redesigning child care: survival, growth and development 107 clearly a need for a more comprehensive view of the needs of the child, one that would correspond to problems as they were encountered in the field (4)and would offer a wider range of responses than the existing programmes. These had been designed to target the most important causes of death and, partly as a result of their success, the profile of mortality was changing. Diarrhoea, for example, now causes 18% of child hood deaths, as opposed to 25% in the 1970s(see Box 6.1) he response to this new situation was to package a set of simple, affordable and effective interventions for the combined management of the major childhood illnesses and malnutrition, under the label of"Integrated Management of Childhood Ilness (IMCI). IMCI combines effective interventions for preventing death and for improving healthy growth and development: oral rehydration therapy for diarrhoea; antibiotics fo sepsis, pneumonia, and ear infection; antimalarials and insecticide-treated bednets vitamin A, treatment of anaemia, promotion of breastfeeding and complementary feeding for healthy nutrition and for recovery from illness, and immunization. Some countries have included guidelines to treat children with HIV/AIDS, others for dengue fever, wheezing, or sore throat, or for the follow-up of healthy children Dealing with children, not just with diseases The second justification for a more comprehensive approach was the recognition that the health of children is not merely a question of targeting a limited number of dis eases that are immediate causes of mortality □ Packaging simple, affordable and effective interventions. Here, a vietnamese boy is vaccinated
redesigning child care: survival, growth and development 107 clearly a need for a more comprehensive view of the needs of the child, one that would correspond to problems as they were encountered in the field (4) and would offer a wider range of responses than the existing programmes. These had been designed to target the most important causes of death and, partly as a result of their success, the profile of mortality was changing. Diarrhoea, for example, now causes 18% of childhood deaths, as opposed to 25% in the 1970s (see Box 6.1). The response to this new situation was to package a set of simple, affordable and effective interventions for the combined management of the major childhood illnesses and malnutrition, under the label of “Integrated Management of Childhood Illness” (IMCI). IMCI combines effective interventions for preventing death and for improving healthy growth and development: oral rehydration therapy for diarrhoea; antibiotics for sepsis, pneumonia, and ear infection; antimalarials and insecticide-treated bednets; vitamin A, treatment of anaemia, promotion of breastfeeding and complementary feeding for healthy nutrition and for recovery from illness, and immunization. Some countries have included guidelines to treat children with HIV/AIDS, others for dengue fever, wheezing, or sore throat, or for the follow-up of healthy children. Dealing with children, not just with diseases The second justification for a more comprehensive approach was the recognition that the health of children is not merely a question of targeting a limited number of diseases that are immediate causes of mortality. Packaging simple, affordable and effective interventions. Here, a Vietnamese boy is vaccinated. WHO
108 The World Health Report 2005 As appropriate technologies became more widely available, a gradual evolution also took place in the content and methods of communication between health workers and parents. Previously, a family who brought a child for curative care had generally received basic treatment with minimal instruction and explanation for use of pre treatments at home. The introduction of oral rehydration therapy, however, new element to the relationship between the family and the clinic. During t isit, families now learnt how to prepare and give oral rehydration salts solution (9-11), to recognize signs of illness, and to treat their children without delay at home; they also learnt to make use of fluids available in the home to make treatment more accessible This led to the development of a systematic process of advising and counselling, and to new partnerships between health workers and households Child health programmes see many malnourished children. Some of these children may be malnourished as a result of lack of access to food, but more often it is because of infection and poor feeding practices, or a combination of the two(4, 12). Counselling on feeding practices naturally became an element of IMCI. As with oral rehydration therapy, this forced health workers to enter into a different kind of partnership with mothers. It was no longer a matter of asking a few simple questions and prescribing a treatment: feeding problems had to be identified and acceptable solutions negotiated with the mother. Counselling carried out in this way requires specific training for the health worker, and the right kind of environment, but it is more effective(13, 14) The next logical step was to pay more attention to the physical and psychosocial development of children. A child's health and development is strongly influenced by the relationship between child, parents and other caregivers. The key is for the caregiver to be receptive to the child's state and needs, to interpret them correctly and be quick to react appropriately (15). This is a critical factor in healthy growth (16-19 ); the absence of sensitive, responsive care is associated with malnutrition and failure to thrive(20-22). The influence of such care on healthy cognitive and social development as well as on survival has been well documented (18, 23) New evidence accumulated during the 1990s shows that mothers can be helped to communicate better with and to stimulate their young children(24). The skills needed for appropriate feeding, psychosocial care and care-seeking are closely linked (24), and improving one of these positively influences the others. Sensitivity and responsiveness can be effectively promoted and taught to caregivers, even in difficult social and economic conditions, or when a mother' s ability to care for her child is compromised by depression(24 ). Specific efforts are required to work with foster parents, or with children who are heads of households. The challenge is to integrate these new findings into public health programming Parents are naturally concerned about the growth and psychosocial development of their children; however, health workers who operate in resource-constrained environments have long considered this more of a luxury or something that they could not influence IMCI changed that: in doing so it created new challenges for what was no longer just a technical programme but became a partnership between parents and health workers ORGANIZING INTEGRATED CHILD CARE The notion of integration has a long history. Integration is supposed to tackle the need for complementarity of different interdependent services and administrative struc- tures, so as to better achieve common goals. In the 1950s these goals were defined in terms of outcome, in the 1960s of process and in the 1990s of economic impact
108 The World Health Report 2005 As appropriate technologies became more widely available, a gradual evolution also took place in the content and methods of communication between health workers and parents. Previously, a family who brought a child for curative care had generally received basic treatment with minimal instruction and explanation for use of prescribed treatments at home. The introduction of oral rehydration therapy, however, added a new element to the relationship between the family and the clinic. During the clinic visit, families now learnt how to prepare and give oral rehydration salts solution (9–11), to recognize signs of illness, and to treat their children without delay at home; they also learnt to make use of fluids available in the home, to make treatment more accessible. This led to the development of a systematic process of advising and counselling, and to new partnerships between health workers and households. Child health programmes see many malnourished children. Some of these children may be malnourished as a result of lack of access to food, but more often it is because of infection and poor feeding practices, or a combination of the two (4, 12). Counselling on feeding practices naturally became an element of IMCI. As with oral rehydration therapy, this forced health workers to enter into a different kind of partnership with mothers. It was no longer a matter of asking a few simple questions and prescribing a treatment: feeding problems had to be identified and acceptable solutions negotiated with the mother. Counselling carried out in this way requires specific training for the health worker, and the right kind of environment, but it is more effective (13, 14). The next logical step was to pay more attention to the physical and psychosocial development of children. A child’s health and development is strongly influenced by the relationship between child, parents and other caregivers. The key is for the caregiver to be receptive to the child’s state and needs, to interpret them correctly and be quick to react appropriately (15). This is a critical factor in healthy growth (16–19); the absence of sensitive, responsive care is associated with malnutrition and failure to thrive (20–22). The influence of such care on healthy cognitive and social development as well as on survival has been well documented (18, 23). New evidence accumulated during the 1990s shows that mothers can be helped to communicate better with and to stimulate their young children (24). The skills needed for appropriate feeding, psychosocial care and care-seeking are closely linked (24), and improving one of these positively influences the others. Sensitivity and responsiveness can be effectively promoted and taught to caregivers, even in difficult social and economic conditions, or when a mother’s ability to care for her child is compromised by depression (24). Specific efforts are required to work with fosterparents, or with children who are heads of households. The challenge is to integrate these new findings into public health programming. Parents are naturally concerned about the growth and psychosocial development of their children; however, health workers who operate in resource-constrained environments have long considered this more of a luxury or something that they could not influence. IMCI changed that: in doing so it created new challenges for what was no longer just a technical programme but became a partnership between parents and health workers. ORGANIZING INTEGRATED CHILD CARE The notion of integration has a long history. Integration is supposed to tackle the need for complementarity of different interdependent services and administrative structures, so as to better achieve common goals. In the 1950s these goals were defined in terms of outcome, in the 1960s of process and in the 1990s of economic impact
redesigning child care: survival, growth and development 109 (25-27) Integration has different meanings at different levels(28). At the patient level it means case management. At the point of delivery it means that multiple interven tions are provided through one delivery channel- for example where vaccination is used as an opportunity to provide vitamin a and insecticide-treated bednets during EPl-plus"activities, boosting efficiency and coverage(29, 30). At the system level integration means bringing together the management and support functions of differ- ent sub-programmes, and ensuring complementarity between different levels of care IMCI is now the only child health strategy that aims for improved integration at these three levels simultaneously IMCI has successfully integrated case management and tasks in first-level facilities by providing health workers with guidelines, tools and training. Progress towards integration between different levels is facilitated by the complementary guidelines for case management at first-level and referral facilities. Health workers at first-level facilities have guidelines for referring severely ill newborns and children, as well those with complex problems. Health workers at the district hospital in turn get the guidelines and training to manage these referred children. MCI has gone a step further. More than just adding more programmes to a single delivery channel, it has sought to transform the way the health system looks at child care. IMCI retained its original name, but with the ambition of going beyond the management of illness (3, 5, 31, 32). Based on experience from single-issue programmes, IMCl designed an approach with three components: improving the skills of health workers, strengthening the support of health systems, and helping families and communities to bring up their children healthily and deal with ill-health when it occurs. In doing so, IMCI had to move beyond the traditional notion of a health centre's staff providing a set of technical interventions to their target population Households and health workers As they increasingly entered into dialogue with households, health workers in child programmes realized how crucial what happens in the household is for the health of a child. Food, medicine and a stimulating environment are all necessarily mediated by what households and communities do or do not do. When a child is ill, for example someone in the household must recognize that there is a problem, provide appropri- ate care, identify signs indicating that the child needs medical care, take the child a health worker, work out a proper course of action with the health worker(which may be to obtain medication and comply with the instructions on how to use it, or to take the child to hospital), provide support during convalescence, and return to the health worker if necessary. Households and communities thus determine whether the health system's intervention can make a difference. Without all this, even the best health centre will get poor results. To look at child health from this perspective may seem obvious today, but for the vertical programmes of the 1980s this was a radical change. It stimulated a flurry of interest in how households can contribute to the improvement of the health of their children: the so-called "key family practices ummarized in Box 6.2 These family practices tackle behaviour that promotes physical growth and mental development, and prevents illness. The importance of this is obvious and has long been recognized. What is new is that seeking care from health services is also considered to be one of the ways households contribute to the health of their children Poor or delayed care-seeking contributes to up to 70%of child deaths(33). Most children die at home, and many without prior contact with competent medical care
redesigning child care: survival, growth and development 109 (25–27). Integration has different meanings at different levels (28). At the patient level it means case management. At the point of delivery it means that multiple interventions are provided through one delivery channel – for example where vaccination is used as an opportunity to provide vitamin A and insecticide-treated bednets during “EPI-plus” activities, boosting efficiency and coverage (29, 30 ). At the system level integration means bringing together the management and support functions of different sub-programmes, and ensuring complementarity between different levels of care. IMCI is now the only child health strategy that aims for improved integration at these three levels simultaneously. IMCI has successfully integrated case management and tasks in first-level facilities by providing health workers with guidelines, tools and training. Progress towards integration between different levels is facilitated by the complementary guidelines for case management at first-level and referral facilities. Health workers at first-level facilities have guidelines for referring severely ill newborns and children, as well as those with complex problems. Health workers at the district hospital in turn get the guidelines and training to manage these referred children. IMCI has gone a step further. More than just adding more programmes to a single delivery channel, it has sought to transform the way the health system looks at child care. IMCI retained its original name, but with the ambition of going beyond the management of illness (3, 5, 31, 32). Based on experience from single-issue programmes, IMCI designed an approach with three components: improving the skills of health workers, strengthening the support of health systems, and helping families and communities to bring up their children healthily and deal with ill-health when it occurs. In doing so, IMCI had to move beyond the traditional notion of a health centre's staff providing a set of technical interventions to their target population. Households and health workers As they increasingly entered into dialogue with households, health workers in child programmes realized how crucial what happens in the household is for the health of a child. Food, medicine and a stimulating environment are all necessarily mediated by what households and communities do or do not do. When a child is ill, for example, someone in the household must recognize that there is a problem, provide appropriate care, identify signs indicating that the child needs medical care, take the child to a health worker, work out a proper course of action with the health worker (which may be to obtain medication and comply with the instructions on how to use it, or to take the child to hospital), provide support during convalescence, and return to the health worker if necessary. Households and communities thus determine whether the health system’s intervention can make a difference. Without all this, even the best health centre will get poor results. To look at child health from this perspective may seem obvious today, but for the vertical programmes of the 1980s this was a radical change. It stimulated a flurry of interest in how households can contribute to the improvement of the health of their children: the so-called “key family practices” summarized in Box 6.2. These family practices tackle behaviour that promotes physical growth and mental development, and prevents illness. The importance of this is obvious and has long been recognized. What is new is that seeking care from health services is also considered to be one of the ways households contribute to the health of their children. Poor or delayed care-seeking contributes to up to 70% of child deaths (33). Most children die at home, and many without prior contact with competent medical care