Focused programme review of the National Programme for the Control of Diarrhoea Diseases

English only

REPOR T FOCUSED PROGR AMME REVIEW OF THE NATIONAL PROGRAMME FOR THE CONTROL OF DIARRHOEAL DISEASES

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC China November 1995

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines March 1996

NOTE

The views expressed in this joint report are those of the COD Focused Programme Review 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 Government of China.

CONTENTS

SUMMARY 1. 2. 3. INTRODUCTION .................................. .. ......... ....................... .... ....... ....... 1 DESCRIPTION OF THE NATIONAL COD PROGRAMME IN CHINA . ................ 1 FOCUSED PROGRAMME REVIEW - PHASE I .. ............... . ........... .......... .. ..... . 2 3.1 3.2 3. 3 3 .4 3. 5 4. Objectives ... .. .... ....................... ... ... ..... ............ .. .. .... . ...... .... .. ... .. .. ... . .. . 2 Methods ...... .............................. . ..... .. ............. . . ...... ... .... ....... .. ..... .. . ... 2 Assessment of progress towards targets and objectives .. . ...... .. ..... ...... ............ . 3 Summary of programme achievements ...... ............. .... .. .. ..... .......... ... .. .. .... .. 5 Identification of priority problems ........................ ..... ......... ........... .. ... ... ... 6

FOCUSED PROGRAMME REVIEW - PHASE II ....... ...... .... .. ...... .......... .. ......... 6 4.1 Objective ....... ... .......... .................. .... .. ...................... ... . ...... .. ....... . ..... 6 4.2 Methods .............. . ... .. .. .. .. ... .... ..... .... . .. ....... ......... .. ........ .. .. ... . ..... ..... ... 6

5.

WORKING GROUP REPORTS ..... ... ... .. .............. .. ......................... .. .... ... .. . . .. 7 5.1 5.2 5. 3 5.4 Working group 1: Management and planning of provincial COD activities .... ... ... 7 Working group 2: In-service clinical case management training ... ...... . ... .. .. .... .. 14 Working group 3: Health education and communication activities .. ......... ......... 24 Working group 4: ORS production, distribution and use .......... .. .. ..... .. ........... 29

ANNEXES : ANNEX 1 ANNEX 2 ANNEX 3 ANNEX 4 ANNEX 5 PARTICIPANTS AND RESOURCE PERSONS IN FOCUSED PROGRAMME REVIEW (PFR) PHASE 1.. .... .. ... ... ...... 45 LIST OF DOCUMENTS REVIEWED IN FOCUSED PROGRAMME REVIEW (FPR) PHASES I AND II .. .. ... 47 LIST OF PROGRAMME ACHIEVEMENTS .......... ... .. ........ ........ 51 PARTICIPANTS FPR PHASE II .. .. ......... .. ........................... .. ... 55 LIST OF PERSONS CONTACTED ...................... .. ............ ....... 57

ANNEX 6 - KEY ACHIEVEMENTS OF THE NATIONAL COD HEALTH EDUCATION CENTRE IN SHAN DONG ............. ..... .......... .. .. .. . 59

SUMMARY

Diarrhoeal diseases remain a major cause of childhood morbidity in China. Although childhood mortality due to diarrhoea is declining, it is still a significant contributor to deaths in children under five years of age in economically less developed counties. The national COD programme (NCDDP) was established in 1985, with prevention of diarrhoeal diseases as the major strategy. The Programme is operated under the leadership of the Department of Disease Control (DOC) of the Ministry of Health, and implemented through the Epidemic Prevention Station (EPS) network. This report describes a Focused Programme Review (FPR) of the NCDDP. The FPR is a methodology for assessing the status of programme implementation. It reviews the progress made by the Programme towards targets and subtargets, documents programme achievements, and guides participants through a systematic analysis of issues or problems that have limited programme effectiveness. The overall objectives of the first phase of the Focused Programme Review of the NCDDP of China were to: (a) identify the achievements of the NCDDP and the constraints it has faced in implementing its activities; (b) establish a list of priority issues for review during Phase II; and (c) plan Phase II of the FPR. Many important programme achievements were documented . There is some evidence that diarrhoea mortality has been declining, however, under-five morbidity levels have remained high. In P.hase I, four priority issues were identified for in-depth review in Phase II. These issues were: Programme planning and monitoring, with special emphasis on improving (1) information exchange between central and provincial levels of the health system;

Training, including how to improve and maintain the quality of in-service (2) clinical case management training ; The overall health communications strategy of the NCDDP, which focuses (3) heavily on the Shandong Centre for Health Education; and (4) ORS: production, distribution, and demand.

In Phase II, the review team divided into four working groups . Each group was responsible for analysing one of the priority issues . Documents were reviewed and key informants interviewed in Beijing, and working groups travelled to two provinces to learn about the priority issue at other levels of the health system. The recommendations of each working group are summarized below.

-2-

RECOMMENDATIONS

Mana~ement

and

plannin~

of provincial activities

(1) Financial resources available to the central level team for the implementation of CDD programmes at lower levels need to be increased.

The Ministry of Health should, based on the findings of this review, revise its targets and strategies for the next implementation cycle, and develop a new programme strategy document and workplan. In the context of this replanning, the Ministry would need to explore all possibilities to increase internal budget allocated to COD. Ways for additional external funding also have to be actively pursued. The new programme plan should be submitted to various multilateral and bilateral donors, and national and international nongovernmental organizations (NGOs) for potential funding and follow-up through personal contacts. (2) In light of the complex functions of the central level team vis-a-vis the project provinces, and their crucial role in providing technical guidance, coordination, and quality control to activities c:onducted at lower levels, the current capacity needs considerable strengthening. If future funding permits it would be highly desirable, to recruit, in addition to the existing staff from the Department of Disease Control, a full-time project officer who would be responsible for Programme coordination in provinces. Similar models have been successfully applied in other projects such as the MCH 300 county project and EPI. The regular technical input from relevant agencies is crucial and needs to be fully exploited. More input from the Chinese Academy of Preventive Medicine (CAPM) and other relevant agencies such as the Capital Institute of Paediatrics (CIP) and some medical schools is important. An operational team, consisting of staff from the DDC, CAPM, and possibly other players such as CIP, needs to be constituted and at least monthly coordination meetings need to be scheduled to delegate tasks and to report on progress. (3) The Ministry of Health should intensify its technical and financial support in a small number of provinces (probably not more than five) during the forthcoming implementation cycle. This support should facilitate the establishment and maintenance of comprehensive CDD Programmes which includes the essential components of Programme planning and evaluation, health education, and health worker training. The following criteria are suggested for selecting these provinces: - magnitude of the disease burden and associated mortality; - agreement of provincial health authorities to a cost-sharing mechanism with the central level; - high likelihood of successful implementation in a province (largely based on past experience with CDD or other relevant Programmes in the province).

-3-

Within the provinces for intensified support, a manageable number of model counties should be selected for implementation. Economically disadvantaged counties need to be given strong preference. (4) Provinces not selected for intensified support, which will not receive special budget from centrallev"el, should benefit from technical input by the central level on a limited basis; in particular technical materials, guidelines, updates and new information needs to be shared as it becomes available. (5) The current planning and budgeting process in the provinces needs strengthening. The following are proposed: - In order to allow realistic planning, which is based on foreseeable resources, the Ministry of Health should agree with the project provinces on a cost-sharing process, in which central level and provincial government would allocate fixed proportions of funds to CDD programmes. - In addition to these in-province planning meetings, one annual meeting should be held to which managers from the five provinces are invited. These meetings, as already experienced in the past, provide important opportunities for provincial staff to share experiences and for the central team to introduce new tools and methods, and to disseminate recent information. (6) To ensure high quality activities at all levels, the following are recommended : - A regular and standardized activity reporting and feedback system should be designed and introduced in the five provinces for intensified support. - As a first step in the design phase, quality criteria for essential Programme activities such as health education and training, indicators and ways to measure those need to be agreed upon. Participation of staff from both the central and the provincial level in the design process would be very beneficial, and could most usefully be carried out in the context of the first inter-provincial annual meeting. Input from persons with specific skills in designing such reporting systems will be crucial. - In this new system, provincial Programme staff will be requested to complete standardized reports twice a year. These reports will provide information not only on quantity but also on quality of activities carried out at both provincial and county levels. Within provinces, it is expected that the reporting system will be established also between the provincial offices and county offices in model counties. The information will be useful for planning purposes at all involved levels. Initially, it may not be beneficial to computerize the system. (7) The potential of the model centres for health education in Shandong and for clinical training in Kunming needs to be more fully exploited in the new implementation cycle. Materials such as health education or training tools produced in these institutions need to be evaluated for suitability of general use in other project provinces. If found appropriate, the central level should assume the task to coordinate the adaptation, reproduction and distribution of these materials to the provinces. The training of trainers (ToT) courses conducted by staff from Shandong and Kunming in Ninxia and Qinghai in 1993/1994 should serve as a positive model for the future. Similar courses should be conducted more regularly and frequently to facilitate the valuable transfer of skills and experience to other provinces.

-4 -

(8) To increase both the motivation and skills of provincial level managers, opportunities to provide additional training in Programme management skills should be actively encouraged. In-service clinical case management trainini: (9) The Ministry of Health and other partners should search for channels in addition to EPS through which health workers could be trained in the standard case management of diarrhoea. For example, the MCH Division currently conducts training of health workers that includes the case management of diarrhoea. The Foreign Loan Office is also conducting a Programme that includes case management training for diarrhoea, with support from the World Ban1<. Within Hospital Administration, annual training courses for the special diarrhoea clinics might be revised to address standard case management. Throughout these training activities, the quality of the training must be carefully planned and monitored. In addition, efforts by both the Ministry of Health and the Ministry of Education to strengthen· the teaching of diarrhoeal disease in medical schools should continue. (10)

H..e.a..l1h. Protocols for diarrhoea case management in hospitals and in medical textbooks should be made consistent with the national COD Programme guidelines. Existing systems for quality control in hospitals (e.g. the "grading" of hospitals that occurs every three years) should include indicators of the quality of diarrhoea case management. (11) EPS should continue to organize and coordinate clinical case management training in hospitals, with a particular emphasis on improving the quality of training . The joint trainings held in Yunnan might serve as a model, with EPS staff leading the planning and organization of training and guiding the training of trainers, and hospital staff serving as the clinical instructors. (12) Yunnan Province and the Kunming Center should continue to receive support for clinical case management training, and should be used as a testing ground to assess the potential of EPS personnel as case management trainers at the village level. Past investments in Yunnan, coupled with local commitment, have resulted in significant improvements in clinical case management training. There has yet been time nor sufficient support, for the step-by-step training approach to be developed from the provincial and county levels to the township and village. This support should be provided, and the experience of Yunnan Province carefully monitored for lessons that can be applied in future training activities. Continued support of Yunnan would also provide opportunities for other important Programme activities, such as the development and testing of materials to be used by health workers in communicating with mothers. (13) The national COD Programme should focus their efforts on only a very few provinces, and introduce a set of systematic criteria for selecting "model" counties within provinces. For training , the assistance provided to these provinces and counties should begin with careful attention to planning. If training is included in the plans, assistance and feedback should be provided to ensure that the training meets quality standards. (14) The national CDD Programme and other partners should continue to try and address the factors other than training that limit the performance of health workers. Health education and communication efforts directed at changing parents' attitudes and beliefs should continue and be strengthened in the next project period (see Working Group report on Health Education). Strategies other than training that could be used to change the attitudes and practices of doctors will need further study . These strategies might include factual accounts of successful treatment of diarrhoea through standard case management in journals or at professional meetings .

Structural barriers to standard case management should be addressed by the Ministry of

- 5-

Doctors' attitudes may also change as a result of increasing experience with the successful treatment of diarrhoea without antibiotic or IV therapy. Financial disincentives to correct case management should be investigated and addressed at all levels of the health system (see Working group report on ORS). To address the problem of high turnover rates, future training plans should explore possibilities for routine and continuing in-service training that will reach village- and townshiplevel workers frequently and regularly. One possibility would be to strengthen the content of the required monthly visits by village doctors to township or county hospitals. This regular contact could be used as a channel for refresher training with supervised practice for both experienced and new village doctors. Health education and communication activities (15) The NCDDP, in collaboration with the National COD Health Education Centre in Shandong, should carry out a review to assess the production, quality and availability of various types of COD related health education materials in Programme provinces, prior to development of new materials. (16) The NCDDP, in collaboration with the National COD Health Education Centre in Shandong and other relevant i:1stitutions and departments, should develop a component for COD health education and communication activities to be incorporated into the comprehensive COD plan for the next period (1996-2000). The' plan should: be focused, realistic and feasible; identify priority strategies; identify target audience;

- provide a detailed workplan (targets, inputs, etc.); identify resources required; identify areas and opportunities for collaboration with other possible COD-related projects.

Funds to support planned activities should be actively sought and mobilized. (17) The role of the National COD Health Education Centre in Shandong should be well defined. The role of the Centre should focus on the following areas: (1) Technical Support planning for communication activities; training on IPC-skills; training on use of mass media (radio, etc.); training on monitoring and evaluation;

- 6-

adaptation process of health education materials. (2) (3) Follow-up and support for provinces in conducting health education activities Material development Development and field-testing of methods and materials in Shandong province The centre should have a workplan, which should provide detailed information about: targets activities time-frames resources expected outcomes follow-up and evaluation mechanisms (18) A mechanism should be developed to improve exchange of information, feedback, data and results of various COD health education activities carried out in different provinces. This could include more interactive ways of conducting annual COD review meetings, printing of updates, which could include summaries of KAP studies, surveys etc. The NCDDP could publish a catalogue (a list) of COD health education materials available in Chinese. The NCDDP and the National Center for COD Health Education in Shandong should be provided with new health education and communication materials and be updated on global and regional developments in this field. (19) Consideration could be given for the use of mass media in promoting, publicizing and mobilizing support for COD Programme activities. High level political leaders, decision makers could be invited to act as spokespersons for the Programme. ORS production. distribution and demand (20) Activities to promote ORS should be carried out within the framework of a strong and comprehensive communications plan. Examples are given in the report.

1. INTRODUCTION

This report describes a focused programme review (FPR) of the national Control of Diarrhoeal Diseases (CDD) Programme in China. The FPR is a methodology for assessing the status of programme implementation. It reviews the progress made by the programme towards targets and subtargets, documents programme achievements, and guides participants through a systematic· analysis of issues or problems that have limited programme effectiveness . The FPR consists of two phases with an interval period. In Phase I, review team members identify programme achievements, select priority problems for in-depth review, and plan for Phase II of the review. In Phase II, the team analyses the priority problems selected in Phase I, conducts field visits to learn more about the causes of and possible solutions to these problems, and develops recommendations for the national CDD programme The FPR differs from more traditional programme reviews in several ways. First, it is designed to be a joint exercise, involving both programme staff and individuals who are external to the programme. Second, it is designed to lead to practical solutions to those specific problems which are hindering programme implementation. This report summarizes the methods and findings of an FPR carried out in China in 1995. The document is intended to serve as a reference for national CDD Programme staff, the Ministry of Health, and technical assistance partners as they plan programmes related to diarrhoeal disease and child survival. The FPR focused on the activities and constraints faced by Epidemic Prevention Stations (EPS) in implementing the national CDD programme plan of work for 1990-1995. There are other groups and institutions in China that are also involved in diarrhoea-related activities, including other sections of the Ministry of Health (e .g. Maternal and Child Health (MCH), Hospital Administration) and projects supported by other donors that do not directly support EPS activities (e.g. the World Bank-supported comprehensive MCH project and the UNICEF/UNFPA-supported "300 counties" project). Given the limited time available for review and the fact that team membership consisted mainly of staff from the Department of Disease Control and its technical support group, it was not possible to conduct a careful review of activities other than those being implemented by EPS.

2. DESCRIPTION OF THE NATIONAL CDD PROGRAMME IN CHINA

Diarrhoeal diseases remain a major cause of childhood morbidity in China. Although childhood mortality due to diarrhoea is declining, it is still a significant contributor to deaths in children under five years of age in economically less developed counties. The National CDD Programme (NCDDP) was established in 1985, with prevention of diarrhoeal diseases as the major strategy . A comprehensive review of CDD activities was carried out in 1990, leading to the drafting of a national policy and the development of an operational plan for the period 1990-1994. The major objectives of the programme identified in the plan were to reduce diarrhoea-associated morbidity and mortality and to improve the case management of diarrhoea, with particular emphasis on the quality and cost-effectiveness

-2-

of care. This five-year plan of action called for the gradual expansion of the programme. The NCDDP plan was reviewed and revised in 1992. By early 1993, 11 provinces had prepared plans of work and implemented diarrhoeal disease control activities. By the end of 1994, 17 provinces were included in the national programme. The programme is operated under the leadership of the Department of Disease Control of the Ministry of Health, and implemented through the EPS network. Programme activities are planned and coordinated by a national team, which consists of a programme manager and technical experts from the Chinese Academy of Preventive Medicine (CAPM), the Capital Institute of Paediatrics (CIP), and representatives from provincial COD Programme staff. Programme activities are funded by the national and provincial governments and through financial support from international donor agencies, in particular AusAID and WHO, as well as UNICEF. In 1994, a WHO/CDD Medical Officer post was established in China, with the aim of enhancing collaboration and provision of technical support for programme planning, implementation and evaluation. Key programme areas indicated in the medium-term plan of action include training in programme management, supervisory skills, and clinical case management skills. Three national "model" centres have been established for information exchange (Fujian), health education (Shandong) and clinical case management (Kunming, Yunnan Province). Other key areas of programme activity include health education and communication and the strengthening of teaching of diarrhoeal diseases in health training institutions, including some major medical universities. Progress towards the NCDDP targets has been assessed through the conduct of annual review meetings, provincial programme reviews, household case management and health facility surveys and a cost-effectiveness study.

3. FOCUSED PROGRAMME REVIEW - PHASE I

3.1

Objectives

The overall objectives of the first phase of the focused programme review (FPR) of the NCDDP of China were to: identify the achievements of the NCDDP and the constraints it has faced in (a) implementing its activities; (b) (c) 3.2 establish a list of priority issues for review during Phase II; and plan Phase II of the FPR.

Methods

Phase I was held from 14 to 19 August 1995. A list of participants and resource persons in Phase I is given in Annex 1. The review team reviewed relevant programme documents (Annex 2) and assessed progress toward targets. Major achievements of the programme were identified and four priority problems identified for Phase II.

-3-

3. 3

Assessment of pro&ress towards tar&ets and objectives

The team listed the subtargets identified in the NCDDP Policy and Programme Workplan, 1990-1995, and summarized activities implemented to date related to each subtarget. This summary included both the total number of activities carried out, and available evidence about the quality of the activities. Subtargets, their current status, and the conclusions of the team are presented in Table 1. After completing Table 1, the review team held a general discussion about the 1990 NCDDP targets. It was agreed that: some targets were difficult or even impossible to measure given the absence of denominator data (e.g. #7, 14) or measurement tools (e .g. until very recently, #7, 9); some targets were not directly related to activities being implemented by the NCDDP (e .g. #4,5,6); some targets were not realistic for achievement by NCDDP during the period of the plan (e.g. #11); the change in the indicator definition for ORT has made it difficult to assess programme progress, for while the NCDDP appears to have made significant progress in the use of oral rehydration salts (ORS) and recommended home fluids, levels of reported ORT (increased fluids) and continued feeding are still well below the target. In addition, the team found that there were no targets for some programme areas, such as the quality of activities and operations research.

-4-

Table 1. Summary of progress towards programme targets Subtarget I. 50% of provinces will have COD programmes 2. 30% of provinces will have conducted household surveys 3. 40% of provinces will have conducted comprehensive programme review 4. 60% of infants exclusively breastfed

StatliS 16/30 or 53%

Conclusion Achieved

Source National and provincial plans Provincial survey reports Provincial summaries, national data MCH/UNICEF ORT Survey (1994)

9/30 or 30%

Achieved

4/30 or 17%

Not achieved

64%

Achieved

5. 30% of children <I correctly weaned 6. 85% population in rural areas will have improved water supply 7. 85% of rural population know how to prevent diarrhoea 8. 40% of caretakers of children < 5 know when to seek doctor for child with diarrhoea 9. 50% access to ORS

Insufficient information

Insufficient information

Insufficient information Probably less than 40% Probably not achieved MCH/UNICEF ORT survey (1994)

No conclusive information seems to be low access in some areas ORS/RHF: 84.5 ORT (inc. tld): 32.8 ORT+cont. fdg: 28.8 In Yunnan, reductions from 1190-1992 were 28% in DTU hospitals; '3% in non-DTU hospitals For provinces, median 42%, mean 53%, range 7-100% For provinces, median 20%, mean 36%, range 0-100% Insufficient information

Varies widely by province Achieved for ORSRHF; not for ORT

Provincial repons, ORS production figures MCH/UNICEF ORT Survey (1994) Health facility surveys, Yunnan

I 0 . 80% diarrhoea cases I cases treated with ORT

II. 70% reduction in antibiotic use in health facilities

Probably not achieved

12. 30% of programme managers trained in programme managers' course 13. 50% of supervisors trained in supervisory skills 14. 20% of county-level doctors and/or nurses, at least two from each county, trained in clinical case management

Achieved

Provincial reports Provincial reports

Not achieved

1 Until 1991, the UNICEF definition of ORT use was the proportion of children with diarrhoea who reported to have been given ORS or a recommended home fluid during the diarrhoea episode. In 1991 the definition changed to include the proportion of children with diarrhoea reported tp have been given an increased amount of fluid during the diarrhoea episode. Because water may also be given in increased amounts, continued feeding during the diarrhoea episode is also required. Estimated levels of all three indicators are reported here.

- 5-

3.4

Summary of proiramme achievements

The team reviewed available information to arrive at conclusions about the overall achievements of the NCDD, which are summarized below. A list of specific achievements is given in Annex 3. 3 .4.1 Diarrhoea mortality

Available data suggest that diarrhoeal diseases contribute substantially to overall underfive mortality, especially in low-income and remote areas of China. Information from the 1992 World Bank baseline survey on the Comprehensive MCH project in economically disadvantaged counties in four provinces show that in the age group below 12 months, diarrhoea on average ranks as the fifth, and in the age group one to four years as the second cause of mortality, and that thus diarrhoea remains a major killer of children in less-developed areas of China. These data confirmed previous data collected in areas with high infant mortality collected in 1990 by the UNICEF/UNFPA-supported "300 counties" project. Data from the National Diseases Surveillance Network collected from 145 counties representative of the whole country for the period 1990-1994 would suggest a significant reduction in under-five diarrhoea mortality over this period. Though insufficient information was available to the team to evaluate any possible relation between this reduction in diarrhoea mortality and CDD programme activities, this reported decreasing trend is a very encouraging finding. 3.4.2 Diarrhoea morbidity

Available information from household surveys do not provide nationally representative trend data on diarrhoeal disease morbidity (the ORT survey from 1995 does not provide seasonally-adjusted annual diarrhoea incidence data). Furthermore, surveys conducted in various provinces are not directly comparable in light of methodological differences over time. Data from the National Diseases Surveillance Network would indicate that under-five diarrhoea morbidity levels have remained high, and practically unchanged in the period from 1990-1994. It is likely that in less advantaged provinces diarrhoea morbidity is considerably higher compared to more developed provinces. 3.4.3 Case management practices in health facilities

Available information and anecdotal evidence suggests that case management practices in health facilities continues to be largely inadequate. Antibiotics and intravenous fluids are grossly overused, and ORS is often not available . There is no conclusive information available to assess improvements of case management practices over time. A conclusion about the effect of ongoing programme activities (e.g. the development of a national case management policy, strengthening of preservice training in Kunming DTU, numerous in-service training activities) is therefore not possible. 3.4.4 Case management practices at the household level

All household survey data suggest that practices at the home leave substantial room for improvement. The nationally representative ORT survey conducted in 1994 by MCH with support from UNICEF shows that the ORT use rate, currently defined in China as the proportio~ of children receiving increased amounts of fluids, is only about 33%, meaning that fewer than one-third of children with diarrhoea receive the potentially lifesaving fluids in the home.

-6-

Even though household surveys have been conducted in several provinces, and in some provinces more than one survey has been conducted since 1990, likely methodological differences in these surveys prevented the review team from reaching a conclusion about trends on case management practices at the household level. There are striking differences among findings of surveys conducted in the various provinces, and even among different areas in the same province. Despite likely variations in methodology across provinces, it is clear that levels of appropriate home case management are particularly low in economically less developed provinces. 3. 5 are : Programme planning and monitoring, with special emphasis on improving (1) information exchange between central and provincial levels of the health system; (2) · Training, including how to improve and maintain the quality of inservice clinical case management training; (3) The overall health communications strategy of the NCDDP, which focuses heavily on the Shandong Centre for Health Education; (4) ORS: production, distribution, and demand. Identification of priority problems Four priority issues were identified for in-depth study in Phase II of the review. They

4. FOCUSED PROGRAMME REVIEW - PHASE II

4.1

Objective

The objectives of Phase II were to analyse the priority problems identified in Phase I and to propose recommendations for the next national COD Programme plan of operation. 4.2 Methods

Phase II was conducted during the period from 19 October to 2 November 1995. Participants in the Review Team are listed in Annex 4. The group was divided into four working groups, each with primary responsibility for one of the priority issues. From 19 to 21 October, the team met in Beijing. Plenary sessions were held to review the findings of Phase I and the objectives and methods for Phase II, and working groups met to finalize plans and data collection instruments for their field visits to provinces. In addition, each working group interviewed key informants from the central level (see Annex 5 for names of infonnants). In the period from 22 to 29 October, each working group visited two provinces to obtain more in-depth information about their priority issue. In addition, each team collected a limited set of information for the other three groups using standard forms. From 30 October to 2 November, the review team met again in Beijing to summarize their findings and integrate them with the findings of Phase I, to analyse the priority issues, to

-7-

develop recommendations for the national programme, and to prepare this report. Full working group reports are available in Section 5.

5. WORKING GROUP REPORTS

5 .1 5 .1.1

Workini iroup 1: Manaiement and plannini of provincial COD activities Problem statement

In view of the large geographical area and increased number of provinces that implement COD activities it has become more challenging for the central level to monitor provincial level activities executing its mandate in overall planning and management of the national COD Programme. In general, information exchange between central and provincial levels has been found to be irregular. The Phase I review team concluded that information on quantity and quality of activities carried out in the provinces was limited and not sufficiently available to the national programme team. In summary, there exists no regular, well established mechanism to monitor provincial activities. 5. 1. 2 Background information

The· National COD Programme was initiated in China in 1985 to implement the control of diarrhoeal disease throughout the country. In 1990, a comprehensive programme review was carried out in collaboration with WHO, the national policy was drafted, and a plan of action was. developed to cover the period from 1990 to 1994. Reduction of diarrhoea associated morbidity and mortality as well as improving case management were identified as major objectives of the programme. In accordance with national policy, special emphasis is given to preventive aspects of diarrhoeal disease control. The first programmes implemented at provincial level with operational workplans were established in 1990 in Beijing, Fujian, Gansu, Hunan, Shandong, and Yunnan. The national plan of action was reviewed and revised in 1992, and the programme expanded to Guangdong, Heilongjiang, Henan, Hubei, and Jiangsu. In 1993, the third batch of provinces establishing COD Programmes included Guangxi, Liaoning, Sichuan, and Xinjiang, and at the end of 1993 also Ningxia and Qinghai developed COD plans, resulting overall in 17 project provinces out of which 16 had plans of action. The COD Programme is coordinated under the leadership of the Department of Disease Control of the Ministry of Health and implemented through the epidemic prevention station (EPS) network. Programme activities are being planned and coordinated by a national team consisting of a programme from the Department of Disease Control (DOC), t~chnical experts from the Chinese Academy of Preventive Medicine (CAPM), relevant other agencies such as the Capital Institute of Paediatrics and programme managers from some provinces. Three national model centres for health education, case management training and information exchange have been established in Shandong, Kunming, and Fujian, respectively, to support programme implementation in these specific areas. Financial resources for programme implementation are provided by the national and local governments, as well as international donor agencies.

-8-

5 .1. 3

Methods of data collection

Relevant key progranune documents were reviewed by the working group and interviews with key informants were conducted at central, provincial, prefectural/city, and county levels. In Beijing, decision-makers within the Ministry of Health were interviewed, including also other sectors, like Maternal and Child Health Care (MCH), Expanded Progranune on Immunization (EPI), and Hospital Administration. Representatives of CAPM and CIP were also interviewed. The working group carried field visits to two provinces, Fujian, and Guangxi. In these two provinces, in total one prefecture, two cities, one county, were visited and interviews were conducted with local officials of the health authorities and EPS stations. In two city hospitals, one county hospital, one township hospital, and one village clinic, interviews were conducted with local administrators and health staff. 5 .1.4 (1) Major findings Planning of COD activities at provincial level (a) Availability and quality of provincial plans

Information was obtained from eight provinces visited by the review team. It was found that: All eight provinces have developed provincial COD plans between 1990 and 1993. Five of the eight provinces have current specific COD plans. These plans usually cover a period of three to four years. The first batch provinces which had developed plans covering the period of 1990-1994 have not prepared new plans for 1995. A review of the five plans showed that their quality is variable: three of the five plans have specified targets; none of the five provinces provide detailed budget information in their initial plans; four of the five plans have training activities; all five plans have health education activities . Provincial plans are in general consistent with the national plan. In fact, targets are very similar to the ones from the national plan. Activities are usually not described in sufficient detail. Provincial plans are apparently not made based on anticipated resources . Activities are not described in sufficient detail to guide smooth implementation. (b) Input from central level into provincial planning The central level has developed a national COD programme document which outlines the national targets, objectives and basic strategies, and a national workplan which details activities and time-frames for

-9-

implementation in the 17 project provinces. This plan serves as a model for planning at provincial level. To date the central level has conducted five planning/review meetings with provincial staff. During the first three of these meetings, in line with the progressive expansion of the national programme, batches of provincial managers were invited and provincial plans were drafted (during 1990 with the group of five provinces, 1992 with six provinces, and 1993 with six more provinces). No guidance was provided to provinces whose plans had expired (written planning guidelines, or direct input by central level staff). (2) Information exchange between central and provincial levels (1)

Activity reporting All eight provinces claim to normally provide activity reports on activities which are funded by specifically designated funds by the Ministry of Health . The epidemic preventive stations at provincial level are required to prepare annual activity summaries on all EPS activities which are forwarded to the provincial Health Bureau. Some, but not all provinces prepare special summaries on COD activities on an annual basis.

(b)

Feedback provided to provincial EPS staff by central level Provinces claimed to not have received any written feedback from the central level . Two of the provinces reported having received informal (by telephone) feedback on the plans once they were finalized and submitted.

(c)

Implementation at provincial level From review of the summaries prepared by provincial staff for the FPR team, it was found that: Shandong and Yunnan have implemented a high level of activities during the current planning cycles. In other provinces the overall activity level was considerably lower. Particularly in 1995 COD programme implementation was very low in some of the visited provinces (e.g. Fujian), and in Henan the programme had virtually ceased. In general, activities with special funding from the Ministry of Health were implemented if requested by central level. Most provinces have allocated funds for COD from provincial resources. During 1994/1995 allocations from central level have decreased in line with the overall reduction of the budget of the Department of Disease Control. It is also noteworthy that a large proportion of funds from the Ministry of

- 10-

Health had come from external donors such as WHO, and that only negligible amounts of funds were derived from goverrunent funds. (d) CDD Programme implementation/reporting at county level All provinces have selected a small number of counties as project counties ("trial counties", "trial spots"). In some (four of eight) of the provinces provincial staff have made special efforts to assist counties in preparing their own CDD plans. In general, with the exception of Yunnan province, specific CDD activities are only carried out by county EPS staff, if special funding is designated by the provincial level. Reports on these specially funded activities are then prepared and forwarded· to the provincial authorities. (3) Analysis of critical functions of the central level in relation to CDD Programme planning and implementation (a) Assistance to provincial level in programme planning See section ahove. (b) Development of national tools/guidelines The central level has to date developed and distributed to the project provinces: national treatment guidelines; training materials (programme management, supervisory skills, clinical skills training). The following tools are currently lacking: standardized instruments for programme evaluation (e.g. household surveys, health facility surveys); programme planning/replanning guidelines; standardized reporting format for provincial activity reports. (c) Quality control of activities conducted at provincial level The central level team has not established quality criteria for programme activities such as training and health education. To most activities conducted at provincial level there is no direct technical input from the central level team to ensure quality. (d) Information exchange with "special centres" and facilitation of exchange between provinces.

Shandong Health Education Centre Approximately two visits were conducted annually by central level staff to the centre.

- 53Annex 3 introduction of post-tests to assess participants at close of training 6. A national medical education workshop was conducted, as a first step in strengthening medical education in five major medical universities and two other health training institutions. Some clinical case management training courses have addressed issues related to communication between health workers and caretakers. Some data on health worker performance are available (Health Facility Survey in Yunnan Province, 1992) indicating improved case management after training . A review of training activities was conducted in Yunnan Province, involving EPS, MCH, and Hospital Administration, as well as UNICEF and WHO.

7. 8. 9.

Prevention and Health Education 1. 2. Numerous health education activities have been carried out by provinces (see detailed list in Annex 4). Training materials on communication for use by programme managers have been prepared, and the WHO manual on improving communication between health workers and caretakers in the health facility (Advising Mothers) has been translated into Chinese. A national health education centre was established in Shandong . A plan for centre activities designed to strengthen communication activities was drafted, revised based on the local situation, and used as the basis for centre activities. The health education messages promoted by the national centre are consistent with the national CDD policy/guidelines. The centre provided technical support to two provinces in the development of a plan for communication activities. Networking with mass media was established in some provinces. Baseline studies of household practices were conducted in some provinces.

3.

4. 5.

Other Achievements 1. 2. 3. Guidelines on cholera have been translated and distributed to all provinces. Almost all provinces have held training course on the diagnosis of V. cholerae 0139. A Chinese version of Dialogue on Diarrhoea was established. The first issue was published in 1988, and since that time there have been two issues per year. Each issue is distributed to all counties. An editing group has been established in Shenyang, Liaoning Province, at the Chinese University of Medical Science.

- 54-

- 55-

ANNEX 4

PARTICIPANTS FPR PHASE II

Department of Diseases Control, Ministry of Health

Dr Nan Junhua, Division Director Dr Wang Wenjie, Section Chief Dr Ren Li Juan, Yunnan Provincial EPS Dr Liu Yongen, Hunan Provincial EPS Dr Zu Wenping, Sangdong Health Education Institute, Shandong Provincial EPS Institute of Epidemiology and Microbiology, Chinese Academy of Preventive Medicine

Dr Xiao Donglou, Deputy Director (14 August) Dr Yu Yongmao, Assistant Professor Capital Institute of Paediatrics

Dr Jia Mei, Assistant Professor WHO/Beijing

Dr Sergio Pieche, Medical Officer, CDD/ARI WHO/Regional Office for the Western Pacific, Manila

Dr Seppo Suomela, Regional Advisor, CDR Dr Marianna Virtanen, Associate Professional Officer, CDR WHO/headquarters, Geneva

Dr Gottfried Hirnschall, COD Programme Manager, CDR Dr Jennifer Bryce, Evaluation Officer, CDR

- 56-

- 57-

ANNEX 5

LIST OF PERSONS CONTACTED

BEIJING Yi Mei, Department of Medical Administration, MOH Ning Yi, EPI Program Manager, Department of Disease Control, MOH Xing Jun, Program Manager, MCH Department, MOH Huang Yuying, Division of Disease Control, Chinese Academy of Preventive Medicine FUJIAN PROVINCE FJ.ljian Provincial Health Bureau Dr Yuan Shouji, Director, Anti-Epidemic Department Dr Zhang Guangming, Anti-Epidemic Department Dr Lin Yongqiang, Anti-Epidemic Department Fyjian Provincial Epidemic Prevention Station Dr Cheng Hangchuan, Honourable Director Dr Lin Chengshui, Section Chief Dr Lin Zhongguan Dr Ou Jianmin Dr Yan Pingping

Dr Chen Ruhan, Deputy Director, Lianjiang Government Office Dr Wu Caigui, Director, Lianjiang Health Bureau Dr Zheng Yongshun, Director, Lianjiang County EPS Dr Yu Bifeng, Director, Section of Anti-Epidemic, Lianjiang EPS GUANGXI ZHUANG AUTONOMOUS REGION Provincial Level Health Bureau Dr Xie Ping, Deputy Director, Anti-Epidemic Department Dr Yang Jinye, Deputy Director, Provincial EPS Dr Dong Boqing, Section of Bacteriology, Provincial EPS Dr Chen Jie, Section of Virology, Provincial EPS Dr Chen Faqin, Provincial EPS Dr Liu Feiying, Section of Bacteriology, Provincial EPS

- 58Annex 5 NINGXIA HUI AUTONOMOUS REGION Dr Ma Yu Zhang, Deputy Director, Public Health Bureau Dr Huo Yaodong, Deputy Director of Division of Epidemic Prevention, Public Health Bureau Dr Zhao Peiting, Deputy Director of Division of Epidemic Prevention, Public Health Bureau Dr Hu Shaowen, Programme Manager, Division of Disease Control of the Regional Health Bureau Dr Li Xuezhi, programme manager, regional EPS station Dr Jia-ren Song, Director of Affiliated Hospital of Ningxia Medical College Dr Zhang Tianfu, Director of the Refgional Health Education Institute Dr Shen Borong, paediatrician, First Hospital of Shi Zui Shan city Dr Lu Dong, Vice-President, Affiliated Hospital of Ningxia Medical College Dr Zhang Rubi, Professor, Paediatrics Department, Affiliated Hospital of Ningxia Medical College Dr Wang Jianguo, Director of Pharmaceutical Centre, Affiliated Hospital of Ningxia Medical College SICHUAN Sichuan Provincial Health Bureau Dr Wang Zai Ying, Vice-Director Dr Kang Junzing, Vice-Director, Anti-Epidemic Department Dr Feng Shuzing, Office Staff in Charge, Anti-Epidemic Department Sichuan Provincial Epidemic Prevention Station Dr Wang Dengzhi, Vice Director Dr Xie Rendong, Director, Bacterial Diseases Dr Yang Hongbin,Vice-Director, Bacterial Diseases Dr Liu Ruifeng, Technician-in-Charge, Bacterial Diseases Dr Wang Zhengchun, Doctor-in-Charge, Bacterial Diseases Dr Yin Zhi Ying, Technician-in-Charge, Bacterial Diseases Dr Luo Xiang Shu, Doctor-in-Charge, Bacterial Diseases Dr Feng Zhehui, Technician-in-Charge, Bacterial Diseases Dr Guo Zhougi, Technician-in-Charge, Bacterial Diseases Dr Xu Yaofang, Technician-in-Charge, Bacterial Diseases Dr Ou Yangbing, Doctor-in-Charge, Bacterial Diseases Dr Liu Honglu, Technician-in-Charge, Bacterial Diseases Dr Gu Jiawei, Doctor, Bacterial Diseases Mr Li (Alexander), Assistant Translator

- 59ANNEX 6

KEY ACHIEVEMENTS AND CONSTRAINTS OF THE NATIONAL CDD HEALTH EDUCATION CENTRE IN SHANDONG

Achievements (related to strategies in the original Communication Plan of Action) Strategy 1:

To strengthen the training of health workers on case management of diarrhoea and communication.

(1) Translation of WHO CDD training modules on Advising Mothers (1994); (2) Translation of the WHO CDD publication "Rational use of drugs in the management of acute diarrhoea in children" (1992; 6000 copies printed and distributed); (3) Dubbing of WHO CDD video "Assessment" into Chinese 1994; 300 copies reproduced and distributed to all programme provinces); (4) Development of "CDD health Education"- a guide for programme managers to plan, implement and evaluate health education and communication activities (1994, 100 copies printed; used in Ningxia, Qinghai and Shandong); (5) Development of a training video "Advising mothers- Interpersonal communication skills " (1995; 20 copies reproduced; used in Shandong); (6) Development of a four-page leaflet for village doctors on key messages for mothers (1993; 10 000 copies reproduced); (7) Development of posters on diarrhoea prevention and treatment ( 1993; 20 000 copies, distributed in Shandong province and send to all CDD programme provinces. A poster on breastfeeding; 20,000 copies printed and distributed to at "least 12 provinces); (8) Other materials developed which cover also CDD topics, such as "Facts for Life". Strategy 2:

To undertake education of the general public by using radio, television and newspaper.

(1) Production of a CDD briefing kit for journalists and radio broadcasters60 questions and answers (1994; 100 copies reproduced; used in Shandong); (2) Networking with mass media (1994; several contacts with radio stations and newspapers; use of airtime and columns); (3) Development of TV spots on diarrhoea horne management (1995; developed three-minute and two x one minute spots; broadcasted already at county level stations; awaiting for central level evaluation); (4) Production of a video on prevention and horne management (for the general public); (1994, used in two counties in Shandong).

- 60Annex 6 .

Strategy 6:

To evaluate effectiveness of CDD communication activities and include the results of the evaluation into future CDD communication strategies. areas). Some of the results indicate measurable progress towards correct behaviour change and knowledge, some indicate more modest improvements;

(1) Baseline and follow-up KAP studies carried out both in test and control areas (four

Regarding the role of the Shandong Health Education Centre as a national centre for the coordination of health education on CDD in China (Strategy 7), the following issues were brought out: (1) Some CDD materials, such as treatment charts and videos distributed to all CDD

provinces; (2) Technical support provided to two provinces, namely Ningxia and Qinghai; (3) Development of the "CDD health education" guide, which was used in two provinces. Problems and constraints Shortage of funds for material development and reproduction Shortage of video and other equipment for development of material Lack of specificity and clarity regarding the responsibilities, resources and activities described in the Shandong Communication plan of action The quantities of materials to be reproduced were not specified in the plan The provinces to which the Centre should distribute the materials or provide technical support for planning and training were not indicated Lack of information exchange between the Shandong Centre and the provinces and the NCDDP Not all provinces have a clear idea about the role of the National CDD Health Education Centre in Shandong, i.e. what kind of support they can request and expect Other provinces do not provide adequate feedback to Shandong on locally developed materials. (Feedback mechanism may also be unclear, i.e. to where materials/ feedback should be provided) Reports (and recommendations) of WHO staff and STCs to Shandong are not shared with the Shandong Centre Some aspects of material development in Shandong Centre, in particular, field-testing, would require further strengthening

- 33-

Table 8. Annual ORS production 1990-1995 in four selected provinces

Province Fujian

1990

1991 285 ()()()

1992 1 358 600

1993 700 ()()()

1994 960 ()()() 140 ()()()

1995 1 500 ()()()

2 040 ()()()

Guangxi

NA

NA

NA

Hunan

2 199 600

5 437 800

2 179 400

2 578 400

Yunnan

-

500 000

900 000

1 300 000

500 000

An example is the Baima ("White Horse") factory in Yunnan, which started ORS production in September 1991 at the request of the Provincial Health Bureau and EPS . In previous years, there were several ORS producers and many formulas and packet sizes were circulating. However, in 1991 the Provincial Health Bureau requested Baima to produce ORS for the province, using the standard WHO formula and the 500 ml size, which became a kind of standard promoted for the whole province. Hospitals then were to stop ORS production and procure their ORS requirements from the Baima factory. Production steadily increased during the first three years. The factory, however, does not have a special marketing and promotional strategy for ORS, except for a colourful flyer showing it together with other few . pharmaceutical products produced by the factory. The ORS packet is standard and resembles the UNICEF packet, with one side mentioning the ORS formula in the English language and the other s.ide giving a thorough pictorial description of ORS preparation and dosing in Chinese. It is unlikely that the majority of people would understand the English text and the dosage instructions, based on fixed volumes in a 24-hour period, would need to be updated according to the national COD guidelines (volume based on number of watery stools). The factory made a considerable investment in production equipment with its own resources, possibly anticipating increasing demands in the future. At present there is one fully operational production line; a second one is expected to be operational soon. The factory reported a maximum capacity of 120 packets per minute, resulting in around 60 000 packets per day. In this way, 10 million packets could potentially be produced per year and this amount could double once the planned second production line was in place. Quality control of ORS is carried out by the Drug Evaluation Administration of the Provincial Health Bureau. Although the ORS price is not much below the price range of other pharmaceutical products (see "Economics of ORS"), Baima considers ORS to be a low profit product with a low return of investment. Provinces that have no local manufacturer, and even some that have local production, import ORS from others. For example, Shandong imports from Hunan province or from Shanghai, while Fujian, which has an ORS factory, procures ORS from at least five other provinces (Table 7).

- 34-

Additional production of ORS takes place in hospital pharmacies at county level (see Table 7), but information on total hospital production is not available and estimates can not be made. This has led to a large variety of packets circulating in the country, as collected during the visits to the eight provinces, all with different packaging and instructions. Provincial EPS managers have shown great interest in establishing ORS production in their own province, in those situations where they have to procure ORS from other provinces. There appears, though, to be little need from a practical point of view, both in view of the current low ORS consumption and the existing potential production capacity, which could easily increase production to levels several times higher than the current ones (Kunming Baima factory alone could reportedly soon produce up to 20 million packets per year). Moreover, it is fair to assume that manufacturers themselves will become more interested in ORS production once the market becomes more clearly visible. Given the various amounts produced or procured from different sources, including those produced by hospitals, it was not possible to estimate the total amount of ORS currently produced in each province and in the country. However, current production levels would appear to be sufficient to meet current demand. (2) Distribution

It was also very difficult to thoroughly assess the availability of ORS in health facilities in China within the framework of the review. Limited information was provided in the questionnaires and only some impressions could be obtained during the field visits, which were carried out to only a few health facilities and COD programme areas. The most remote areas were not visited. In the eight provinces visited, ORS was found in all health facilities in sufficient amounts based on the reported diarrhoea case loads. Six out of nine provinces reported in the questionnaires that ORS can be produced in hospital pharmacies. This production was said to be easily adjustable to local needs, making ORS available also through this channel. More commonly, health facilities are either supplied with ORS by EPS, and/or they order it together with their general drug requirements from wholesalers. In the areas visited, health facilities reported they could easily request or order more ORS if they needed to. ORS is supplied only when institutions ask for it; no fixed or regular distribution schedules are usually in use. ORS is typically distributed through the following channels, with unknown proportions for each of them : EPS, which distributes ORS through its network to provincial, county, and township hospitals. Village health centre can often obtain their supply from the township hospitals; a great number of pharmaceutical wholesalers (e.g. 150 just in Shandong Province), which can sell ORS together with other drug items to hospitals if requested; ORS manufacturers, which may sell directly to health facilities and other institutions (e.g. army). Overall, availability of ORS did not seem to be the real problem for diarrhoeal disease control, but some provinces reported problems with transport for delivering ORS to remote areas, with prices being higher because of transport costs.

- 35-

(3)

Use of ORS by patients

ORS use rates appear to be low; provincial managers of seven out of nine provinces reported that demand for ORS was low (see Table 7). Household surveys have suggested a low use of ORS at community level. Consequently, there is little demand for ORS from the public. Although ORS is a non-prescription drug, apparently few pharmacies would be willing to stock it since the demand is so low. Prescription of ORS by health personnel Diarrhoea was not a major problem in most of the health facilities visited. For instance, out of a total of 40 000 outpatient consultations in the provincial hospital of Kunming around 2000 (5%) were for diarrhoea; similarly, only 2249 (0.3%) of the 800 000 outpatients per year at the provincial hospital in Jinan and only 33 (0.13%) diarrhoea patients of the 25 000 outpatients at a township hospital in Shandong Province were seen for diarrhoea. Based on the information from the questionnaires, interviews with health staff and records reviewed during the visits, ORS appear to be prescribed rarely at health facilities. ORS use is also low in health facilities. Use of IV fluids and antibiotics, on the other hand, was found to be very high in practically all hea!th facilities visited. Typical values for ORS prescribing rates were 10% or lower while IV and antibiotics prescribing rates were more than 50%. Inpatients received IV fluids in as many as 80% of cases in some hospitals. It was observed that even outpatients with diarrhoea assessed as having no dehydration received IV fluid therapy. Even village doctors can, and do, administer IV fluids to diarrhoea patients. There are reasons to believe that doctors at health facilities are not yet disposed to prescribe ORS. Although ORS could be prescribed in addition to other treatment, and IV patients could receive follow-up treatment with ORS, this seems to be rarely the case. Doctors often believe that profits on ORS are too low to make it an interesting item to prescribe. On the other nand, there appears to be a strong belief that antibiotics can shorten the duration of the diarrhoea episode, which would explain why antibiotics are so frequently prescribed (Table 7). A worrisome finding was that of the frequent use of non-recommended antibiotic treatments for diarrhoea, such as oral gentamicin and kanamycin. Even though the national COD guidelines on diarrhoea case management were found in some health facilities, most doctors do not follow them; observed and reported practices are not in line with the recommended treatment guidelines of the programme. Also, recommendations on diarrhoea treatment in medical text books have not yet been updated and are inconsistent with the national COD guidelines. (4) Economics of ORS

It was commonly mentioned during visits that profit on ORS was low for the producer, as well as for the prescriber. According to informants, several factories had stopped ORS production in the light of the low profits. The price of ORS was said to be regulated. Profit margins are usually 10-15% at the levels of the manufacturer, wholesaler, and health facility. For example, the Price Administration in Yunnan province stipulated ORS prices for all levels, to be as presented in Table 9.

- 36-

Table 9. Price of ORS in Yunnan province Price level Costs of materials Ex-factory price Wholesale price Retail price

Price (Yuan) 0.41 0.51 0.63 0.80

Price (US$) 0.05 0.062 0.077 0.098

The wholesale prict! compares favourably with world market prices from non-profit sources, averaging US$ 0.096 (range US$ 0.068- 0.15, not including freight and insurance) An overview of prices of ORS at various levels of the health care system in Yunnan province is presented in Table 10. In other provinces, factory prices fluctuated between 0.35 Yuan and 0.50 Yuan, mostly depending on the quality of packaging. Retail prices were often reported to be in the range of 0.28 Yuan to 0.50 Yuan, depending on the quality of packaging (see Table 11). However, it was reported that ORS is sold at varying prices to the public, sometimes reaching the price of 1 Yuan per packet.

- 37-

Table 10. Sale prices of ORS, IV fluid, and commonly used drugs in diarrhoeal diseases Yunnan and Shandong provinces, China (Prices per unit in Yuan, October 1995)

Kunming hospital

Sha Lan township hospital 0.8

Dong village

HC 0.5

Jinan provincial hospital 0.7

Gaomi provincial hospital

Xia Zhuang township hospital 0.36

RANGE

ORS

0.7

0.36-0.8

Penicillin G inj 0.8 MIU Ampicillin inj 500 mg Amoxicillin syrup 125 mg Amoxicillin caps 250 mg APC tabs Gentamycin inj 8::> mg Gentamycin tabs 40 mg Cotrimaxazo1e tabs 400/80 Norfloxacin caps 100 mg Kanamycin inj 500 mg PPA tabs (pipemidic acid) IV fluid (glue 5%; NaCL 0.9%, 0.5ltr)

0.6 1.2 1.5 0.48 0.015 1.25 1.48

0.8

0.71

0.7 1.18

0.7 1.18

0.6-0.8 1.18-1.25 1.4-1.5

1.4

O.Q38 0 .31 0.096 0.13 0.15 0.15 0.61 0.122 0.155 0.61 0.13 4 4 0.31 0.43

0 .015-0.038 0.31-0.43 0.096 0.122-0.13 0.15-0.155 0.61 0.13 4

- 38-

Table 11. Production costs in three selected provinces (price in Yuan)

Hunan Production costs - Simple packaging - Full packaging Ex-factory price - Simple packaging - Full packaging Retail pric'e - Simple packaging - Full packaging

1990 0.18

1991 0.21

1992 0.20 0.32 0.23 0.40 0.31 0.55

1993 0.22 0.37 0.25 0.40 0.35 0.55

1994 0.25 0.39 0.28 0.41 0 .38 0 .38

0.23

0.23

0.31

0.31

-

-

Fujian Production costs Ex-factory price Retail price

1990

1991 0 .28 0. 23 0.50

1992 0.24 0 .23 0.50

1993 0 .21 0.20 0.50

1994 0.20 0 .20 0.50

-

Yunnan Production costs Ex-factory price Retail pric.e

1990

1991 0. 34 0.35 0.48

1992 0.34 0.35 0.48

1993 0.42 0 .35 0.48

1994 0.48 0 .35 0.48

-

-

Contrary to profits being made on antibiotics· and IV solutions, it was often reported during the field visits in some provinces that the social benefits of ORS were given priority over the profits, the latter being felt counterproductive to the effective control of diarrhoeal diseases, especially in remote, low-income areas. In some cases it was reported that ORS was provided by EPS to health facilities without any profit. Health facilities were commonly allowed to make a modest profit of 10% (against 15% of profit for other drugs). Although the profit percentage is very similar to that for other pharmaceutical products by national regulation, the absolute value of profit is higher for more expensive products. Contrary to what was felt by the large majority of doctors interviewed, ORS treatment is not cheap in comparison to other commanly used drug treatments, and in some cases is even more expensive (see Table 12). On the other hand, IV fluid therapy is, in terms of profit, more attractive than ORS, both to the manufacturers and to the prescribers.

- 39-

Table 12. Costs of commonly used drug treatments in China

Drug treatment

Estimated number of units needed 6 6 3 6 12 6 3 9 gr 3

Unit price (Yuan)

Estimated treatment costs (Yuan) 3.6 4.2 1.2 0.75 1.56 0.93 3.54 0.225 12

ORS Penicillin G inj 0.8 MIU Gentamycin inj 80 mg Cotrimoxazole tabs 400/80 PP A tabs (Pipemidic acid) Norfloxacin tabs 100 mg Cough remedy (allopathic; Gancao vials) Cough remedy (traditional; Gancao

0.6 0.7 0.4 0.125 0.13 0.155 1.18 0.025 4

+ Huashi)

IV fluid glucose 5%; NaCI 0.9%, .5 litre

In addition to the profits made from prescribing antibiotics and IV fluids, hospitals generate income by admitting patients to the ward. Interviews in some hospitals revealed periods of admission of a few days up to two weeks for a diarrhoea episode. Data from questionnaires supported field observations (including record reviews) that diarrhoea cases without dehydration may be admitted to hospitals and that diarrhoea cases at all levels of care may frequently be treated with antibiotics and IV fluids, irrespective of whether dehydration is present or not. 5.4.5 (1) Conclusions Supply

Is ORS availability an issue? It is likely that ORS is available in the areas covered by the COD progranune and that ORS supply is adequate in the current situation of progranune development and implementation. An issue, however, is the availability of ORS in remote areas where transportation problems may exist, as reported by some provinces. This conclusion is based on the following considerations:

Production Many provinces have local production facilities. Current production appears sufficient to meet current demand.

-40-

-

The existing potential production capacity in China could probably easily meet increased needs, if demand increases. Current low production is ascribed to low demand. Many ORS-producing factories were reported to have stopped ORS production because of low demand and low profit.

Procurement and distribution

(2)

ORS can be procured from different sources, either directly from ORS factories within or outside the province, or through EPS or pharmaceutical wholesalers. ORS is often also prepared in hospitals at the provincial or county level. ORS was found in all visited facilities in sufficient amounts, according to the reported diarrhoea case load. From some provinces there were reports of problems with transportation of ORS to poor, remote areas .

Demand Is ORS a profitable product?

ORS does not appear to be less profitable than many other drugs but may provide limited profits only, if sales volumes are low . The following considerations were made: Profit related to price: The profit from selling an ORS packet is higher than the profit from other commonly used drugs. Cost (and profit) of a three-day treatment course of ORS is comparable with the cost of a three-day treatment course with other commonly used drugs.

Profit related to volume of sales: Overall profits from ORS sales remain low if demand is low. Demand is low .

Do doctors prescribe and use ORS?

- ORS does not seem to be commonly used, either alone or in combination with other treatment schedules. Doctors believe more in the effectiveness of treating diarrhoea with antibiotic and IV than with ORS, even in areas covered by the CDD programme.

- Currently, there is no strict regulation for hospitals to follow the national CDD guidelines on standard case management, including the use of ORS. ORS use was low in the hospitals visited.

- 41 -

Do people use ORS? The ORS use rate reported in household surveys and during field visits appears to be low, even in areas covered by the COD programme.

Can people who need ORS afford it? Costs due to current treatment practices (e.g. antibiotics, IV therapy, admission costs etc.) are much higher than those due to ORS use. It may be assumed that people in urban and more developed areas may be able to afford such high treatment costs. However, there is not sufficient information from poor and remote areas.

Are current CDD strategies sufficient to increase ORS use in the future? Quality and coverage of case management training and health education are not optimal. Currently there are no clear criteria for prioritizing programme implementation in selected high risk areas. Marketing strategies to place the product in the community and among doctors have · not yet been developed and carried out. Even in areas where ORS is produced and distributed to health facilities, ORS use is low and, hence, demand is low. 5.4.6 ( 1)

Major causes of, and potential solutions for low ORS use and demand

Established inappropriate practices of medical personnel in managing diarrhoeal diseases

Inappropriate case management of diarrhoea was seen in all health facilities visited. There appears to be a strong belief with medical professionals that antibiotics can shorten the diarrhoea episode and IV fluids are to be used to treat and prevent dehydration. The vast majority of EPS programme managers reported this to be a serious problem. The magnitude of the problem does not appear to differ much between provinces or types of health facilities. Potential solutions would be to conduct quality in-service training and to improve preservice training with respect to diarrhoea. In addition, ORS (as a product) may be promoted to the general public, side by side with quality health education in the provinces selected for intensified support. This could have a positive spill-over effect on medical professionals. (2)

General belief in the appropriateness and effectiveness of antibiotics and N fluids in Cf?Se management of diarrhoea among the population

Reportedly, patients often share with medical personnel the belief in the appropriateness and effectiveness of using antibiotics and IV fluids, not only in diarrhoeal diseases. ORS does not seem to have the appeal of antibiotics and IV fluids in the management of diarrhoea. A potential solution would be to promote ORS (as a product) to the general public, side by side with quality health education in the provinces selected for intensified support.

- 42-

(3)

Low awareness of correct case management of diarrhoea (including the use of ORS) amongst the general public

Whereas there have been health education efforts in many provinces in China, they have often focused on general prevention messages (e.g. improving hygiene in general). It seems that these efforts have mainly concerned promotion of ORS, rather than promoting correct case management of diarrhoea. A potential solution would be to provide quality health education in the provinces selected for intensified support. (4)

Pre-service training of medical personnel is not consistent with correct case management of diarrhoea

Pre-service training is not consistent with correct case management of diarrhoea as recommended by the national COD guidelines. This appeared to be confusing for medical personnel. Furthermore, knowledge obtained during pre-service education is often given a higher priority than the knowledge offered during in-service training. Potential solutions would be to strengthen the curriculum of medical education, to include training in correct case management, and to conduct training of trainers courses for senior university staff. In addition, established reference text books could be updated to be consistent with national guidelines on correct case management of diarrhoea. (5)

Protocols for diarrhoea case management in hospitals are not consistent with national CDD guidelines

At present, national COD technical guidelines are seen as a reference, rather than standards of performance. They carry no regulatory power. This may make the guidelines ineffective in demanding their application in daily practice in health facilities, this fact having much importance in the Chinese context. A potential solution could be to carefully review all existing protocols and regulation and to modify regulatory documents where needed, to be consistent with national guidelines . (6)

Low availability of ORS in remote areas A few provinces reported that transport to remote areas may be a problem.

A potential solution could be to collaborate with other Ministry of Health programmes, e.g. the EPI programme, in combining transport of EPI supplies (e.g. vaccines) with ORS to remote areas. 5.4.7 Recommendations Recommended activities would fall within the following categories: training: pre-service (medical, nursing, other levels), in-service, revision/updating textbooks; health education! communication; ORS promotional activities (direct and indirect); regulation.

- 43-

The recommendations on training, health education/communications, and regulation are dealt with in more detail elsewhere in this report (see Sections 5.1.6, 5.2.5, 5.3.5). Potential activities regarding promotion should be carried out within the framework of a strong and comprehensive communications plan. Some examples are described below: (1) Direct promotion

Preparation and distribution of printed materials

Printed promotional materials, such as posters, pamphlets for medical doctors, pamphlets for community members, and cartoons could be developed, field tested, printed and distributed by the Health Education network in selected provinces with intensified support. Coordination with Health Education should be assured. Preparation of information kit for journalists

To enhance publicity in the mass media, an attractive information kit could be designed for use by journalists. The kit would have to be prepared in collaboration with one or more journalists, aware of the specific information needs of this group of professionals. Competitions and awards

Competitions and award winning are popular in China. This popularity could be used to promote correct case management and appropriate use of ORS. Examples include holding competitions for the "Best diarrhoea treatment centre" in the province, and awarding the status of "ORT-promoting hospital" (or health centre) if defined conditions are met. Competitions could be organized for best designs of health education materials, probably a low cost method to obtain such materials and a method to promote the idea of correct case management with the competition itself. Radio spots, TV spots

Attention-catching spots that promote correct case management, including the appropriate use of ORS, could be carefully designed, field-tested, and transmitted with regular frequency and during a sufficient period of time in the provinces selected for intensified support. (2) Indirect promotion

Create diversity in the supply of ORS

If the purpose is to enhance the use of ORS, it would be desirable to increase the attractiveness and the range of ORS products available on the market in China. To enhance this process, the COD programme could prepare an information kit for potential ORS manufacturers, giving examples (from within and outside China) of attractive package designs. Informing producers about the possibility of flavouring ORS may be given consideration. The information kit should be carefully designed, keeping in mind the information needs of manufacturers. The amount of technical information on diarrhoea case management should be kept to a minimum number of selected key messages. The kit would have to be distributed by the provincial health bureaus.

- 44 -

- 45-

ANNEX 1

PARTICIPANTS AND RESOURCE PERSONS IN FPR PHASE I

Department of Diseases Control, Ministry of Health .E>r Nan Junhua, Division Director (14, 19 August) Dr Wu Wenhua, Deputy Director (14 August) Dr Wang Wenjie, Section Chief*

Institute of Epidemiology and Microbiology, Chinese Academy of Preventive Medicine Dr Dr Dr Dr Xiao Donglou, Deputy Director (14 August) Song Ying Tong, Assistant Professor Lai Xin-He, Assistant Professor* Yu Yongmao, Assistant Professor*

Capita/Institute of Paediatrics Dr Jia Mei, Assistant Professor*

UNICEF/Beijing Dr Liu Bing, National Programme Officer (14, 18 August)

AusAID /Beijing Ms Jacinta Leahy, Second Secretary, Development Cooperation (18 August)

WHO/Beijing Dr Sergio Pieche, Medical Officer, CDD/ARI*

WHO/Regional Office for the Western Pacific, Manila Dr Seppo Suomela, Regional Advisor, CDR* Dr Marianna Virtanen, Associate Professional Officer, CDR*

WHO/Headquarters, Geneva Dr Gottfried Hirnschall, COD Programme Manager, CDR* Dr Jennifer Bryce, Evaluation Officer, CDR*

*Full-time review team members .

- 46-

- 47-

ANNEX 2

LIST OF DOCUMENTS REVIEWED IN FPR PHASE I AND PHASE II

1.

Policy and Plan of Work, 1990- 1994. Programme for Control of Diarrhoeal Diseases, The People's Republic of China, May 1992. COD Country Programme Profile, China. WHO, 1994. Revised National Case Management Policy, 1993. WHO Travel Report, November 1993, Dr N. Pierce. COD Review and Planning Visit, Beijing, Shandong and Yunnan Provinces, China . WHO Travel Report, February- March 1994, DrS. Suomela. COD Review and Planning Meeting, Urumqi. WHO Travel Report, September 1994, Dr G. Hirnschall. COD Plan of Action for Ningxia and Qinghai. January 1994. Report of the Fifteenth Meeting of the China/WHO Joint Coordination Committee, Urumqi, China. 17-19 August 1993. COD Clinical Case Management Training- Yunnan, July 1991. WHO Travel Report, Dr G. J. Ebrahim. CDD.Clinical Case Management Training- Gansu. December 1990. WHO Travel Report, Dr 0. Christensen.

2. 3. 4. 5. 6. 7. 8. 9.

10. COD Clinical Case Management TOT- Kunming, Yunnan Province. November 1993 . WHO Travel Report, Dr H. Lindblad. 11. Training Study Tour and DTU Training. WHO Travel Report, August-September 1993, Dr I. Lejnev. 12. MedEd Workshop. WHO Travel Report, November 1994. Dr N. Pierce . 13. Breastfeeding Counselling Course. WHO Travel Report, November 1994. Dr F. Savage. 14. COD Health Education and Communications Activities, Shandong Province . WHO Travel Report, September 1991. Dr J. Hubley. 15. ORS Production. WHO J:ravel Report, October 1990, Dr H. Faust. 16. Research Skills Workshop. WHO Travel Report, October- November 1993 . Dr J. Martines. 17. Joint MOP/UNICEF/WHO Review and Planning of COD Training in Yunnan Province, 16 - 27 February 1993. 18. Programme Review, Yunnan Province, 1990. Dr Salmonson.

- 48-

Annex 2

19. CDD Household Survey, Beijing. August- September 1991. WHO Travel Report, Drs Jansen and Gaumerais. 20. COD Health Facility Survey, Yunnan Province. August- September 1992. WHO Travel Report, Dr H. Gaumerais. 21. A Household Investigation Summation of Children Diarrhoea in Partial Areas of Ningxia in 1993. 22. Summary of the Household Survey on the Incidence and Case Management of Diarrhoeal Diseases in Qinghai Province, September- October 1993. 23. A National Survey on the Use of Oral Rehydration Therapy for Children under Five Years of Age, 1994. 24. Cost effectiveness of current and ideal case management of acute childhood diarrhoea. WHO Travel Report, August- September 1991, Dr J. Picard. 25. Household Survey, 1995. MCH. Unpublished . 26. Revie.w of Communication Activities, Shandong, 1995. Dr Wang/Or Pieche. 27. Poverty Alleviation Strategies. Targeting Groups, Encouraging Participation, Mobilizing Technical and Political Support. Report of UNICEF/UNFPA Project, 1990. 28. Summary Report of Training Course on the Case Management of Diarrhoeal Diseases, Yunnan Province, May 1995. 29. Report on the Case Management Training Courses of COD in Liaoning Province, May 1995. 30. Summary Report of Workshop on Clinical Case Management of Diarrhoeal Diseases, Guangxi Anti-epidemic and Sanitary Centre, May 1995. 31. Summary Report on the Communication Skills of Case Management and Advising Mothers. Dr Li Hailin, Kunming Medical College, June 1995. 32. Ministry of Health Kunming Workshop on Diarrhoea Case Management, Summary. May-June 1995, Kunming. 33. Article for "Dialogue on Diarrhoea", May 1995, Beijing. 34. Report on the COD Communication Activities in Ningxia Autonomous Region, Dr Wang Wenjie, March 1995. 35. A Summary of Training Course on Health Education for Diarrhoea Disease, Xining, Xinghai, June-July 1994. 36. CDD Health Education Course, Quinhai, June 1994. 37. Summary of the CDD Training Course for Programme Managers in Qinghai. CDD Programme Office of Qinghai Anti-Epidemic Station, April 1994.

- 49Annex 2 38. Report on Xinjiang Programme Activities Carried out for the Control of Diarrhoeal Diseases (Training Course for Programme Managers and Supervisors), Urumqi, Xinjiang, April 1994. 39. Diarrhoea Case Management Training Course in Huainin County, March 1994. 40. Yunnan Diarrhoea Case Management Training Course in Lichuan, February 1994. 41. The Seminar on Supervisory and Management Skills in Sichuan Province, December 1993. 42. The brief summary of managers and supervisors training course of diarrhoeal diseases in the whole autonomous region, Yinchuan, Ningxia, December 1993. 43. Report on the Training Courses for COD in Liaoning for Programme Managers and Supervisors, November 1993. 44. COD Programme KAP Survey in Shandong Province, China. November 1993. 45. Execution of Diarrhoea Control Programme in Guangxi. Health and Epidemic Prevention Station of Guangxi Zhuang Autonomous Region, November 1993. 46. A Report of the Training Course on Diarrhoea Diseases Management in Ningxia, October 1993. 47. Training Course for CD D Programme Managers and Supervisors and Planning Meeting, Yinchuan, Ningxia, September 1993. Dr Wang Wenjie. 48. National Training Course for Programme Managers and Planning Meeting for the Four New Provinces, June-July 1993. Dr Wang Wenjie. 49. Report of a meeting on ORS Production. WHO Travel Report, May 1992. Dr H. Faust. 50. Provincial programme reports submitted to NCDDP. Full reports in Chinese, summary reports in English. Notes to Reference List: a) Many provincial documents in Chinese are not listed here.

b) Many of the documents reviewed are internal documents that were made available only for this review.

- 50 -

- 51 -

ANNEX 3

LIST OF PROGRAMME ACHIEVEMENTS

Planning, Management, Finance Central: 1. Various planning and review meetings were conducted. One review meeting (Yunnan) was conducted jointly with various sections of the Ministry of Health and major donor agencies. A national plan was established in 1990 and revised in 1992. A national CDD case management policy was developed, adapted to China's needs, and distributed. WHO training materials for progranune management, supervisory skills and clinical case management were adapted and translated. For communication activities, training materials, videos, and technical references have been printed. Some materials have been translated into local dialects. Both external and internal funds have been mobilized for the CDD Progranune. A rough estimate is that about US 450 000 was mobilized from external sources (US$400 000 from WHO/AusAID, US$50 000 from UNICEF) a~d a total400 000 Yuan (about US$50 000) were obtained from the Government of China. Three centres were established: the Fujian Centre for Information Exchange, the Shandong Centre for Health Education and the Kunming Centre for Case Management. A national team for CDD was established, with participation by the Ministry of Health, the Chinese Academy for Preventive Medicine, the Capital Institute of Paediatrics, and some provincial technical EPS staff members.

2. 3. 4.

s.

6. 7.

Provincial: 1. 2. 3. 4. 5. Provincial plans have been developed in 16 of 30 provinces. Targets, indicators and strategies in the provincial plans are consistent with those of the national programme. A coordination group for CDD has been formed in 17 of 30 provinces. Budget information was provided to the NCD DP for 12 of the 17 provinces targeted by the progranune. Eight provinces have mobilized local government funds equal to the amount provided by the Ministry of Health. Training materials have been developed and reproduced in eight provinces.

I

Preliminary figures, not for quotation.

- 52Annex 3 ORS 1.

Available data suggest that there are at least four manufacturers of standard ORS in China, who produced 5 500 000 500 ml packets of ORS in 1994.

2

Evaluation

1. 2.

Household surveys were conducted in nine of 30 provinces, providing these provinces with data for future programme planning (see summary of household surveys in Annex 4) For three provinces (Yunnan, Hunan, Shandong), input by the Ministry of Health staff has led to a transfer of skills and additional household surveys have been conducted independently by provincial staff. Comprehensive programme reviews have been conducted in four provinces. The research workshop in 1993 initiated prevention research activity; four of five proposals developed in the workshop were found to be technically strong by a WHO review group. One was funded by WHO; others have not yet been funded . The national team is functioning well in relation to the conduct of household surveys. The collaboration between the CAPM and the Ministry of Health has resulted in a number of high-guality household surveys being conducted.

3. 4.

5.

Training

1. 2. 3. 4.

Leaders throughout the health delivery system now see CDD case management training as more important than before. A considerable amount of training and orientation has been carried out (see lists of training activities in Annex 4.) DTUs and ORT corners have been established in some facilities . The national case management training centre at DTU Kunming has conducted training for health providers from a number of other provinces, and provided leadership in activities related to improvement of case management in health facilities (see list of specific activities in Annex 4) . There is some evidence that new (interactive) and high-quality training methods have been accepted in some areas, including: smaller courses with few participants per facilitator 3

5.

use of role plays, group discussions, case studies, etc. increased use of clinical practice in training sessions

2

"Standard" indicates that the composition of the ORS meets international WHO/UNICEF standards. WHO recommends a minimum of one facilitator for every four to five participants .

3

- 19-

Table 4.

Target populations and number trained to date as reported by provinces on written questionnaire

Province

Number in target population 27 ()()() 23 488 Not reported 10 ()()() 44 802 10 ()()() 4 953 83 548 2 070

Number trained from 1991 to September 1995

Fujian Gansu · Guangdong Henan Hunan Liaoing Qinghai Sichuan Yunnan

16 479 194 Not reported 3 ()()() 3 386 2 ()()() 953 1 972

2 657

In addition, each Phase II team requested information about the number of courses and people trained by EPS during 1995 in the provinces they visited. Team reports were supplemented by provincial documents when necessary. The current best estimate is that clinical case management training at any level occurred in 1995 in only four of the eight provinces visited. The total number of individuals trained appears to be very low (less than 1000).

(c) Quality of case management training. Quality of training was assessed by examining the following factors: whether any training of trainers was conducted; duration of training (minimum of three days); ratio of trainers to trainees (no less than 1: 5); use of materials based on national guidelines; opportunities for hands-on practice by trainees; scheduling of courses during peak diarrhoea season (to ensure sufficient cases for hands-on practice); number of cases managed by each participant (minimum of two).

-20-

Data on the quality of training were available both from the provincial questionnaires and from the information collected by Phase II teams in the provinces they visited. Selected results are presented in Tables 5 and 6. In provinces where multiple courses were conducted, the responses indicate whether the quality criterion was met in at least half of the courses for which information was available. when data were incomplete, the team tried to arrive at a decision through the review of reports or supplemental interviews with key informants.

Table 5. Indicators of quality of case management training as reported by provinces on written questionnaire Province Any TOT reported Duration of training (days) %Time in hands-on practice Scheduled in peak season? No. cases managed by each trainee

Fujian Gansu Guangdong Henan Hunan Liaoning Qinghai Sichuan Yunnan

YES YES YES YES YES 3 3 3 3 3 0% 50% 40% 50% 30% 50%

>4

33%

YES

6-7

NO NO NO NO NO YES

NA

DK 1-2 3-5

NO YES YES YES

2-4 10-20

- 21 -

Table 6. Indicators of quality of case management training as determined by Phase II teams Province Duration of Training (Days) Ratio of trainers: trainees Materials consistent with national guidelines? YES

%Time in hands-on practice

No. cases managed by each team

Fujian Gangxi Henan Hunan Ningxia Shandong Sichuan Yunnan

3 4 1:5 1:20 1:6 1:21 1: 10 1:20 1:8

17 0 0 0 0 33 0 50 NA NA

YES YES YES YES YES YES YES

3 1 3-4 3

1-2 NA NA

< 31 3-4

4-10

(d) Follow-up and supervision after training. There was no follow-up after training in most provinces. Among the nine provinces responding to the questionnaire prior to Phase II, none reported that training participants had developed work plans to guide their use of appropriate case management after they returned to their facilities. Supervision of health workers is not the responsibility of EPS. After training, health workers are supervised by Hospital Administration . These people have not been trained in standard case management. (2) Factors other than training that limit correct case management in health facilities (a) Characteristics of the health system. EPS personnel reported that it is often difficult for them to be effective as trainers in hospitals, as they are perceived as "outside" the hospital system, do not supervise the hospital staff after training, and do not usually have clinical responsibilities. Some EPS and Health Bureau staff interviewed in the field reported that they do not believe that clinical training is, or should be, their responsibility. The present structure of the health system makes coordination between EPS, MCH and Hospital Administration difficult. Few examples of effective coordination were found during field visits to provinces. The team received anecdotal reports of high turnover rates among health workers, particularly at the township and village levels. This means that trained staff are often transferred from their posts, and replaced by individuals who have not been trained.

- 22-

(b) Hospital policies and .financing procedures. In many provinces, EPS staff reported that the case management guidelines in hospitals are not consistent with the national CDD Programme guidelines. This means that after training, health workers cannot apply their new skills. Hospitals can retain up to 15% of the selling price of the drugs sold in their pharmacies. At present, very little profit is made through sales of oral rehydration salts (ORS). (c) Attitudes of health professionals. Doctors report that while they believe that ORS is effective in the treatment of diarrhoea, antibiotics and IV treatment are also effective and can shorten the duration of the diarrhoea episode. They also report that antibiotics are warranted for any child with fever. (d) Attitudes and beliefs of mothers. EPS staff and clinicians at all levels reported that parents demand (and can pay for) antibiotics and IV treatment for their child, and that they are not satisfied with ORS in the absence of other treatment. It is not known whe"ther this is also true in poorer areas of the country. 5.2.5 (1)

Conclusions

Much more training in clinical case management, and training of high quality, is needed if health workers are to provide standard case management for children with diarrhoea. Few children with diarrhoea receive ORS, and most receive antibiotics and/or IV fluids. Some training has occurred, but much more is needed. (2) The current structure of the health system makes it difficult for EPS personnel to be effective as trainers in clinical case management for hospital staff. Because EPS staff are training health workers who work for and are supervised by Hospital Administration, their effectiveness as trainers is limited. After EPS training, health workers return to clinical settings where their supervisors and the case management guidelines do not support their new skills. In addition, EPS staff are usually not clinicians, and are not accepted as clinical instructors by hospital staff. Therefore, some EPS!Health Bureau staff and most hospital staff do not believe it is appropriate to have EPS staff function as trainers for clinical training in hospitals. (3) EPS staff have been the primary stimulus for the training of hospital staff in clinical case management, and in Yunnan province the use of mixed teams of clinicians and EPS staff has been successful. Although information is available only from provinces with active CDD programs,. it appears that no training of hospital staff in clinical case management would occur if it were not for the initiative of EPS. Despite the systemic barriers described in point b above, in Yunnan province EPS staff have worked together with hospital clinicians to conduct case management training. This might serve as a model for other provinces. (4) More information and experience are needed to determine whether EPS personnel can realize their potential as case management trainers at the village level. In household surveys, village and community doctors are reported by parents to be the primary source of care for their children with diarrhoea. One of the original reasons for selecting the EPS system as the channel for CDD programme activities was that EPS has excellent outreach to and credibility with rural communities. In the short period since the CDD programme has been active, there has not been sufficient time for training activities to reach the township and village levels. In Yunnan Province, training in clinical case management is only now beginning at the county and township levels. An important and unanswered question is whether EPS personnel, once trained, can fulfil their potential as trainers of village doctors.

- 23-

(5) High-quality training requires significant inputs of human and financial resources. EPS staff in most provinces do not currently have the knowledge and skills to plan high quality training. The experience in Yunnan Province suggests that EPS staff and hospital clinicians can plan ahd conduct high-quality training, and can work together effectively, if sufficient technical assistance is provided. Without these inputs, training is unlikely to be successful in improving the quality of case management. Given the limited human and financial resources available, the COD Programme will need to focus their efforts on only a very few provinces and on priority counties within those provinces. (6) There are many factors other than training that limit the perfonnance of health workers. High-quality training of health facility staff is an essential foundation for reductions in diarrhoea morbidity and mortality. Opportunities to conduct training in other parts of the Ministry of Health system (e.g. Maternal and Child Health, Hospital Administration) should be energetically pursued. Any effort to improve health worker performance should take into account, and address if possible, factors other than training which serve as barriers to correct case management. In this review, these factors were found to include: parents' attitudes and beliefs (parents want, and insist on, antibiotic or IV treatment for their children with diarrhoea); doctors' attitudes (informants reported that doctors do not believe in ORS; they believe antibiotics and IV will reduce diarrhoea episode duration, and are needed if there is fever); financial disincentives for correct case management (hospitals make money by selling drugs; they make relatively little profit from selling ORS); high turnover rates among health workers, particularly at township and village levels. Recommendations

5. 2. 6

(1) The Ministry of Health and other partners should search for channels in addition to EPS through which health workers could be trained in the standard case management of diarrhoea. For example, the MCH Division currently conducts training of health workers that includes the case management of diarrhoea . The Foreign Loan Office is also conducting a programme that includes case management training for diarrhoea, with support from the World Bank. Within Hospital Administration, annual training courses for the special diarrhoea clinics might be revised to address standard case management. Throughout these training activities, the quality of the training must be carefully planned and monitored . In addition, efforts by both the MOHand the Ministry of Education to strengthen the teaching of diarrhoeal disease in medical schools should continue. (2) Structural barriers to standard case management should be addressed by the Ministry of Health. Protocols for diarrhoea case management in hospitals and in medical textbooks should be made consistent with the national COD Programme guidelines. Existing systems for quality control in hospitals (e .g. the "grading" of hospitals that occurs every three years) should include indicators of the quality of diarrhoea case management. (3) EPS should continue to organize and coordinate clinical case management training in hospitals, with a particular emphasis on improving the quality of training. The joint trainings held in Yunnan might serve as a model, with EPS staff leading the planning and organization

- 24-

of training and guiding the training of trainers, and hospital staff serving as the clinical instructors. Yunnan Province and the Kunming Centre should continue to receive support for clinical (4) case management training, and should be used as a testing ground to assess the potential of EPS personnel as case management trainers at the village level. Past investments in Yunnan, coupled with local commitment, have resulted in significant improvements in clinical case management training. There has not yet been time, nor sufficient support, for the step-by-step training approach to develop from the provincial and county levels to the township and village. This support should be provided, and the experience of Yunnan Province carefully monitored for lessons that can be applied in future training activities. Continued support of Yunnan would also provide opportunities for other important program activities, such as the development and testing of materials to be used by health workers in communicating with mothers. · The national COD Programme should focus their efforts on only a very few provinces, (5) and introduce a set of systematic criteria for selecting "model" counties within provinces. For training, the assistance provided to these provinces and counties should begin with careful attention to planning. If training is included in the plans, assistance and feedback should be provided to ensure that the training meets quality standards. The national COD Programme and other partners should continue to try and address the (6) factors other than training that limit the performance of health workers. Health education and communication efforts directed at changing parents attitudes and beliefs should continue and be strengthened in the next project period (see Working Group report on Health Education). Strategies other than training that could be used to change the attitudes and practices of doctors will need further study. These strategies might include factual accounts of successful treatment of diarrhoea through standard case management in journals or at professional meetings. Doctors attitudes may also change as a result of increasing experience with the successful treatment of diarrhoea without antibiotic or IV therapy . I I

Financial disincentives to correct case management should be investigated and addressed at all levels of the health system (see Working group report on ORS). To address the problem of high turnover rates, future training plans should explore possibilities for routine and continuing inservice training that will reach village- and townshiplevel workers frequently and regularly. One possibility would be to strengthen the content of the required monthly visits by village doctors to township or county hospitals. This regular contact could be used as a channel for refresher training with supervised practice for both experienced and new village doctors. 5.3 5.3.1 Working group 3: Health education and communication activities Statement of the priority problem

COD health education and conununication activities are not well coordinated and are not specifically implemented in a sound manner . The national COD progranune has identified health education and communication as a priority area to be strengthened, based on findings from household surveys showing clear need for improvement of diarrhoea case management and the household level. The NCDDP has stimulated the establishment of a National COD Health Education Centre in Shandong province to assist the programme in the development and implementation of a national COD communication strategy. A major objective of the Shandong centre was to

- 25-

support communication activities not only in their own but also in other provinces where CDD programmes are implemented. A recent review in Shandong has concluded that improvements in both planning and the design process may be needed, and that in particular the centre's support role vis-a-vis other provinces in the context of the national communication strategy needs to be further strengthened. 5.3.2 (1) Review methods Review of written documents

Documents reviewed by the team included the CDD Communication Plan for Shandong province (1992-1994), mission reports covering visits of WHO consultants and staff of the National CDD Health Education Centre in Shandong and reports and data provided by Shandong province. (2) Interviews conducted in Beijing

Representatives from EPI programme of the Ministry of Health Disease Control Department, acute respiratory infection programme of MCH, and director of the Shandong Health Education Institute were interviewed. Key points are summarized in Section 5.3.3. (3) Field visits

Team 3 visited two sites, Henan Province and Ningxia Hui Autonomous Region, from 22 to 28 October 1995. Visits were made to the provincial health bureau, provincial and county EPS stations, the health education institute and county and township hospitals to interview staff responsible or related to diarrhoeal disease control activities. 5.3.3 (1)

Findings National COD Health Education Centre in Shandong

Dr Yu Wenping, Director of the Health Education Institute in Shandong, was interviewed to obtain further information on achievements of and constraints on the functions of the Centre. A CDD communication plan for Shandong, covering the period 1992-1994 was developed in 1991 and further revised in October 1992 in collaboration with a WHO consultant and the staff of the Shandong EPS and Health Education Institute. The initial plan included seven strategies targeting doctors, school children, journalists, broadcasters and the community. The implementation of the plan was further reviewed in February 1994 and June 1995 . The findings summarized in this document are largely based on the discussions carried out during the above-mentioned visits to Shandong, as well as information provided by Dr Yu Wenping of the Shandong Health Education Institute. The centre has been very active under the leadership of the Department of Disease Control of the Ministry of Health and Shandong Provincial Health Bureau with the support of the Shandong Provincial EPS Station and the Provincial Health Education Institute. It has developed various types of health education materials (IPC-skills training modules, posters, videos, etc.) and supported two other provinces in development of plans and conduct of training courses.

- 26-

The centre has also collected baseline information and carried out follow-up studies in selected pilot counties. It has established a good network with mass media, in particular with the local radio stations and journalists in Shandong province. However, due to limited financial and manpower resources, the centre did not have the capacity to fully address all the strategies identified in the initial plan and, therefore, to carry out its function as a national centre for COD health education activities. A detailed list of achievements and constraints are provided in Annex 6. (2) Summary of information collected through field visits (a) Planning for health education and communication activities. In most provinces, activities related to COD communication and health education are included in comprehensive provincial health education plans. However, these plans are often not specific and do not provide detailed information about planned activities, timeframes, resources, targets, expected outcomes etc. Three provinces have provided more detailed information about COD health education and communication activities in their provincial plans. Some of these plans lack focus and prioritization. The National Health Education Centre in Shandong had provided technical support for the development of plans in two provinces. (b) Local development of health education and communication materials . All provinces visited during Phase II of the FPR had locally-developed COD health education materials. All provinces had locally-developed printed materials, such as leaflets, posters, booklets, pamphlets. Videos were produced in five provinces. Three provinces indicated that none of the local materials were field-tested and four proyinces had field-tested most or all of the materials . Some of the messages in locally-produced materials were outdated, and some provided confusing or too many messages (for example a poster on mixing ORS). In some cases materials did not focus on the most important messages related to prevention or home case management of diarrhoea. (c) Conduct of key health education activities. It appeared that health education is a strong component of all public health programmes and is widely used in all provinces visited. A wide scope of health education activities had been carried out, including development and use of printed media, as well health education given directly to the target audience. In some provinces activities included also the use of mass media, such as TV and radio, particularly during diarrhoea peak season from May to September. Propaganda and village "black boards" were also mentioned as means to educate community members. Little emphasis, however, was put on improving face-to-face health education, for example, through training of health workers on IPC skills or developing materials, such as flipcharts or mothers cards. Only two provinces visited (Ningxia and Shandong) indicated that they had conducted training on IPC skills.

- 27-

(d) " Monitoring and evaluation of health education activities. All provinces visited indicated that they had carried out household case management surveys and/or knowledge-attitude-practice (KAP) studies for planning and/or evaluation purposes. However, it appeared that some health workers lacked skills in conducting these surveys and, in particular, in analysing results and using them for revising and/or developing new health education materials and messages. Results, particularly from Shandong Province, indicate some positive trends with regard to improving maternal knowledge and case management practices.

(e) Key problems and constraints . The most commonly expressed constraint was lack of funds to carry out CDD (health education) activities . Several provincial CDD programme managers, or other staff related to CDD communication activities, mentioned that there is a lack of materials as well as equipment.

Lack of support from central level, and a lack of feedback and information, were also commonly mentioned. It also appeared that some provinces were not aware of the role of the National Health Education Centre in Shandong, or the types of materials or technical support they could request and expect from this centre or from the central level. In addition, there is little exchange of locally developed materials among provinces. 5. 3 .4 Conclusions

(1) Health education, as a concept in disease control programmes, is well accepted and widely used in China, and many health educators have the basic skills needed to carry out these activities . (2) There are an encouraging number of provinces that have locally produced various types of health education materials, such as pamphlets, posters, videos, etc., which also include messages on diarrhoeal diseases . However, it appears that sometimes these messages are outdated or confusing, or are not focused on home case management and prevention, as is suggested by the NCDDP policies. Materials that have been locally developed sometimes lack appropriate steps of need assessment and field-testing . In most provinces, little emphasis has been given to the development of materials to support face-to-face health education or to improve health workers interpersonal communication skills through training. (3) The existing national CDD plan (1990-1994) lacked detailed information about specific CDD communication activities to be implemented and prioritized. Only some provinces have provided detailed information about communication activities in their provincial CDD plans of action. Activities carried out have often not been well coordinated, targeted and focused. They have often not planned and carried out as part of a comprehensive health education plan. (4) The National CDD Health Education Centre in Shandong has been very active and indicated great dedication to implement and evaluate CDD health education and communication activities . It has developed several CDD materials and provided technical support for two provinces. However, due to very limited financial and manpower resources, the Centre was not able to provide technical support and share locally developed materials with all CDD programme provinces, as was initially planned. Certain steps regarding material development process require further improvement.

- 28-

(5) There is not enough information, data and material exchange between provinces, and between the provinces, the NCDDP and the National COD Health Education Centre in Shandong. Some provinces are not well aware of the role of the National Health Education Centre in Shandong, i.e. what kind of support they can request. (6) Few efforts have been made by the COD programme staff in some provinces to invite and use political leaders and decision-makers to publicize and mobilize support for COD programme, through the mass media 5. 3. 5 Recommendations

(1) The NCDDP, in collaboration with the National COD Health Education Centre in Shandong, should carry out a review to assess the production, quality and availability of various types of COD-related health education materials in programme provinces, prior to development of new materials.

(2) The NCDDP, in collaboration with the National COD Health Education Centre in Shandong and other relevant institutions and departments, should develop a component for CDD health education and communication activities to be incorporated into the comprehensive COD plan for the next period (1996-2000). The plan should: be focused, realistic and feasible; identify priority strategies; identify target audience; ~rovide

a detailed workplan (targets, inputs, etc.);

identify resources required; identify areas and opportunities for collaboration with other possible COD-related projects.

Funds to support planned activities should be actively sought and mobilized. (3) The role of the National COD Health Education Centre in Shandong should be welldefined. The role of the Centre should focus on the following areas: (a) Technical Support: planning for communication activities; training on IPC-skills; training on use of mass media (radio, etc.); training on monitoring and evaluation; adaptation process of health education materials.

- 29-

(b) (c)

Follow-up and support for provinces in conducting health education activities; Material development : development and field-testing of methods and materials in Shandong Province; The centre should have a workplan, which should provide detailed information about: targets ; activities; time-frames; resources; expectt!d outcomes; follow-up and evaluation mechanisms .

A mechanism should be developed to improve exchange of information, feedback, data (4) and results of various CDD health education activities carried out in different provinces. This could include more interactive ways of conducting annual CDD review meetings, printing of updates, which could include summaries of KAP studies , surveys, etc . The NCDDP could publish a catalogue (a list) of CDD health education materials available in Chinese. The NCDDP and the National Center for CDD Health Education in Shandong should be provided with new health education and communication materials and be updated on global and regional developments in this field. Consideration could be given for the use of the mass media in promoting, publicizing (5) and mobilizing support for CDD programme activities . High level political leaders and decision-makers could be invited to act as spokespersons for the programme. 5.4 5 .4. 1 Working group 4 : ORS production. distribution and use Problem statement

Availability of properly constituted ORS is essential for the reduction of diarrhoearelated mortality. ORS remains the cornerstone of treatment of non-severe dehydration in diarrhoea cases. Reports from provinces frequently indicate that ORS is not available, but in 1994 even the limited amount of ORS produced was not fully distributed . ( 1) Production

Local production seems to be significantly lower than it could be. Available data indicate that in 1994 only 5.5 million 500 ml packets of standard ORS were produced in China in four factories. This amount is very low, considering estimated needs if diarrhoea cases were managed according to the national CDD guidelines at health facilities and in the home. An assessment of ORS production capacity in China in 1992 found that 65 enterprises had registered ORS, although it was not known whether they actually produced ORS and, if so, in

- 30-

what amounts. County hospitals may produce and sell their own ORS, but the prevalence and possible impact of this practice are unknown. (2) Distribution

Only an estimated 60% of the ORS produced in 1994 was actually distributed. The remainder was not purchased by the Government for distribution through the health system and in the community. The reasons for this are not known. (3) Demand

One factor responsible for low production and partial distribution may be that there is little demand for ORS by the public, and this hypothesis is supported by household surveys indicating that relatively few mothers know about or use ORS. A second factor may be that health providers at all levels do not prescribe or administer ORS in health facilities. The one available survey of hospital management of diarrhoea cases 1 indicated that only 44% of children with diarrhoea were given ORS, but even then the packets were often simply handed to mothers along with other medicines. 5.4.2 Terms of Reference The terms of reference were : - to review available information on ORS production, distribution and use in China; to conduct a situation assessment with respect to ORS in China, addressing the fullowing questions: why is local production of ORS so low? what are the major barriers to increased availability of ORS, considering supply, demand and distribution issues? what practical steps could be taken over the next two to three years to increase ORS availability? 5.4.3 Methodology The team reviewed the issues related to ORS production, distribution and use by : reviewing key reference documents on this subject identified in Phase 1 of the review; interviewing representatives of the Department of Medical Administration at central level, to learn about guidelines on the treatment of diarrhoea for hospitals, including use of ORS; visiting two provinces, one with established ORS production (Yunnan) and one without central production (Shandong), to collect additional information on ORS ·availability and use;

1 CDD Health Facility Survey, Yunnan Province, 1992.

- 31 -

reviewing additional infonnation contained in: a) ORS questionnaires which had been sent to and returned by provinces before the field visits; and b) ORS forms filled in by the other three review teams during their visits to other six provinces. During the visit to the two provinces, the team: interviewed key infonnants of the Provincial Health Bureaus (from the Departments of Epidemic Prevention, Drug Administration, Medical Administration and MCH) and Epidemic Prevention Stations, to collect infonnation on ORS procurement and distribution, guidelines on use of ORS at health facilities and policy on price of ORS; visited a factory producing ORS, to collect additional infonnation on ORS . production, distribution, profit and demand; visited health facilities at provincial, county, township and village level to obtain infonnation on ORS stocks, prices, use and demand. Major contacts during the visits are given in Annex 5. 5.4.4 ( 1) Findings Production

Many ORS producers were active in various provinces some years ago, producing ORS with various fonnulas and presentations. A number of them, though, were reported to have stopped production. Five out of nine provinces surveyed through a questionnaire reported having a local ORS production factory (see Table 7). Most ORS appears now to be produced in 500 ml packets and the WHO citrate-ORS fonnula is most commonly used, although a number of manufacturers still uses bicarbonate. ORS production greatly increased in 1992, according to data reported from four provinces, as shown in Table 8. The potential production capacity of these factories seems therefore easily to allow increased production if the demand increases.

- 32-

Table 7.

Selected information from questionnaires returned by nine provinces in China ·October 1995

Hunan ORS production -ORS factory -County hospitals yes yes

Liaoning

Gansu

Sichuan

Henan

Guangdong

Qinghai

Fujian

Yunnan

no yes

no na

yes no

yes yes

no no

no no

yes yes Zhejiang Jiangsu Jiangxi Sichuan Beijing

yes yes

Procurement (province from which ORS is procured if no own production)

-

Beijing

Yunnan

-

-

na

Shanghai

Demand (ORS demand as assessed by provincial EPS manager) Medium "High " Low Low Low Low Low Low Low

Distribution (problems with ORS transportation to remote areas?) yes na na na na na yes

na

na

ORS use/prescription -ORS used at HF' s? -Cases without dehydration admitted to hospital? -ORS commonly used in children with some dehydration? -AB's and IV commonly used for diarrhoea? -Training on communication conducted? yes yes na yes na yes na na na no na na yes na

na na

na na

na

no

no

na

no

no

no

na

no

yes no

yes no

yes yes

na na

yes yes

na na

yes yes

na na·

na

na

na = No information provided

HF = Health facility

AB = Antibiotic

IV = Intravenous fluid

- 11 -

Staff from the Shandong Centre attended planning meetings organized by Ministry of Health. The centre translated the diarrhoea treatment chart into Chinese, reproduced it locally and distributed it to other provinces. One video tape was translated and two videos were produced locally and distributed to other provinces. Two training of trainers courses on health education were conducted by Shandong staff in Ningxia and Qinghai. Kunming Diarrhoea Training Unit (DTU) Approximately one annual visit is conducted be central level staff to the DTU. Kunming staff participated in four of the five national meetings. To date the centre has not developed any training materials. Kunming staff conducted two clinical case management courses for staff of Ningxia and Qinghai. · A workshop to strengthen teaching in medical schools with participants from six medical colleges was conducted (MEDED).

Fujian Centre of Infonnation The review visited the centre and observed that the following activities had been carried out: An index of Chinese Literature of Diarrhoeal Diseases from 1981-1990 including various information on diarrhoeal diseases, had been established. These materials had been delivered to 200 units of provincial and city EPS and scientific research institutes. A bulletin, the "Fujian Prevention Medicine Information" had been published since 1990 containing translations of articles from international journals. To date, 13 issues have been distributed to 400 units of provincial and city EPS and research institutes. In 1995, a booklet of Questions and Answers about Cholera was published and made available to other provinces and cities. A data bank of files on diarrhoeal diseases on foreign and domestic publications . was established, but not satisfactorily utilized. 5.1.5 ( 1) Conclusions Planning/target setting

Even though all provinces had developed plans during the current implementation cycle, the planning process was in general not based on resources and the setting of targets was therefore not realistic. There is high dependance of the provincial teams on central level assistance in planning and funding of activities.

- 12-

(2)

Funding of COD activities

Both at provincial and central level inadequate financial resources are allocated to COD activities. (3) Activity reporting from provincial level or county levels

Currently there is no regular routine activity reporting system in place which also includes activities funded by the local governments. (4) Input/feedback from central level

At the current stage of the programme the central level does not systematically provide formal feedback to provincial staff. Given the large number (17) of programme provinces, the absence of adequate criteria and methods, and its limited manpower capacity, the critical function of ensuring quality of provincial level activities cannot be adequately fulfilled by the central level team. (5) Programme implementation at provincial level

Funds available to provinces (from both central and provincial contributions) are currently insufficient to allow the implementation of comprehensive provincial COD programmes (defined as sets of activities including programme planning and evaluation, health education and training, etc.). (6) Programme implementation at county level

With the exception of sporadic, specially funded :tctivities, coherent COD programmes are currently not implemented at county level. (7) "Special" centres

Shandong and Kunming centres are maintaining high levels of quality in essential programme areas. A limited "spill over" from these two model centres to other provinces has happened. Despite some achievements at an early stage of the current implementation cycle, the Fujian centre is, at this point, not functioning as a national centre for information exchange. 5.1.6 Recommendations

Financial resources available to the central level team for the implementation of COD (1) programmes at lower levels need to be increased. The Ministry of Health should, based on the findings of this review, revise its targets and strategies for the next implementation cycle, and develop a new programme strategy document and workplan. In the context of this replanning, the Ministry would need to explore all possibilities to increase internal budget allocated to COD. Ways for additional external funding also have to be actively pursued. The new programme plan should be submitted to various multilateral and bilateral donors, and national and international nongovernmental organizations (NGOs) for potential funding and follow-up through personal contacts.

- 13-

In light of the complex functions of the central level team vis-a-vis the project provinces, (2) crucial role in providing technical guidance, coordination, and quality control to their and activities conducted at lower levels, the current capacity needs considerable strengthening. If future funding permits it would be highly desirable to recruit, in addition to the existing staff from the Department of Disease Control, a full time project officer who would be responsible for programme coordination in provinces. Similar models have been successfully applied in other projects such as the MCH 300 county project and EPI. The regular technical input from relevant agencies is crucial and needs to be fully exploited. More input from CAPM and other relevant agencies such as Capital Institute of Paediatrics and some medical schools is important. An operational team, consisting of staff from the Department of Disease Control, CAPM, and possibly other players such as CIP, needs to be constituted, and at least monthly coordination meetings need to be scheduled to delegate tasks and to report on progress. The Ministry of Health should intensify its technical and financial support in a small (3) number of provinces (probably not more than five) during the forthcoming implementation cycle. This support should facilitate the establishment and maintenance of comprehensive COD programmes which includes the essential components of programme planning and evaluation, health education, and health worker training. The following criteria are suggested for selecting these provinces: magnitude of the disease burden and associated mortality; . agreement of provincial health authorities to a cost sharing mechanism with the central level ; high likelihood of successful implementation in a province (largely based on past experience with COD or other relevant programmes in the province). Within the provinces for intensified support, a manageable number of model counties should be selected for implementation. Economically disadvantaged counties need to be given strong preference. Provinces not selected for intensified support, which will not receive special budget from (4) central level, should benefit from technical input by the central level on a limited basis: in particular technical materials, guidelines, updates, and new information needs to be shared as it becomes available . The current planning and budgeting process in the provinces needs strengthening. The (5) following are proposed: In order to allow realistic planning, which is based on foreseeable resources, the Ministry of Health should agree with the project provinces on a cost sharing process, in which central level and provincial government would allocate fixed proportions of funds to COD programmes. · In addition to these in-province planning meetings, one annual meeting should be held to which managers from the five provinces are invited. These meetings, as already experienced in the past, provide important opportunities for provincial staff to share experiences and for the central team to introduce new tools and methods, and to disseminate recent information.

- 14-

(6)

To ensure high quality activities at all levels, the following are recommended: A regular and standardized activity reporting and feedback system should be designed and introduced in the five provinces for intensified support.

- As a first step in the design phase, quality criteria for essential programme activities such as health education and training, indicators and ways to measure those need to be agreed upon. Participation of staff from both the central and the provincial level in the design process would be very beneficial, and could most usefully be carried out in the context of the first inter-provincial annual meeting. Input from persons with specific skills in designing such reporting systems will be crucial. In this new system, provincial programme staff will be requested to complete standardized reports twice a year. These reports will provide information not only on quantity but also on quality of activities carried out at both provincial and county levels. Within provinces, it is expected that the reporting system will be established also between the provincial offices and county offices in model counties. The information will be useful for planning purposes at all involved levels. Initially it may not be beneficial to computerize the system.

(7) The potential of the model centres for health education in Shandong and for clinical training in Kunming needs to be more fully exploited in the new implementation cycle. Materials such as health education or training tools produced in these institutions need to be evaluated for suitability of general use in other project provinces. If found appropriate, the central level should assume the task to coordinate the adaptation, reproduction and distribution of these materials to the provinces. The training of trainers courses conducted by staff from Shandong and Kunming in Ningxia and Qinghai in 199311994 should serve as a positive model for the future. Similar courses should be conducted more regularly and frequently to facilitate the valuable transfer of skills and experience to other provinces. (8) To increase both the motivation and skills of provincial level managers, opportunities to provide additional training in programme management skills should be activity encouraged. 5.2 5.2.1 Working group 2: In-service clinical case management training Statement of the priority problem

Training of health workers in the correct case management of diarrhoea (assessment, classification, treatment, and advising mothers) is a national programme priority. Programme efforts since 1991 have focused on strengthening the diarrhoea training unit (DTU) in Kunming, Yunnan Province. The aim has been to develop this DTU into a "centre of excellence" that could serve as a model and training site for other provinces. Regular reviews of progress at the DTU have documented slow but continued improvements in the quality of training and case management. During Phase I, the team reviewed available documents about the amount and quality of clinical case management training in both Yunnan and the 16 other provinces targeted by the programme. Although the information from provinces other than Yunnan was incomplete, a number of achievements were documented. These achievements included the establishment of DTUs in some provinces, the increasing use of interactive methods in some training activities, and the inclusion of training on interpersonal communication into some courses. The Phase I team also found some evidence that suggested that less training had occurred than expected,

- 15-

and that the quality of the training was often inadequate. Before moving into the next period of programme activities, the team recommended that more information be collected and analysed the current status of training in clinical case management. Information about the quality of case management in health facilities was limited. One health facility survey was carried out in Yunnan Province in 1992. The results (Table 2) indicated that even in the Diarrhoea Treatment Unit, appropriate care was not being provided for children with diarrhoea. It was assumed that the quality of care in Yunnan Province was better than that in other provinces. Even after training, there appear to be other factors that limit the quality of case management in health facilities. More information is needed about these factors before planning for continued CDD Programme activities. The two priority problems investigated in Phase II of the review were therefore: low quantity and quality of clinical case management training for diarrhoea; factors other than training that limit the performance of correct case management in health facilities.

Table 2.

Case management practices by health workers in Yunnan Province, Health Facility Survey, 1992 Percentage performing correctly Performance element DTU Non-DTU 67 3 33 2

Assessment Rehydration Advising mother Appropriate antibiotics for dysentery

77 10 50 0

5.2.2

Background

Early efforts by the national CDD Programme to strengthen the clinical case management of children with diarrhoea focused heavily on Yunnan province. A DTU was established in 1989, and in July 1991 training o:f trainers courses were held in Kunming and Simao. A joint Ministry of Health/UNICE F/WHO review of CDD planning in Yunnan Province was held in February 1993. The review team recommended that the First Hospital of Kunming ~edical College be strengthened as a centre for diarrhoea case management training. As a result of the review, a team of senior clinicians and public health officials undertook a study tour in Manila to learn from the experiences of an established DTU in September 1993, and subsequent ToT courses in Yunnan have included EPS staff from other provinces (e.g. Qinghai and Ningxia Provinces in November 1993). During this period, EPS programmes in other provinces also planned and carried out clinical case management training. Input for these training activities from the national level

- 16 -

was limited. Incomplete information is available on the quantity or quality of the training courses. Before moving forward with planning for the next period of programme activities, more information is needed on clinical case management training in provinces other than Yunnan, a·nd on the potential of training and other interventions as strategies for improving the performance of health workers in the case management of diarrhoea. 5. 2. 3 (1) Review methods Review of written documents

The team reviewed all reports of national and provincial activities related to clinical case management training that were available in Beijing and in the two provinces visited. A complete list of the documents reviewed is available in Annex 2. In addition, information provided by eight provinces in response to a special request for information from the national programme was summarized and is reported here . (2) Interviews conducted in Beijing

Interviews were conducted with four persons representing various Ministry of Health units in Beijing. (See Annex 5 for a list of persons interviewed by the team.) (3) Field visits to Hunan and Sichuan Provinces

Field visits were conducted by the three team members during the period from 22 to 28 October 1995. A summary of the activities in each province is available in Table 3. Three types of interview guidelines were used by the team as a starting point for their discussions in the field . The first set of guidelines was used in interviews with EPS, MCH, and Health Bureau managers at the provincial and country levels. The second set of guidelines was used in interviews with trainers who had conducted clinical case management training courses. The third set of guidelines was used with those who had been trained in these courses. A training summary table was prepared for each province, indicating the quantity and quality of clinical case management training and provincial, county and township levels. This table was also completed by the three other Phase II teams in the provinces they visited . The information collected through field visits should not be considered representative of the province, of the 17 programme provinces, or of China. Time was very short, and visits to counties, townships and villages often had to be arranged based on convenience. For this reason, for example, the team visited DeYang County in Sichuan Province, which is reported by provincial staff to have a much higher socioeconomic status than the other counties in the province. (4) Data summary and analysis

In most cases, data from any one source were found to be incomplete. The team therefore drew on multiple sources to try and arrive at a valid conclusion. The sources drawn upon for various conclusions are identified in the narrative. 5.2.4 (1) Findings Quantity and quality of clinical case management training conducted by EPS (a) Planning of training. A review of plans by all Phase II teams indicated that training activities are included in provincial CDD program plans. However, the information provided in the Sichuan and Hunan plans was usually very general (number of courses

- 17-

and/or people to be trained, type of course, type of people to be trained) . These plans did not specify when the courses would take place, the training site, who would serve as trainers, or the estimated cost of the training. County plans were available in the sites visited in Hunan and Sichuan provinces, and included the same information as the provincial plans. EPS staff reported that plans were developed only in "model" counties (four in Hunan; 12 in Sichuan). (b) Quantity of case management training. The team found it difficult to estimate the actual quantity of clinical case management training that had occurred . On the questionnaire sent before Phase II, provinces were asked to indicate the staff they had planned to train, and the number of people trained to date. The results are summarized in Table 4. Based on these figures, it is clear that even if all reported training courses were of adequate quality, much more training would need to be done . The numbers presented in Table 4 should be interpreted with care, as some provinces (e.g. Fujian) included training conducted by MCH in their estimates of the number trained, while others (e.g. Yunnan) limited the target population to the number of people they planned to train during the planning period.

- 18 -

Table 3. Summary of activities during field visits Level Site Visits/Interviews Province Hunan Sichuan

Health Bureau: Director, Vice Directors Epidemic Prevention Station: Director, other personnel working on CDD Programme Province Provincial Children's Hospital (Special CDD Clinic, Paediatric Outpatient Section, Pharmacy): Director, pharmacist, clinicians Provincial MCH Programme: Director Health Education Institute: Director Interviews with case management trainers Health Bureau: Director, Other staff Epidemic Prevention Station: Director, other personnel working on CDD Programme City (Prefecture~

./ ./

./ ./

./

./

./ 2 1

./ ./

Factory Hospital (Special CDD Clinic, Paediatric Outpatient Section, Pharmacy): Director, pharmacist, clinicians Interviews with case management trainers Interviews with case management trainees Health Bureau: Director, Other staff Epidemic Prevention Station: Director, other personnel working on CDD Programme

./

1 1

./ ./

./ ./

County

County Hospital (Special CDD Clinic, Paediatric Outpatient Section, Pharmacy): Director, pharmacist, clinicians Interviews with case management trainers Interviews with case management trainees I:ownship Hospital (Special CDD Clinic, Paediatric Outpatient Section, Pharmacy): Director, pharmacist, clinician

./

./

1 4

1 1 ./

./

Township

Interviews with case management trainers Interviews with case management trainees Village clinic: Village doctor

1 1

0 0 ./ ./

Village

Homes : Residents