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									Technical Brief and Updates – CARE Nepal, Child Survival Project

Community Based – Integrated Management of Childhood Illness (CB - IMCI)
CB-IMCI Integrated Management of Childhood Illness (IMCI) is a strategy formulated by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF), presented in 1996 as the principal strategy to improve child health. It focuses on the care of children under five, not only in terms of their overall health status but also on the diseases that may occasionally affect them. IMCI incorporates a strong component of prevention and health promotion as an integral part of care. IMCI implementation involves the participation of the community, the health-service sector and the family. The implementation of the IMCI strategy has three components: 1. Improving the performance of health workers when tending to children under five and their families (health-worker component). 2. Improving the organization and overall functioning of health-care services so that they offer efficient, good-quality care (health-service component). 3. Improving knowledge on best practices for the care of children at home and in the community (community component). IMCI is currently regarded as the most efficient strategy for reducing the burden of disease and disability among the population in this age group. Its main goal is to contribute to healthy growth and development during the first five years of life. Community Based- IMCI (CB -IMCI) program in Nepal developed through the years with preceding programs such as Control of Diarrhoeal Diseases (CDD) Program initiated in 1982 and Acute Respiratory Infection (ARI) Control Program initiated in 1987. Nepal also implemented Community Based CDD and ARI Control (CBAC) Program since 1995. The CB -IMCI program was first implemented in 1997 and gradually expanded to 27 districts by the end of 2005. The objectives of the CB-IMCI program are: to reduce the morbidity and mortality among children under-five due to pneumonia, diarrhea, malnutrition, measles and malaria; and to promote healthy growth and development of children. Child Survival Project Child Survival Project, CS XIX (Oct 2003 – Sept 2007) is one of the CARE Nepal Health project, implemented in four districts (Bajhang, Doti, Dadeldhura and Kanchanpur) of Far West Nepal after the successful completion of Child Survival Project XV (Oct 1999 – Sept 2003) in Kanchanpur. The project goal is to reduce child and maternal mortality and morbidity through strengthened community, local NGO and MOH capacities. The project has four objectives: increasing access to services and supplies; improving quality of care; bringing positive change in behavior and building local capacity. The project is based on the framework of the CBIMCI and integrate d complementary initiatives for greater program impact and sustainability (e.g. Dabi, HFOMC strengthening, FCHV support etc). The project targets to benefit 146,514 under-five children and 47,484 pregnant and lactating women among total population of 932,054 from the four project districts. CB-IMCI Training CARE Nepal in collaboration with Child Health Division, Far West Regional Health Directorate and District (Public) Health Offices implemented CB -IMCI program in Bajhang, Dadeldhura, Doti and Kanchanpur. CARE Nepal was involved in training health workers, volunteers, traditional healers and drug retailers in Kanchanpur (through CS XV) in collaboration with JSI/USAID and was fully involved in training and mobilization of health workers, volunteers and communities for CB-IMCI in Bajhang, Dadeldhura and Doti (through CS XIX). CB -IMCI training for Health Workers (medical officers, health assistants, staff nurse, auxiliary nurse midwives, auxiliary health worker) was conducted in Bheri Zonal Hospital, Nepalgunj and was facilitated by the experts from the Nepal Pediatric Society (NEPAS). Training for Village Health Workers (VHWs) and Maternal and Child Health Workers (MCHWs) was conducted in respective district headquarters and facilitated by the experts from the Integrated Rural Health Development and Training Center (IRHDTC). Training for FCHVs and Traditional Healers was facilitated by trainers from the District (Public) Health Office and CARE Nepal, Child Survival Project. IMCI Trained resource persons from CA RE Nepal were involved in monitoring the quality of training and follow-up/monitoring at sites. Onsite coaching and support was provided to health workers and volunteers. Staff from the local NGO partners were also involved in facilitation and monitoring training for FCHVs and Traditional Healers.

Table 1: CB-IMCI Training Achievement
SN 1 2 3 4 5 6 6 7 8 9 10 11 12 Name of Activity/Training Clinical Training (7 days) Clinical MToT Training (7+2 days) Faciliation Training (+4 days) t Clinical training for Managers (7 days) Supervisory Training (4 days) District Supervisor Training (4 days) District level Training of Trainers (5+2 days) Management T raining (2 days) Training to VHW/MCHWs (5 days) FCHV Phase I Training (5 days) Traditional Healers Orientation (1 day) FCHV Phase II Training ( 2 days) Review /m onitoring meeting Total 184 20 13 8 27 10 38 189 191 1560 456 1528 Participants Male Female 138 17 10 8 24 10 34 147 114 00 389 00 46 3 3 0 3 0 4 42 81 1560 27 1528 Dalit 7 0 0 0 1 0 3 10 3 135 108 135

c. at community level
Availibility of essential commodities at FCHV level 70 60 50 40 30 20 10 0 Cotrim ORS 2002/03 2005/06

13 14

Community level Follow up after training Training to transferred in staffs (3 days)

• •

District level

138 1138 105 60

128 00 97 40

13 1138 8 20

2 153 3 1

As a result of the CB-IMCI program in CS Project districts, improvement in access t services, quality of care, utilization o of services, and positive change in behavior has been observed. (Source: HMIS data, KPC HH Survey, Health Facility
Survey, Health Worker Survey, FCHV Survey)

Note: The table only includes training achievements during CS XIX in Doti, Dadeldhura and Bajhang and transferred in staff in Kanchanpur.

Changes Observed
After the CB-IMCI Training, following changes were observed at district, health facility and community level. a. At district level
500 400 300 200 100 0 Doti Dadeldhura Bajhang Increased utilization of services for ARI 2002/03 2005/06

Challenges and Lessons Learnt
Challenges The program was implemented at the time when conflict was on its height, which resulted difficulties for program planning, implementation and monitoring. Frequent transfer of health workers trained on IMCI, hi gh drop out of FCHVs, maintaining regular stock of essential IMCI commodities (e.g. Cotrim-P and ORS) were major challenges for the program. Lessons learnt CB-IMCI training helped to improve the motivation of community health workers and volunteers in delivering better quality of services at community level. Using standard methodology, applying cascade approach, mobilization of local human resource in program helped to successfully implement the program and to achieve desired results. Integration of other complementary activities within the CB IMCI framework (e.g. Health Facility Operation and Management Committee Strengthening, Formation and mobilization of community pressure groups, training and mobilization of local resource persons, mobilization of local NGO partner in program implementation and monitoring etc) helped to achieve better program outcome in project districts. Regular review meetings at district and community level helps for tracking and correcting strengths gaps in performance and to provide necessary support to health workers and volunteers.

b. At health facility level
Improved care and services at HF 100 80 60 40 20 0 Correctly diagnose Propor management Proper counseling pneumonia of pnuemonia cases on diarrhoea case 2002/03 2005/06

For more info: CARE Nepal, Krishna Galli, Pulchowk, PO Box 1661, Kathmandu Nepal (Phone: 5522800, Email: Child Survival Project, Regional Office, Silgadi, Doti (Phone: 094-420 518, Fax: 094-420 519, Email:
August 2007

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