|Essays on Food, Hunger, Nutrition, Primary Health Care and Development (AVIVA, 480 p.)|
IMCI, the Integrated Management of Childhood Illness programme is slowly gaining some recognition in our everyday parlance. We applaud IMCIs positive aspects, i.e. its attempt to integrate care activities (albeit curative) for the five or so main childhood killers, as well as to improve clinical practices and thus child survival. It is already apparent that IMCI is bringing about some changes in many countries where primary child care is poor. (Lambrechts, T. et al, 1999)
Too bad that its name was so poorly chosen. In this day and age, it is hard to justify a global programme of that magnitude that is illness-centered; if we wait until the child gets sick to reach her/him, how far can we really go? Where did all our long efforts to focus on Health and Wellness go here?
And where are the efforts to focus on the Community to be prominently seen in IMCI (as opposed to focusing on the established health system to take the initiative)? The belated and add-on incorporation of a community component to IMCI is very unfortunate in that, for a long time before, IMCI marginalised the promotive, preventive and home-based curative interventions which are the most important and sustainable components of child wellness. Facility-based IMCI undermines such an approach, unless its community component is implemented with equivalent resources, vigour and commitment. (Orinda, V., 1999)
It is not that IMCI --on top of its well justified and proven life-saving algorithms and gunshot therapeutics-has been oblivious to the important role of action at the community and household levels . Its Component 3 addresses just that. (WHO, 1999) But it is taking so much longer to get to it wholeheartedly while spending most efforts and resources on the technical challenges of the other two components. As it stands now, IMCI risks reinforcing the long-standing convention that facility-based health workers should focus their effort predominantly in clinical, facility-based care. The role of health workers simply needs to become much more centred around at risk peoples homes.
Furthermore, how can we leave the mother --the front line duty bearer to the child-- and her needs out of an integrated approach to care for the child? Should we not rather be talking about the Integrated Promotion of Maternal/Child Health Initiative (IPMCHI) --or something along these lines? But this does not sound too new, does it...? It goes back at least to Alma Ata.
Preliminary results from IMCI pilot sites (e.g. Cambodia, Vietnam and Tanzania) are showing that a strong initial community/household focus/component yields more effective and lasting outcomes. (UNICEF Cambodia, 1998, and MOH Vietnam, 1999) The old wisdom that we need to empower people to fight for and get the health services they need seems to be prevailing at least in a few places, after all. If this is so, then those who have community mobilisation experience/skills should be working with local people so they can satisfy their felt needs for preventive and curative maternal and child health services. Only by first working with communities, for them to claim their inalienable rights from national and local health programme operators can we expect effective and lasting outcomes. IMCI has instead chosen to start from the top.
From such a perspective, several concrete imperatives emerge: Not surprisingly, the imperatives are challenging and difficult.
We need a better name/acronym for IMCI and the renamed entity needs to more aggressively emphasise its upfront community mobilisation component to de-facto empower/capacitate child carers at the household level so they can, on the one hand, adopt a set of needed home preventive, curative and early referral practices, and on the other, gain ownership and control over the Initiative as a whole.
Claudio Schuftan, Hanoi (firstname.lastname@example.org)
David Sanders, Cape Town (email@example.com)
Lambrechts, T., Bryce, J., and Orinda, V. (1999), IMCI: A summary of first experiences, Bull. WHO, 77(7), pp. 582-594.
MOH Vietnam (1999), IMCI: Background in Vietnam, Oct.
Orinda, V. (1999), Home and community healthcare to enhance child survival, growth and development, UNICEF Working Paper, Programme Division, UNICEF N.Y., Dec.
UNICEF Cambodia (1998), Mid-term review Report: Community Action for Social Development (CASD) Programme, Nov.
WHO (1999), The role of IMCI in improving family and community practices to support child health and development, IMCI Information Sheets, WHO/CHS/CAH/98.1G, Rev.1.