) num. 28

Place Kunming Simao Honghe Linehan

level p p

time 90.7 91.7 91.6 91.8 91.12 91.3 91.1 91.8 91. 7 92. l' 91.7 91.1 91.6 91.6 91.6 91.9 91.8

num. 33 23 40 46 34 62 61 34 37 35 39 30 41

Gejiu t Huanin t Jiangnian t Menzi t Luxi t Funin t Luchun t Jianpin t Xuanwei t Xuanwei t Tonghai t Malong t Dongchuan t Jianchuan t Huizhe t Yanshan t Xiaquan t Maquan t Binchuan t Wens han t Kunminq t Fugonq t t Fengqing Luopin t Total: 2218 Place Boushan Total: 72

92.5 92.2 92.5 92.7 92.6 92.7

42 40 41 39 39 38 53 25 37 48

92.8 92.7

44 14

92.8 92.1 91.8

23 38 41

level p

time 92.4

num. 44

Supervisory Skills Place level time num. Yuxi p 90.11 37 Simao p 91.4 44 Honghe c 91.5 44 Menglian t 91.9 22 Jingu t 91.10 20 xianyun t 91.8 47 We shan t 91.6 20 Kunming t 92.7 19 subtotal 81 (p); 165(c); 258(t)

Place Dali Yuxi Lanchan Simao Xianyun Yongdin Niujian

level c c t t t t c

time 91. 5 91.4 91.9

num. 42 31

91.10 91.7 91.7

32 36 40 22 48

92.5

Total: 504

* p -- provincial;

c -- county level; t -- township.

- 30 -

Annex 4

COD TRAINING COURSES(I989--1992J PLACE GEJIU YUXI WEHSHAH BAUSHAN KUHII ING VUXI YUXI aUJIH LINCANG HOHGHE HOHGHE VONGPIN SIMAO SIMAO IIEHGUAN JINGU XIANYON XIANYOU OUJIN IIIDU LANCHAN HULlAN KUNMING KUNMIHG JIANCHUAN J INPIN GEJ IU KUHMIHG SIMAO HOHGHE LUOPIH HONGHE MEHZI MEHZI KAlVUAN SHIPIH PINB IAN LUCHUH JIHPIH JIANSHVI DALI SlIMO

COURSE P.H P.II P.M P.II P.II S S S S S S S S S S S S S S S S S S

TIME MANAGEMENT 89.10.16--21 90.11.15--19 91. 4.3 ---08 91.12.9---13 92.4.30--5.4 SUPERVISION 89. 5. 90.12.9--13 91.5.28--6.2 91.4.7--14 91.5.13--18 91.8.26--31 91.5.25--30 91.6.5--10 91.7.8--12 91. 4. 3-8 91.10.7--10 91.9.13--16 91.10.7--10 91. 8.10--14 91.7.24--28 91.6.17--20 91.8.20--23 92.7.27-8.1 92.5.29-6.4 CASE MANAGEMENT 89.7.6--11 90.7.16-20 91.1 91.10.10-13 91.12.28-31 91.7.8--12 91.7.14--18 91.12.10-14 91.6.19--23 91.10.8--13 91. 7.25--28 91.8.1---04 91.10.17-19 91.6.28--30 91. 9. 5---8 91.7 .16.18 91.10.10-12 91.6.25--28

HO.OF TRAIHHER 28 37 35 30

30 31 42 28 45 46

44 40

22 20 47 40 50 18 19 48

36 36

C.M C.M C.M C.M C.M C.H C.II C.M C.M C.M C.M C.II C.H C.II C.M C.M C.M C.M

20 33 61 35 34 36 23 24 41 40 28 34 33 37 37 39 35 36

- 31 -

Annex 4

TONGIIAI CIIENJIM Y IM~]1 liEU lNG IIIIUAN ruG XUANIJE I XIIANWE I XUfltlWE I XIJAHI)IAN GEJ IU IIIJIZE YUAHYAHG GEJ IU XIAHGYIJH XIANGYIJN XIANGYUH XIAHGYUH XIANGYIIH X IANGYIJH ZIlEHKAHG MALOHG DOHGCIIIJAN ~ESIIAH

C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M C.M M. 5 174

\11.3.1---04 91.1.11--13 91.3.25--28 \) 1.7.5---07 \)1. 3. 13--15 \)1.5.27-6.1 91.6.17--20 \)1.6.21--24 91. 9.17--21 91. 12.7--10 .91.6.15--17 91.9.7---10 91.10.20-23 91.7.19--20 91.6.20--21 91.7 .11--12 91.7.8---09 9l.G.14--15 91.6.29--30 91.7 91.9.10--13 91. 8. 27--29 91. 6.19--22 \12.7.6---11 \)2.3.20--25 !l2.G.8---11 \)2.4.2/1--30 92.4.18--20 92.7.2---04 92.8.30-9.2 92.5.7---9 92.2.27--29 92.7.2\1--31 92.8.24--26 92.3.4---7 92.9.20--24 92.6.10--12 92.6.28.7.2 92.1.7---9 92.5.25--29 92.7.27--8.1 92.8.21--23 92.1.18--20 92.8.6---8 92.6.2---6

40 70 95 33 63 57 41 42 41i 39 73 47 33 24 41 26 26 28 60 24 41 39 20 25 3\) 37 41 52 48 44 39 38 46 56 24 43 48 39 38 53 14 23 35 40 26

DflL I YIJNLONG MflGIJAH QtullE I GUflNNfIIl BINCIIVAN IIEHSIIAH JIAHCIIUAH IIIJIZE XINGPING LUQIAH IIEKOIJ IIEXI XICIIOU ERYUAN I'EHGQING YANSHAN KUHMIHG FUGON FUNIN ZHOHGOIAII YUXI 1989-1992

S. 20 600

CM. 63 2482

COURSES TRAINHER

- 33 ANNEX 5

LIST OF REFERENCES

The progralle of Diarrhoeal Diseases Control in Yunnan Province (1990-1994) . Yunnan COO Progra.. e Phase SUllarization's (1987-1992) Yunnan COD progra..e (COD office) The Report on IIPlelenting the Project for Strengthening Chinese Maternity and Child Health Services and Falily Planning of Grass-root Units" (The provincial MCH project in Yunnan, Jan. 1990- Dec. 1992) COllprehensive Review of the Diarrhoeal Disease Control Progralle (8-26 October 1990), Yunnan Province. People's Republic of China; Dr Staffan Sal.onsson, WHO Consultant The Cost Effectiveness of Case Managelent of Acute Childhood Diarrhoea in Yunnan Province, People's Republic of China Dr John Picard. Dr Zheng Qingsi. Dr Ren Lijuan. Dr Xie Lichuan Prelilinary Results of the Health Facility Survey in Yunnan Province, People's Republic of China (Septelber 1992) COD Case Managelent Training Course. 15-21 July 1990, Kunling. People's Republic of China (Professor Ebrahil) COD Clinical Managelent Courses. 7-23 July 1991, Silao and KUDIing, Yunnan Province, People's Republic of China Training of Trainers (ToT) Courses in Clinical Case Managelent. 4-25 July 1992, Dali, Yunnan Province. People's Republic of China

- 35 ANNEX 6

TRAINING PIAN:

WORKSHEET

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- 36 -

Annex 6 0

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- 39 -

ANNEX 7

Comments and guidelines for the development of workplans for 1993-1996 for the comprehensive approach to CDD Implementation in Yunnan Province, China

1. 1.

General guidelines It would he useful if all plans followed a similar format (see outline in Attachment I). The national COO programme has developed a computer programme available to all provinces with an outline tilr a COD plan of action, which may also be useful. As the training plan is of particular importance, please tind also attached detailed guidelines till' how to revise the intilTlnation on the worksheets (Attachment 2). As discussed, the worksheets prepared during the review and planning meeting need to be radically revised as well as the workplans. All departments need detailed schedule of activities with time, responsibilities, budget and external resource requirements indicated. Specific wmmenls The EPS work plan

3. II.

The pmvindal COD pmgramme. EPS, already has a plan of action; only a brief outline was prepared during the meeting. The original plan needs to he reviewed and the fi:lllowing considered: (I) Suh-targets: careful consideration as to which are the main target groups for training. It seems advisahle that the EPS ctlntinue to mainly tilCUS on provim:e and prefecture and county level training of trainers. The main role of EPS should he to do the training

of trainers in case management. (2) Training: A detailed plan tilr the development of the new OTU and tilr how to expand to other OTUs in 1993-1995 should he induded in the plan. Training of trainers courses should be scheduled tilr each year. The training subtargets need to be revised in view of how many courses can actually he done in the next few years. An important review tinding W<lS the need to use the treatment chart in training; the EPS may need to print more pocket dl.lrts to use in the training. (3) Supervision and follow-up: the plan should include a schedule of activities to do the fo!low-up. Who will do the visits and when? The current plan has no details on this. There seems to he no need to do another household or health facility survey until some changes can he expected. The province already knows what the prohlems are - it does not seem worthwhile investing in repeat surveys now. We suggest that a household and a health facility survey he conducted in the evaluation of COD in 1995 followed by a review. Monitoring of COD, using check lists or simple questionnaires (Attachment 3) seems more useful til CDD than repeat surveys. The health euucation anu prevention section of the plan needs more detail. What exactly uo the EPS plan to do? Here it seems important to detine the strength of EPS and to concentrate on a few interventions. One of the most important activities is the need tilr a clearing house; to coordinate this activity in the province.

(4)

(5) (6)

(7)

Annex 7

- 40 -

(8)

The EPS m<ly also want to schedule coordinating meetings to follow up on the review and to coordinate the finalization of the plans. The COO worknlan of the ACWF 1993 -1995 me~ting

The draft out Iine prepared during the time schedule.

will need detailed planning, including

We suggest th<lt the ACWF ti,CUS on the development of a comprehensive communication plan with specific ohjective.\. target audiences, etc. spelled out. The training that is now planned should focus on communication skills, and it will be important that any mmerials developed ,Ire checked for technical accuracy by the COD clearing house. 3. MCH

MCH already has a plan fm the next period. In view of the meeting, the gradual expansion needs to he realistically planned amI the targets reviewed. (I) Targets/suhtargels: It does nol seem necessary, or feasihle to achiew 100% coverage in just 3 years: instead we suggest that training progress in a slower pace with more ,lttention to the effect of the training. Re-fresher or "reinforced" training in clinical skills seems important. The MCH strength is the three-tier h,CUS - it is suggested that the training also continue to hlCUS on these levels. to supplement EPS. However. use of the new COD guidelines for training at small hospitals and health centres. and the ARI outpatient guidelines emphasising dinical skills of COD and ARI may he a usen,l way of reinforcing clinical skills in areas where training has already heen conducted. Monitoring: the system heing developed hy MCH seems to have a potential to provide us~flll information for rl)lItin~ monitoring and sllpt!rvision. This one activity, in addition to training. seems to the most useful input of MCH into the overall COD plan. We suggest that the estahlishment of a COD cooperation group at provincial level involve EPS. Medical Administration. H~alth Education and ACWF so that the result would he one provind,d group that would help in coordination "etween the dep'lrtments. Medical Administratipn and PHC

(2)

(3)

(4)

The key role of Medical Administration in support of COD (and ARI) programmes could ti,CUS in the following areas: (I) advocacy to raise the consciousness of the leaders that improved CDO/ARI management is essential to reach HFA 2000 goals: and (2) advocacy and planning with provincial level Medical Administration in the health hureaus in hospitals as part of their monitoring process. The Medical Administration plan in the province should indude how it intends to coordinate with EPS anu MCH at the provincial level. With respect to training. further discussions should he held. in particular, with EPS, in the conduct of training, identitication of roles of each department and ways to enhance collaboration. This could signiticantly reduce the hudget amI enhance the development of a feasible plan for funding.

- 41 -

ANNEX 7

APpENDIX 1 OUTLINE OF A PROGRAMME PLAN*) :~~~od~c~ion

and

9ackgrou~d.

The ?"oblem defined ?rogramme Curre~~ his~ory

s~a~us

of ~he

~he

progra~me

Objec~ives Lis~ed

orogramme

here are the general objectives of ~he programme staced in qualitative te~ms. Once you nave defined the objec~ive5 working out the rest of the p~an is mainly a technical mat~er. objec~ives

The

should be

for~u~aced

in a few

sen~e~ces.

Example: The objec~ives of a CJD programme are u5~a._y to reduce morbidity and mor~ali:y f"om diarrhoeal diseases (DD). Some~i~es o~he" objectives are added such as s~rengthening health services, enhancing co~~~nity participa~ion e~c.

Targe~5

Targets are goals of the programme sta~ed in quanti:ative terms. The ~arge~s are related to objectives, bu~ need not be the same.

~he

Example: The targets of a CDD programme can be to reduce morbidity from DD by 20\ and mortality by 10\ in a five-year period. However, the programme can instead set the targets that 50\ of children should have access to clean water by (year), 80% access to ORS and that 50% of children with diarrhoea should be treated with ORT by (year). This will ensure that morbidity and mortality is reduced. The variables used when defining the targets are usually also used as indicators in programme evaluation. It is therefore important to have variables which are measurable. (It is for instance, difficult to measure diarrhoea-associated mortality.)

This attachment is for reference only and not to be considered binding. Its main purpose is to facilitate the finalization of the draft plans developed during the review and planning mission.

- 42 Annex 7 Appendix 1

4. Sub-targecs These are quantified goals which are necessary to fulfil in order to reach the targets. Example: A sub-target in COO could be that x% of health workers should have been trained in proper DO case management by (year). Another sub-target: y% of health facilities should provide ORS regularly. The targets and sub-targets together make up the set of indicators for measuring programme impact. A problem when defining targets and sub-targets is that they will on the one hand be used for programme promotion ("We can achieve this if the programme is supported!"), on the other hand have to be realistic and attainable (to avoid the reaction "'{our programme has failed because it did not reach the targets set in ( year) " ) . 5. Strategies List the main strategies of the programme. Example: In COD the strategies to reduce DO morbidity and mortality are 1. Promotion of proper case management (ORT, proper use of drugs, IV only when indicated) 2. Promotion of proper nutrition (breast-feeding, adequate weaning) 3. Promotion of proper hygiene (hand washing, correct food preparation, domestic hygiene including disposal of babys' stools) 4. Provision of ample quantities of safe water. Under strategies you deal with issues such as intersectoral collaboration, community participation etc.

• 43 •

Annex 7 Appendix 1

6. Activities The activities are usually divided into sub-headings like A. Staffing Covers items like staffing at different levels, special programme s~aff vs. ordinary staff, external personnel assistance etc. a. Management and planning. ,Covers items like managerial structure of the programme, full-time/part-time managers, procedures for integration of management functions into existing system etc. Covers issues related to planning: Will local plans be written? Are planning seminars needed? If so, which people to include? When? Where? Will the community be involved in the planning? If so, how? C. Logistics Here you deal with questions concerning "hard-ware" such as type and quantities of equipment or drugs needed, distribution mechanisms, responsibilities, transport needs etc. D. Training "Training" usually include educational activities directed at health professionals, pharmacists, traditional healers, teachers etc. (Note: The terminology used for activities directed at the general public is usually "education" or "information" and not "training"). This section describes targets groups for the training, type of courses planned, number of courses, number of persons to be trained, teaching material needed, responsibilities etc. Activities in medical/nursing schools should also appear under this heading.

- 44 -

Annex 7 Appendix 1

E. Health education Health education is infor~at~on to the public delivered through face-to-face contact with a health worker. This section deals with issues such as scope of heal~~ education activities in the programme and where i~ will take place (at home visits? at health centres?)? When? (During routine work or during special sessions?) Who will be responsible? What material is needed: Type of material (posters, pamphlets etc.), quantities produced and dist~ibuted (to whom?). F. Communication This section covers activities in mass media and at public meetings like political rallies and religious ceremonies. Which communication channels will be used (radiO, TV, mullahs etc.) by the programme? How of~en? Where (country-wide, local)? In which languages? Who will be responsible? G. Monitoring and Supervision By monitoring is meant day to day activities for assessing how the programme is progressing. Here is described what type of data is needed for monitoring and how to get it (Is it available through the establiShed reporting system? If not, are new forms or collection procedures required?). Also, what type of supervision is planned (Will it be carried out by special programme staff or during routine supervisory visits?). How often will it take place at different levels? Which staff will be responsible? Any need for special training of this staff? Any need to develop supervisory check-lists? !f so, who will be responsiole? H. Evaluation activities, not routine monitoring, Outlines how the programme will be evaluated: List indicators which will be used for measuring programme aChievements. Describe the instruments that will be used (health facility surveys? household surveys? programme reviews?) and when. Define who will be responsible. ~pecial ~valuation ~s descr~bed here.

I. Other activities Covers for instance research.

TRAINING Pl.AN: WORKSIIEET TYPE OF TRAININ(;

Cat<gory or health worker (a)

Num ..... responsible ror (b)

Total num"'rs train~d in (e)

Num"'rs nrrdlnR training (d)

Training method. to'"

usrd (e)

Num"'rs to'" trained annually (0

% trained by

rib (g) ------

Responsible ror organizing ---

Source or rundlnl

J!-

- 47 -

ANNEX 7

APPENDIX 2

A. 1.

GuJde lor plannln, tralnlni used In Yunnan re"lew and plannlni meetln, Identify cbe la;", "oyp for

epp mana,crjal/supervjsory ,kill, trljnin,

Use the organogram of the whole health care system to identify your target groups for training. Note that overlap should be avoided by each department clearly defining their prima(\' target group and the levels of the system to focus on. At least for the period 1993 • 1995 each department should concentrate on training only those most important for the implementaion of COD. Question: Who is directly involved in supervision or programme management of COD? Do not include all the participants in the leader groups. If job descriptions exist - refer to them. Question: How many managers/supervisors are there? Put numbers of managers or supervisors. Question: What are their tasks? Define the tasks. Who should supervise who? Or who is who reporting to? Draw arrows between the boxes. 2.

Identify the target group. for

case mlnaurn!!"' skills training

Draw another organogram as above. Concentrate on the priority levels of the department. Question: Who treats cases of diarrhoea in children at these levels? If job descriptions exist - refer to them. Identify the key categories of staff who treat children with diarrhoea. Question: How many health care providers are there? If there are no records of the exact number of staff. then count the units/facilities and estimate the number of health workers that should be treating children with diarrhoea at each unit/facility. Put the numbers of health providers in the organogram. Question: What are the tasks of these health care providers? Consider whether reponsiblities cover all aspects of case management (assessment, treatment. advice); prescription/dispensing only; advice only; referral.

- 48 -

Annex 7 Appendix 2

B. a)

Instructions 10 worksheet on planning Inlnlng Use information from organogram to write the categories with responsibilities for management/supervision or case management. One worksheet for programme management/supervision and one for case management. Use information from organogram to write the total numbers. Put the total number already trained - from records or reports. Note definition of training: In case management training. only hands-on practical training is defined as training. Seminars and lectures are referred to as orientation. The number still needing training,. b - c. Select training method/course/materials or modules. e.g. COO programme managers training or COO supervisory skills training or other training course which match the responsibilties defined in organogram. For case management training consider venue (OTU or small hospital or health center). formal course. on-the-job training, other methods. This is the most important step to plan more realistically. To decide how many staff can be trained per year. consider: (i) (ii)

b) c)

d) e)

the optimal number of participants per course (e.g. ~ for case management training. 40 for supervisory skills/programme management); and the number of courses thai are feasible per vear (take into account the availability of trained facilitators. availability of materials. other resources. and season for case management training). (i) x (ii) • total trained per year.

g) h) i)

Target for each category of trainers will be equal to (f) x (the number of years of the planning period) + (c) : (b). Identify who will be responsible for organizing the training courses. and who ill coUabgrate with.

Deteraine the budget and identify the source(s) of funding. Use this information on the worksheet to prepare a detailed plan of action and schedule for training (workplan). The workplan should consider:

development of training materials (translation. adaptation. field test). Note there is no need to develop new materials if they already exist; preparation of venues (for case management site with patients and good case management practices); training of facilitators or trainers; monitoring of the training (who will monitor and how);

- 49 -

Annex 7 Appendix 2

follow up and support to participants after training (equipment. support. visits. newslelter ); evaluation of quality of care (eg. health facility survey); phasing of activities, timing; feasibility, budgel and manpower. C.

Planning of other actlvilies

The next step will be to consider and plan other activities [hat will increase the dfeet of the training. and contribute to quality of care. For example: Medical education/pre-service [raining Training of nurses/pre-service training Communication targetting the caretaker ORS availability Social mobi1ization/advocacy (targeting leaders, groups supporting caretakers and faail1es) Recordkeeping and reporting Activities to improve the rational use of drugs

- 51 ANNEX 7

APPENDIX 3 MONITORING PROGRESS IN eDD Evaluation Indicators A.

:\<lethods" Household survey

Monitoring Indicators ORT (increased fluid) and feeding'"

Methods EPI survey addendum' Supervisory visits interview with mothers' Intercept interview' EPI survey addendum' Supervisory visit interview with mothers' Intercept interview' Supervisory check list Intercept interview Records of media channels Supervisory check list - record review - observation Community investigation EPI survey addendum' Distribution reportS and/ or records Supervisory checklist - observation - case simulation

Use of ORT (increased Quid) plus continued feeding'"

B. Maternal ,knowledge

Household survey

Maternal knowledge

Health workers advising mothers Population exposed to messages C. Access to ORS'" Community investigation in conjunction with household survey Health facilities with ORS'"

Communities with ORS'"

D. Diarrhoea case management at health facilities

Health facility survey

Case management at health facilities

Health workers' knowledge Health facilities with trained staff Health facilities able to provide case management'"

Interview with health worker Supervisory check List

Supervisory check list

, standard interview questionnaire (WHO/UNICEF monitoring questionnaire for mothers) •• WHO COD survey methodology ••• indicators for political and social mobilization

- 52 Annex 7 Appendix 3

C . . __ W_H_O_/U_N_I_C_E_F_C_D_D_ln_d_ic_a_to_r_s___ ) Summ.,y for:

. Ar.,' nam.·"

Dc.,,"lry 0 o St.,. 0 OR••lan

DI"lrlot~..:.

qountry ~

Olh.,.:· -.-

J Sourc. 01 d.ata:

.' Number. .1 unll. ,epOftlng In lila .r •• ',1·-'" ...- . • ". . Tol., nu.mIII~ 01 unll, In thl It • • .

',., ,... . '~

ORT (increased fluids) plus Proportion or c.... conllnued , ..dln9 thai ,ecalyed _ Incr.... d fluids AND -

feedin~

o o o

WHO,CDD Household IU,VIY

Olh., Hou.ehold .ur....y. (EPI)

'~~~ .. ~.• ,-:,::~~

L..._-'--'-__- '

:-., "'7-:-

.; ~ :::- %

Soutc. 01 dala:

Maternal knowledgE Proportion who know 3 rul•• of

WHO/COO Hou.ahold IU'''''Y Olh... Hou .. hold IUrvey. (EPI)

o o o

Quullonnal,. lor molh,,. admlnl".,.d al:

0' molh,,. = hom. car.

c o

Alt.rnatlv. Indicators: ProporUon of h..nh lacHlll•• wllh • r'gular supply 01 DRS

ORS

~cces~

ProporUon 01 communUl•• ."Utl a ,.gula, .upply 01 ORI

= =

poPu'aUon wllh. "Quia, supply at OAS

Proportion

the

=~itiie~~N I~

Saurc. 01 clala

AII.mallY. indica lars: Proportion 01 huntl 'acIUU., with Iraln,d .laU ProporUon of h.aUti laclUll .. wlltl minimum requlrtm.nl,· lor ca •• manav.m.nl Sowe. o' dala: WHO/COD H.alltl laellily 'UN.y

Case managemen = ProporUon o' c •••• corr.cUy m.naged

= o

o o

Sup.rvl.ory ... 1.1\ u.lnv ch.ckll.1

•

1••• 1

AtI'4Ut.a 0"1, ."IIIII.U•• , .41011,,,, ... 1 ,,.. I .". "tU tul".,. I" c... "'.,.., .......

- 53 -

Annex 7 Appendix 3

WHO/UNICEF: Mon'lotlng 01 COD Indicalors Questionnaire lor mothers Health facility I Olharl--'---''-...J---------

Calo,

Commun''Y,..i_ _ _ _ _ _ _ _ _ _ _ _ _-j District I

S181e'Country Region

1-_

~I~============================j

f'9':'TaCkif mother knows the 3rt1es 01 home care

(i.e. there must-be a tick in Question 6, a ~More4 in Question 7, and a "Somewhat less I

iii

~~~~~H~~1}'6~§~Pn~t~i~'~~muniiy--=---~.J~=L-:~ . .L . ~~L.=L l!

O-:-Ounng yourctiifa's lastepisoaaofCJiarrtiOe'a

About the same.L,M.ore" in Question 8)

=-:..~~=::~;::=;:=jl

I 1--:,...,,,,, =T1t i

i'-here you need it'? can v.g!Lget bRS ,I you need II~

:_...I -=.:.= :====i __ =_T_'q.: f

r===l

I--:--:~ I . I I .

I i I . .•

Iii I I : I 1_'LL.,--,

:.-.1 I.-I ' - - - - '

54 Annex 7 Appendix 3

WHOJUNICEF Mani,a~9 01 coo ,"OIe'lor, Que.,toM ..,. 'Of mathe"

This quOIllIlO-.,. "'1'1 , . "siICI 111'"'1 III ,..•• t~ flll ••IV •••" ."Ir_. onl._.'"

_"''''''1 dO". Iv ..... .",..0" or CI ..........UO" I. GIM' ...,....YIII IIII.g. IP'llMC",,~ "''''''11111.

'Of "'41'''.'': 0'

oft •

tift"

C~'Y'" •

10.c,loe

:ill' '''III CII.'I.III'"' D.st ",dom.", o' u,. 'eI.CI .... _ ~

....... 0'

••"'1 ",,0 no, II.no........... .. ." 10 .",''''.,. tlell 000•• nolll"."",.I. Ta , . cou",1d II CO"."

.1"" ..

.n•••,o.

1'._ ••••

I'", .......ICI , • ...,... ......" . .,•• " Of

a.....ot

II ..."", !CIV.lly eo"'y"'" Dy ,,,. cnolcl. All

II~.

are

"CN4'eI. nOl "''' s•• e •• 0"" OIv." o",,,"g • .""•••. FOI . ' ..... 01 ...... '.,. , ••. "UII ",IC'" Oftl" ,",Ik, IncI '0""",1111 .,. '''CI... <I.O II ....11 III. 'OIC'. Ilu'<I' .uen •• O"S .oiwllon ':"'y 10 g.1 '1'1 "I,mlll'. of ... " .. tel""ly 1I ....."iICI. 1101 ""hit III. ;".1.... " IN""" 0\19"1 10 h ..... "'OO.l'IId. A" .uen •••

III. C.,.'....., _ .. n ..... ""Il'Il'O"ICI QU • •

1••11 ~ 0' 1". " •• 0111 IIlIiICI .11 1M II'" OOX.

• " e"'leI "".Ih eI ••"n.o•• mO'1II lIuld'" II 1'101 I.D.'actory. '1'0.., ,",.ullll " ••0 10 ..II.: ·V.s, 0 ..., how IfItICh ~ I"OUI' r:1tIHI

1'1.1<1.

.1'1''''.'

"'.'11' no, eo"....o"" 10 1". wo,•••" .". " '1'1.

III,. ,,,.

QU • • trO"

lX.ellv ••

",,"n.n. The c... '",,,·, ."' •••

Ir:,.,."" __

tlWfI'09 Utos ,*-,tto• •

.ltOIOld IN'" 1M M •••' Ct•••" '0 """••• no c, • IIVI 0". lhoukI ...... twoe. II'lI lilY_ "'Sul'll. YOU _10100 lIell S_wne. 'fO'I mov " .... t. ' ..... "'. QU .... ; .. F., •• .",....;" ttwI ~ •• _ .. .on .............. I... '''''....,:

.av.. 'or ..... t".

UO""..,.: .....

·Mor.·.

'I "".... O. o.fI,~"n ,., • c.,., .... ' 10 ,"''''0'. '". '...a .... 11"'101.1"1 01 0'•• 1l ""'III. I_III" D., '''. el'lltCl. Sh. ""• ., _ . '" Utr"".I . . . . .0 on ",1'1.'''.' CIWO I'IUrllCI ,onv.' or mer. ,' • ..,."11 ... .

......cn 1.", t. t. A.... U'II

0u1 _ . 0'........... you "" .... nolCl '0 ... ·SI'IouWI '"'' :. U'II • . -• . , mot ......... : ... .. ",. clIokI ,........., .... ,. 111 . . .__ . . . . . . "110M '" au.... OI"

_.,... ••••. ....."

If'.

QU01lon •• oeav ., ."nOft. F...w

U'IIo

.lg.,,'.

Qu.,.OIl OIol •••Oft 7 .

'0""" 1 bCIl

'or

In. 'oc,,' '. 01'1 ho .... """en ......cW,lly con,,,,,,.; 0'1 III. O.

,n,IO. "In. c.,..... " oll"teI ""0" '000 Illan ...." ... Du' III. '1'1110 I "

nol ••k

1....

m ...cn

1.11.

In••,...""" •• • ...... CII ,.... "

Q", . . .O" I. I. . . . . . """

tflI lIMe.

CO"_."d .001II ...... II 1kMI. . . In .... Cou"l .1'1 10111 ....Ou,,' 01 t009 c_."",,1CI ......... oft 11'1 ...' ..... 0101. QIoI.,llon .ooul 11"'00'. .to I 2·"",,"1"'''''' .... lOOk mo •• "" .........11. lIul ........ e .. I••• o. "'. """'. c.,•• ""OM "-" "Mo•• ' .n Q",.II'on 2 IfId · , _....'1••• • emor. 0' ••11 ""'II ,,,. mue" I••• '1'1 Q",•• IIO'" 3. .nd '0''''''''• •"

8, .... """II

Di"'. ·M.,.· ," Q ....,OOft 7. -..,.,. ·S."....... " eN Mo,.· '" Ow.....'" t.

me",... "" ""OClOII.

m.,. ,.

YOU ",til 0I;a j

,fl.

The OC'" ,.C.... '0".,1 ",...llCIg. . . . . . ,of."•• ""'illS• I....., . d","'"'G • ." ......

...,0::1

." .""'.., o. T·c'"

c.",,1

10. AtIL IIMCItocIllV....,..........ICI n..tI. DUe d. '-I .. ~ ... You "'.'1 ....... '0 ,.sene. OIiliS on toe.. ""''' 0' ",.""on corrwnon D'.... n....... nO .... VIf.

'''0", .,. :s

I.... AOO\lI III. ,..,., •. 0' Mo,.· ,n O\l.,uon 3. 5 T.... CII"lk." " IlIcouI.OId 10

",ft. C"'11li ".0 11'1 ·Uo,.- ,n 0",,,110" 2 I!!Il ·Some.hli 12 ...

.n•••,

,~.,

0'1 "'''no G.M,.,

P'_OIl l101en II • Allvt"'no .. ,.1" bill do

W ..' .......

t.,

tI\o ."•••'.0 a".,UCi" 11 " • .... 111 ......... , .... mo'"'' 10 oCI.,,"fy • ,,,.OIfie ..... 111 """.,. 0'" Cin D. OOt.". . 111'1 •

pn.orm.ov•• ""....... " ... '" '.c""v, .tc.) .,.." ..." .... , .. MI..,..

',am ''''. 0'0'<1'10."

ellis

Calculation of indicators For each of the rates below use the total from the tar right hand Side of the ."estionnaires. If you use more than one set of questionnaires, add the total from each set of questionnaires. Proportion of cases that received increased fluids Proportion of cases that received continued feeding Proportion of cases that received increased fluids and continued feeding Proportion of mothers who know signs of referral Proportion of mothers who know to give more fluids Proportion of mothe", who know to conllnue feeding Proportion of mothe", who know 3 rules of home care Proportion of cases that received OAS

T1 T3

'Yo % %

= =

= T4 =

= -

T1 T6 T7

T1 T8

1'1 T1

= =,

,. .,,. '" % %

T1 T1

= T9

= T10 =

- 55 -

ANNEX 8

FIRST DRAFT OU11.INE EPS WORKPLAN FOR COO PROGRAMME, 1993-1995 YUNNAN PROVINCE

General objectives

I) 2)

Reduction of morbidity and mortality in diarrhoea in children under 5 years old. To improve case management and the quality and cost-effectiveness of diarrhoea case management.

Targets and subtargets 1) 2)

Targets: to reduce the morbidity of diarrhoea by 15%. Subtargets: programme planning and evaluation; prevention; case management; training: 73% of programme managers to be trained 97% of supervisors to be trained 100% case management: provincial level prefecture level 100% county level· 100% township level 30% village level 22% (see other table)

Role of EPS 1) 2) 3) Supervision and follow-up of training. Training of trainers in case management. Baseline survey (extension) household survey facility survey surveillance Dissemination of materials on COD. Establish clearing house in EPS. Evaluation. Health education and intervention. improve access to clean water promote chart use and ORS/ORT practice education in schools mass media. such as posters. video. radio breastfeeding. personal and family hygiene Management and supervision of provincial COD programme implementation.

4) 5) 6) 7)

- 56 Annex 8

FIRST DRAFT OUTLINE MEDICAL ADMINISTRATION WORKPLAN FOR COD PROGRAMME, 1993-1995 YUNNAN PROVINCE

Reducing child mortailly rate In COD Objectives

To develop preventive medical care. comprehensive case management. increased use of ORS. to promote health education. and to reduce the .child mortality rate by expanding PHC activities in the community .

Conditions 1)

Medical Administration has experience in MCH and EPS. Training materials are available. MOPH and four other ministries have promoted the WHO aim "Health for All by the Year 2000" in rural areas of China. This includes 12 items:

2) 3)

2. 3. 4.

5. 6. 7.

8. 9. 10. 11. 12.

The government's role in PHC. increasing financial assistance for heallh activities. Health education. Building medical. preventive and care network in county-towns hipvillage levels. Reducing child mortality rate. Reducing pregnancy death rate. EPI. Nutrition management. Reducing communicable disease rate. Water sanitation. Medical cooperation. Epidemic disease control.

There are now 293 counties which have reached over 10% of these aims. Leader groups and PHC offices have been set up in 26 provinces. The vice-directors of governments in these 26 provinces are Chiefs of PHC leader groups. involved bureau chiefs are deputy chiefs and members. The heallh bureau directors are chiefs of PHC offices.

- 57 -

Annex 8

Targets I)

Reducing child mortality rate. Increasing ORS use rate, to control abuse of antibiotics. Improving self-care of people in rural areas. Reducing costs of medical care and drugs in rural areas. Improving cooperation between department~

in the interest of social health.

Problems I)

Doctors fear that the use of 0 RS can reduce hospital incomes; new technology has to compete with traditional medicine practices. Improve clinical staff training (doctors and supervisors); and health education.

Solution: 2)

Rural people do not visit doctors when they are ill because of their limited health knowledge and because they do not have enough money. Change attitudes of rural people; improve health education. (ncr ease medical cooperation.

Solution:

Repeat input results. Choose different counties from MCH and EPS project counties; use existing experience and COD materials.

Solution:

Activities I) Basic investigation. Training. It is important to develop training for rural doctors in township health centres and village health stations. Health education, through use of television and radio; family health information, family health supervisors. General development of PHC. to support the project. Support of hospital policy. Inclusion of activities to reduce COD mortality rate in PHC plan. Evaluation and summary. Five counties from Yunnan Province 10 be chosen for activities, aparl from EPS and MCH project counties.

2) 3)

4) 5) 6) 7) 8)

- 58 -

Annex 8

Budget US S I)

Training: Materials: Health education information and activities Basic investigation Evaluation of project Meeting (opening and closing of project)

200.000 20.000 50,000 10,000 10,000 10,000

2) 3) 4)

5) 6)

Total:

300,000

- 59 Annex 8

FIRST DRAFT OUTLINE MCH WORKPLAN FOR COD AND ARI PROGRAMMES. 1993-1995 YUNNAN PROVINCE

The objectives are to continue and strengthen the MCH project as fo/lows: 1) 2) Reinforce ARI and CDD case management training. Conduct management and supervision training on ARI and CDD at different levels. Continue to revise ARI and CDD routine record systems; learn how to use them for project management and to reinforce training. Promote breastfeeding and the baby-friendly hospital initiative. Conduct small hospital (first level referral hospital) ARI and CDD case management training.

4) 5)

- 60 -

Annex 8

FIRST DRAfT OUTLINE MCH WORKPLAN FOR COD AND ARI PROGRAMMES, 1993·1995 YUNNAN PROVINCE

1. Z.

Target population: Time period: Location: Objectives: I) 2)

Children under 5 years.

1993-1995 All provinces.

Reduce mortality rate of children under 5 Reduce diarrhoea morbidity and mortality rate and pneumonia in children under 5

Specific: indicators: I) The coverage rate of management training on ARI and COD: 1993 - 20% 1994.40% 1995 - 60% 2) Exclusive breastfeeding rate (0-4 months): 1993·75% 1994 - 80% 1995 - 85% 3) ORS use rate: 1993· 10% 1994·20% 1995·30% 4) ORT rate: 1995·80% 5) Health education coverage rate for mothers with children up to 5 years old: 1993 - 30% 1994 - 60% 1995·80% 6) Antibiotic use rate for COO cases reduced by: 1993·20% 1994·35% 1995 - 50%

- 61 -

Annex 8

MCH Training

Province Manager Supervisor Case Management (health workers) Sub-total 6 29 26

Prefecture 34 281 264

County 274 939 712

Township

VlJlage

Sub-total 314

1566 2171 30021

2818 33194

579

1925

3737

30021

36323

Timetable

1993 Management Supervision Case Management Total 314 (10 course @ 35) 2815 (94 course) 6638 (221 course) 9767

1994

1995

13278 50% 443 course

13278

· 62 . Annex 8

M"or activities 1)

Implementing case management in ARI and COD. Continue ARI and COO morbidity and mortality. surveillance. Health education: (target population - housewives and women cadres.) Scientific feeding: exclusive breastfeeding from 0-4 months and weaning foods.

3) 4)

5) 6)

Promote ORS and ORT. Supervision and monitoring for ARI and COO case management.

Strategy I) Organization and administration: a) b) 2) set up a provincial COO programme leader group; set up a cooperation group of medicine. prevention and treatment. Each section to have their own role.

Training: a) b) Training materials: use same material in whole province. Training time: County and above Management Monitoring Case management 7 days 15 days Township 5 days 10 days 7 days Village

Training topics: a) b) c) d) Case management on ARI and COO Scientific feeding Practice of ARI and COO case management Training methods (for county and above)

- 63 -

wex 8 FIRST DRAFT OUTIINE ALL CHINA WOMEN'S FEDERATION WORKPLAN FOR COO PROGRAMME, 1993-1995 YUNNAN J.>ROVINCE

General objectives

To change the attitudes of the people in the remote and poor areas, to emphasize the prevention of diarrhoea and promote the use of ORS and ORT. The persons who need to be trained are the official cadre at different levels and caretakers. The role of the Women's Federation will be to organize, mobilize and involve educators and mass media in order to change the concepts of the people. Z. Activities 1)

Train the cadre level by level. then have the trained cadres actively educate the caretakers. Mass media: promote the use of posters, leaOets, cassenes, videos, etc. to inform official women's cadres. teachers and caretakers. Make periodical visits to assess 0 RT use (note the change of people's anitudes). Follow-up (surveillance and evaluation).

Targets 1) 2) To encourage the government to promote the COD programme by mass media and mobilization. To change the behaviour of the caretakers by educating them on the use of latrines, clean water, handwashing. breastfeeding, etc. Targets: 80% ORT use at township and village level; 80% knowledge of when to go to hospital; 60% exclusive breastfeeding until 4-6 months; 50% awareness of use and preparation of weaning foods; 80% of mothers advised about unnecessary use of antidiarrhoeals and drugs. 3) Mobilizing schools: Undertake a campaign "Help each other" in children's schools; hold a training course for caretakers; establish health behaviour; promote knowledge of diarrhoeal disease prevention, continued feeding during diarrhoea, and the use ofORT.

- 64 -

Annex 8

Challenae \) 2) 3)

Short of fmance and equipment. 11 will take time to change the people's altitudes. There is some difference between the coverage (knowledge, awareness?) and the practice.

Budget \)

Training:

,,5,000

Printing, transportation, payment for facilitators, accommodation. 2) Mass media: 2,800

Posters. leaflets, charts (total of 350.000 copies) 3) Equipment: 40,000

Equipment for mass media. such as tape recorders. televisions. Equipment will be located in prefectures.

Основные сведения

Организация Всемирная организация здравоохранения (ВОЗ / WHO)

Тип документа Technical Documents

Дата принятия 31 декабря 1993 г.

Источник Всемирная организация здравоохранения