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Letters to the Editor Indian Pediatrics 1999;36: 1178-1179 |
IMCI Strategy for India |
| This refers to the editorial "Is India Ready for the Integrated Management of Childhood Illness Strategy(1) and the lead article by Shah and Sachdev(2). On "Evaluation of the WHO/UNICEF algorithm for Integrated Management of Childhood Illness between the age of 2 months to five years" Dr. Costello(1) has made a good case for it and cited experience in Africa and now India. Shah and Sachdev(2) have shown that it is a useful tool for management of childhood illnesses, which are usually multiple. Of course it is one thing to evaluate the efficacy of a strategy which Shah and Sachdev have done and another its application in a field situation. The study was carried out in a leading teaching hospital with well-trained personnel at different levels, under good supervision and without constraints of drugs. The results were good. Does that mean that it can be replicated in a field situation? Dr. Costello has stated that efficacy was reduced when used by trained paramedical personnel. In Tanzania the strategy was used in a project mode which had several additional inputs. We have an extensive multi-tiered primary health care infrastructure in the rural areas, which unfortunately does not by and large exist in the urban areas. The rural infrastructure suffers from perennial problems_lack of basic and refresher training, inadequate and ineffective supervision, innumerable job vacancies, shortage of drugs, long distances, paucity of conveyance, etc.(3,4). The result is that a large number of illness episodes are managed by the local private health care, often of poor quality and use of multi-drug therapy, not always needed. The cost of such treatment to the patient is very heavy. Even in Thiruvanthapuram district of Kerala, one of the most health conscious states, the manpower, supplies and logistics were found to be far from satisfactory(5). The second problem is of forever changing health program and strategies with their attendent training programmes. MCH was considered not to have sufficient child health inputs and gave way to GOBI. Several Fs were added over time (which Dr. Costello refers to also). This gave way to UIP which later changed to CSSM, which was much more comprehensive and included for the first time emphasis on newborn care and nutrition, and diarrheal disease and ARI programs became a part of it instead of vertical programmes and training materials were produced and training initiated. Hardly had the dust settled, when RCH became the buzzword and while the contents remained more or less the same (with addition of emphasis on women's health and more specifically infections of the reproductive tract) once again new training material and training program was initiated. In a large country like India, it takes a long time for a message to get universalized and even before the strategy has been adequately tried and training put into top gear, a new strategy and training module for IMCI is proposed. Health is supposed to be a state subject but infact all new strategies emanate from New Delhi, and the chain of communication is indeed long and arduous. Costello makes a referene to Bang's work. Indeed it is excellent and I have the greatest admiration for Dr. Bang and his team, but let us not forget that the crucial elements of the strategy are community level involvement, training, supervision, adequate supplies and logistics and good referral facilities not forgetting the committed leadership. Dr. Bang's earlier excellent model of treatment of ARI by community level workers has not been replicated anywhere, because government does not want to take the prescription of anti-microbials below the ANM level, who is not easily accessible and again the private practi-tioner is to the fore. Let me emphasize once again that Integrated Management of Childhood Illness is a good strategy. However we have to assess the soil before the seed is planted and create all the requisites necessary for that seed to grow and thrive. Dr. Costello affirms that essential components are a functioning health service, adequate drug supply and developing commu-nity awareness about prevention and treatment of common illnesses. Some evaluations have shown that immunization rates are falling and it has been attributed to pulse polio campaigns (which have increased to four a year now). In certain parts of India, tetanus toxoid and even vitamin A is being given in a pulse mode. This is exactly the opposite of "integration". Under the circum-stances, an excellent strategy like the Integrated Management of Childhood Illness will have to compete with many diverse strategies. I wish to reiterate that IMCI is an excellent strategy (even though I do not agree to newborn care not being a part of it) but the question is whether our primary health care system can take it on and deliver the goods. It would be more realistic to try it out initially in a limited way around a few District or Taluq hospitals. Shanti Ghosh, References 1. Costello A. Is India ready for the Integrated Management of Childhood Illness Strategy. Indian Pediatr 1999; 36: 759-762. 2. Shah D, Sachdev HPS. Evaluation of WHO/UNICEF algorithm for Integrated Management of Childhood Illness between the age of two months to five years. Indian Pediatr 1999; 36: 767-777. 3. Indian Council of Medical Research. A Baseline Survey of Reproductive Health Care Services in 23 Districts (14 States), New Delhi. Indian Council of Medical Research, 1997. 4. Mavalankar DV. Human resource management: Issues and challenges. In: Implementing Reproductive Health Agenda in India. Ed. Pachauri S. Population Council, India, 1999. 5. Homan RK, Thankappan KR. An examination of public and private sector health care providers in Thiruvananthapuram District, Kerala. Studies in Human Development in India. Project of the United Nations Development Programme, 1997. Reply Dr. Umesh Kapil and Dr. Shanti Ghosh are wise to urge caution about the implementation of the IMCI strategy in India. They have raised four important issues: the confusion generated by constant changes in training programs, which might be compounded by a new IMCI approach; the need to replicate the Shah and Sachdev study(1) under different district conditions, ideally where there are high, moderate and low rates of infant mortality; the importance of addressing infrastructural and drug supply problems at primary health care facilities in rural areas (component 2 of the IMCI strategy); and the problems with going to scale with interventions that might look good in small pilot projects under charismatic leadership (e.g., the work of Bang). In addressing these points I agree that action is more important than words or acronyms. There is no necessity to instantly replace the new national RCH program with IMCI.One option would be for a senior working group at Ministry level to examine the IMCI training approach, and to consider how the RCH program might be modified to incorporate the best aspects of IMCI, e.g., the use of the guidelines handbook by primary care workers. Certainly the training component of IMCI implicitly believes in such a process of national adaptation, and I see no reason why the title RCH needs to be changed if this will avoid confusion. The Ministry working group might also commission and fund the ideas of both correspondents for further piloting of an IMCI-type approach in a few districts, to examine implementation problems and outcomes. Inadequate or inappropriate drug supply and declining primary care infrastructure remain universal problems in developing countries. The eminent Dr. Ghosh knows better than any of us that there are no simple solutions. Personally, I think the best short-term strategy, and arguably the most cost-effective one, is to address the problem of primary care and public health leadership at district level. In my experience, the presence of a committed and well-trained professional, undistracted by private practice, who sets out to involve community representatives in supporting their local helath services and health promotions, can make all the difference to demoralized PHC staff, and to bureaucratic delays in supplies. Incentives (such as greatly increased remote area allowances, and subsidized Masters-level training linked to job contracts) will be needed to encourage young doctors to move into public health or community mother and child health positions in rural areas. This should be a major priority of state government. The returns could be enormous. An individual full-time commu-nity pediatrician could make a large difference to the health and welfare of a population of 200,000 or more. In the process he or she might do much to reverse immunization coverage declines, whether by pulse or integrated strate-gies depending on the local conditions. The Indian Academy of Pediatrics has a crucial role in developing the training, status and rewards for doctors interested in a career in community pediatrics. Anthony Costello, Reference 1. Shah D, Sachdev HPS. Evaluation of the WHO/UNICEF algorithm for Integrated Managament of Childhood Illness between the age of two months to five years. Indian Pediatr 1999; 36: 767-777. |
