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close this bookEssays on Food, Hunger, Nutrition, Primary Health Care and Development (AVIVA, 480 p.)
View the document(introduction...)
View the documentAbout the Author
Open this folder and view contents1. The Causes of Hunger and Malnutrition: Macro and Micro Determinants
Open this folder and view contents2. Technical, Ethical and Ideological Responsibilities in Nutrition
Open this folder and view contents3. De-Westernizing Health Planning and Health Care Delivery: A Political Perspective1
View the document4. Book Review: Susan George. A Fate Worse Than Debt: A radical new analysis of the Third World debt crisis (Or, the world financial crisis and the poor)
Open this folder and view contents5. Viewpoint - Ethics, Ideology and Nutrition
Open this folder and view contents6. Ethics And Ideology in the Battle Against Malnutrition
Open this folder and view contents7. The Challenge of Feeding the People: Chile under Allende and Tanzania under Nyerere
Open this folder and view contents8. The Role of Health and Nutrition in Development (Le Rôle de la Santé et de la Nutrition dans le Développement - El Papel de la Salud Y la Nutrición en El Desarrollo)
Open this folder and view contents9. Multidisciplinarity, Paradigms and Ideology in Development Work
View the document10. Survey on Attitudes to Nutrition Planning
Open this folder and view contents11. “Household Purchasing-Power Deficit” - A More Operational Indicator to Express Malnutrition
Open this folder and view contents12. Foreign Aid and its Role in Maintaining the Exploitation of the Agricultural Sector: Evidence from a Case Study in Africa
View the document13. Low School Performance: Malnutrition or Cultural Deprivation?
View the document14. Hunger and Malnutrition: Outlook for Changes in the Third World*
Open this folder and view contents15. Viewpoint: Nutrition Planning - What Relevance to Hunger?
View the document16. Rosalia
Open this folder and view contents17. The Political Economy of Ill Health and Malnutrition
Open this folder and view contents18. Commentary - The Markets of Hunger: Questioning Food Aid (Non-Emergency/Long-Term)
Open this folder and view contents19. Activism to Face World Hunger: Exploring New Needed Commitments
Open this folder and view contents20. The Child Survival Revolution: A Critique - or Health Still Only for Some by the Year 2000?
Open this folder and view contents21. Development Nemesis
View the document22. Looking Beyond the Doable: Resolutions for a New Development Decade
Open this folder and view contents23. Egos/ Alter Egos of the Main Actors in Development Projects:
Open this folder and view contents24. Positive Deviance in Child Nutrition: a Discussion
View the document25. The Project Approach in Development Assistance
View the document26. Triage Management in Third World Health Ministries
Open this folder and view contents27. On Behalf of the African Child: Challenges and Windows of Opportunity for the Donor Community.*
View the document28. The Household Entitlements Revolution or a Women-Centered Approach to Family Security
View the document29. Brave New World: A Political Pendulum in Search of its Balance
Open this folder and view contents30. Malnutrition and Income: Are We Being Misled? (A Dissenting View with a Confusing Literature)
View the document31. A Path for the 1990s?: Government-Donor Partnership to Finance PHC in the Third World
Open this folder and view contents32. Downsizing the Civil Service in Developing Countries: The Golden Handshake Option Revisited.
Open this folder and view contents33. The World Declaration on Nutrition and the 1992 International Conference on Nutrition (ICN) Plan of Action: The Cutting Edge of Conventional Thinking.*
View the document34. Income Generation Activities for Women, the Ninth Essential Element of Primary Health Care? An Idea Whose Time has Come!
View the document35. Some Reflections on ACC/SCN's 'How Nutrition Improves'
View the document36. Nutritional Goals for the Mid-Nineties: A Call for Advocacy and Action
Open this folder and view contents37. A. The Emerging Sustainable Development Paradigm: A Global Forum on the Cutting Edge of Progressive Thinking
Open this folder and view contents37. B. Sustainable Development beyond Ethical Pronouncements: the Role of Civil Society and Networking
View the document38. Foreign Aid: Giving Conditionalities a Good Name or Conditionalities: the Launching of a South-South Counter-Offensive
Open this folder and view contents39. The Community Development Dilemma: when are Service Delivery, Capacity Building, Advocacy and Social Mobilisation really Empowering?
View the document40. Development in the Mid 1990s: Reflections of an Old Socialist
View the document41. Book Review: Questioning the solution -The politics of primary health care and child survival with an in-depth critique of oral rehydration therapy
View the document42. Equity In Health and Nutrition and the Globalization of the World's Economy
View the document43. A. Different Challenges in Combating Micronutrient Deficiencies and Combating Protein Energy Malnutrition, or the Gap Between Nutrition Engineers and Nutrition Activists
View the document43. B. Micronutrient Deficiencies and Protein-Energy Malnutrition
Open this folder and view contents44. Northern-Led Development: is it Selling Technical Fixes to Solve the Problems of Ill-Health and Malnutrition?
View the document45. Actions and Activism in Fostering Genuine Grassroots Participation in Health and Nutrition
Open this folder and view contents46. Health, Nutrition and Sustainable Development.
View the document47. New Perspectives, Old Risks: our Need to Change and to Reconceptualize or Reemphasizing the Need to Tackle the Causes of Poverty in the Battle against Ill-Health and Malnutrition
View the document48. Health Sector Reform Measures: Are they Working?... And where do we go from here?
View the document49. On Development, the Real World, Power Games and the Ugly Faces of Greed (Food for thought about a state of mind).
View the document50. So What... in Search of the 'Big Picture' in Development (Food for a depressive thought)
Open this folder and view contents51. Can Significantly Greater Equity be Achieved through Targeting?: An Essay on Poverty, Equity and Targeting in Health and Nutrition. (*) (Food for a targetter's thought)
Open this folder and view contents52. Globalization, or the Fable of the Mongoose and the Snake (Fableous food for thought)
View the document53. Elements for a Nutrition Activism Course and Curriculum*
View the document54. The Role of Human Rights in Politicizing Development Ethics, Development Assistance and Development Praxis
View the document55. A Letter to the Student Erica who is Planning to Specialize in International Nutrition
View the document56. Food for a Capitalist thought - Book Review - The Lugano Report: On Preserving Capitalism in the Twenty-First Century
View the document57. Food for Finding where Your Thoughts Are - Variations on a Theme by the Chilean Writer Isabel Allende
View the document58. Remembering
View the document59. Letter to The Lancet - Draft 2 IMCI: An Initiative in Need of a New Name, a Greater Community-Centered Focus, and a Grassroots Mandate
View the document60. Food for Planning the Right Human Thoughts - Human Rights Based Planning: The New Approach
View the document61. Food for an Ombudsman's Thought - On Health Sector Reform, Health and Poverty and Other Herbs
Open this folder and view contents62. What does the New UN Human Rights Approach Bring to the Struggle of the Poor?
View the document63. Food for a Poor Thought on Health and Poverty - Health a Precious Asset, But Not ‘A New and Potentially Powerful Exit Route from Poverty’
View the document64. Food for a Poor Thought on Attacking Poverty - The WB’s World Development Report 2000/2001 or the Trivialization of the Concept of “Empowerment”
View the document65. Human Rights or the Importance of Being Earnest: A Personal Account
View the document66. AID and Reform in Africa: Lessons from Ten Case Studies, Final Report
View the document67. Food for Thought About a State of Mind (2) - On Morality, Freedom, Choices, Justice and the Need for People’s Power
View the document68. Thinking Loud - On Statistics*
Open this folder and view contents69. A Reader in Human Rights (1) - The Short Papers Here Collected are Part of an Ongoing Series the Author Irregularly Submits to About a Half Dozen E-Mail List Servers
Open this folder and view contents70. Aiming at the Target: What’s Left for the Devil to Advocate?

59. Letter to The Lancet - Draft 2 IMCI: An Initiative in Need of a New Name, a Greater Community-Centered Focus, and a Grassroots Mandate

Dear Editor,

IMCI, the Integrated Management of Childhood Illness programme is slowly gaining some recognition in our everyday parlance. We applaud IMCI’s 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 people’s 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 (aviva@netnam.vn)
David Sanders, Cape Town (lmartin@uwc.ac.za)

References:

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.