Message-ID: <Pine.3.89.9803011640.A23333-0100000@lan.vita.org> Date: Sun, 1 Mar 1998 16:22:43 -0500 From: Dania Granados <mailto:granados@LAN.VITA.ORG> Subject: Your Newsletter To: mailto:DEVEL-L@AMERICAN.EDU
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March 1998 Volume 8, No. 3
IN THIS ISSUE
FOCUS ON CHILDHOOD ILLNESS
The Pathway to Survival: An Integrated Approach to
Childhood Illness in the Developing World
LITERATURE REVIEW
"The Revolution of Inclusion"
ORGANIZATION
BASICS (Basic Support for Institutionalizing Child Survival)
VITA PROJECTS
Satellite Capacity Sharing
New Internet Conference
CONFERENCE ANNOUNCEMENT
Helping small businesses in Transition and Developing Countries
* * *
DevelopNet News is published monthly by Volunteers in
Technical Assistance (VITA) in Arlington, Virginia, USA. For
additional information, please see the end of this newsletter.
* * *
F o c u s o n C h i l d h o o d I l l n e s s
THE PATHWAY TO SURVIVAL: AN INTEGRATED APPROACH TO CHILDHOOD
ILLNESS IN THE DEVELOPING WORLD
In the 1980s, strategies to improve child survival in developing
countries focused on several disease conditions which contribute
to a high proportion of infant and child deaths and for which
there existed effective prevention and/or therapeutic strategies.
Immunization against the six vaccine-preventable diseases
targeted by the Expanded Programme on Immunization (EPI) of the
World Health Organization (WHO) and the control of diarrheal
disease (CDD), primarily through the use of oral rehydration
therapy, were cornerstones of child survival programming.
As those programs were implemented, it became clear that more
diseases required attention if infant and childhood mortality
rates were to be maximally reduced. There were acute respiratory
infections, malaria, and malnutrition. For each, technical
interventions and program strategies were developed.
Nevertheless, even with reasonably safe and effective technical
solutions available to prevent or treat all of these conditions,
broad implementation of control programs aimed at reducing the
toll of these diseases has generally exceeded the capability of
developing countries. Today, for example, only a relatively
small proportion of first-line health care workers have been
adequately trained in standard case management techniques.
But, even if technically sound and programmatically feasible,
single disease algorithms were fully developed and implemented,
they might not result in optimal management of the sick child.
Studies suggest that a disease-specific case-management
orientation may not be appropriate when clinical syndromes
overlap, diagnostic resources are limited, and most children
present to health care services with a clinical tableau
consistent with more than one acute and/or chronic condition.
In addition, the continued development of individual vertical
approaches for the case management of a growing number of
diseases (diarrhea, pneumonia, dysentery, malaria, measles,
malnutrition, and HIV-associated illnesses) would create
increasing inefficiencies in management, training, and resource
utilization for already over-extended health systems and
personnel. Conversely, coordination or integration of program
support elements such as these could produce efficiency in
resource utilization. Integration of the monitoring and
evaluation of child health services is not only logical, but is
becoming increasingly essential. Finally, a more holistic,
integrated approach to the management of childhood illness would
represent a substantial improvement in the way that health care
workers should manage patients.
Growing perception of the need for integration of programs and
services for children in the developing world motivated WHO and
UNICEF to develop an algorithm for case management of sick
children at first level health facilities.
The algorithm and associated training materials are designed to
facilitate the recognition and treatment of children with fever,
acute diarrhea, dysentery, persistent diarrhea, ARI, malaria,
measles, and nutritional deficiencies, conditions which are
responsible for more than 70 percent of disease-specific
mortality in children less than five years old. In the context
of health facility encounters for the treatment of sick children,
this algorithm also instructs health workers to update the
child's immunizations and provide counseling to the child's
caretaker on nutrition practices and other areas pertinent to the
current illness.
The 1993 World Development Report of the World Bank identified
the integrated management of childhood illnesses as one of the
most cost effective public health actions for developing
countries, since a large share of total global
disability-adjusted life years (DALYs) could be addressed through
a single programmatic intervention.
The Pathway to Survival
In addition to integrating disease management, two areas must be
addressed in order to bring about continued and sustained
improvement in child survival. The first is strengthening
support systems. Case management programs have frequently been
inattentive to developing and implementing effective support
systems. Inadequacies and inefficiencies in management,
supervision, training, and logistic support often limit the
success of child survival programs.
The second priority stems from a growing understanding that
changing behaviors of caretakers and providers is critically
important for effective child survival programs. In most
cultures, individuals' actions to prevent or treat child illness
are influenced by their perception and understanding, by
community norms and other social and peer-related factors, and by
circumstances and resources. Behavioral research can identify
the determinants of behaviors critical to child health and
survival. Such a behavioral orientation can help identify the
interventions required to facilitate caretakers and health
workers adopting desired behaviors.
A conceptual framework that describes the essential elements of
childhood illness management could serve to clarify and direct
attention to the additional, non-technological improvements
required for the effective delivery of child health services.
Such a framework could guide the development of assessment tools,
interventions, and evaluation strategies. It could serve as a
matrix for collaborative program development, and it could also
help to clearly define the critical areas of management of child
illnesses which should be targeted.
Collaborating institutions (BASICS, the Centers for Disease
Control and Prevention, USAID) prepared such a framework, the
Pathway to Survival, to assist in the development of integrated
management programs and to facilitate dialogue with partners in
development. This framework identifies two critical boundaries
related to integrated management of childhood illness:
* Wellness/Illness: Most children in the developing world
experience illness on multiple occasions. The framework deals
only with the management of child illness, in which a caretaker's
recognition of the need for care is the first essential step.
* Care inside the home/Care outside the home: Care provided in
the home can prevent more severe morbidity and complications,
improve the health and nutritional outcome of the illness, and in
some cases directly prevent mortality. The quality of the care
children receive at home, both at onset of illness and in
follow-up with a health professional, is likely to be the most
important contributor to health and survival.
When the caretaker perceives the need for support or for care
beyond her capability, availability of care outside the home and
the decision to seek that care are critical. Health services
should provide the required skills and resources. They should
provide support and appropriate advice for the caretaker for
continuing care of the child. They should also provide referral
capability, if required. In the case of a severely ill child,
the availability and quality of care outside the home are likely
to substantially determine the health and survival outcome of the
child.
The pathway (figure at www.basics.org/Pathway/path.htm) defines
the key action steps between the onset of illness and the
restoration of the health, embodies the principles described
above and highlights the events occurring inside the home (above
the dotted line in the accompanying diagram) and in the
supporting child health services in the community and health
facility (below the dotted line).
The pathway promotes examination of the requirements for quality
case management by identifying specific actions, identifying key
determinants of those actions and interventions that influence
them. These determinants and corresponding interventions are
behavioral and programmatic. For example, determinants of
quality care in the home or in the facility include, among
others, the level of knowledge, motivation, and skill of the
caretaker, as well as the availability of essential drugs and
commodities.
The pathway is divided into three distinct areas:
1. Case Management in the Home: When illness occurs, several
critical steps necessary for restoring child health must be taken
in the home: recognizing the need for treatment, providing
appropriate treatment in the home, seeking additional appropriate
care when necessary, providing continued care after receiving
outside assistance, and recognizing the need for further
care-seeking if the child's condition worsens. These steps may
differ in complexity and required action for different disease
syndromes. For example, the recognition of diarrhea is
relatively simple and the appropriate case management (increased
fluids and continued feeding) frequently may be provided in the
home. In contrast, recognition of acute lower respiratory
infection may be more difficult. The appropriate management
(antibiotics) may require initially seeking care outside of the
home but, subsequently to the visit, ongoing care should be
provided in the home.
When illness occurs, the critical determinant of a desirable
outcome is whether the caretaker recognizes the illness as one
requiring care in time for that care to be effective. The public
health actions available to strengthen the case management of
illness in the home include adapting case management content to
the circumstances and capabilities of the household, providing
effective information to the caretaker, and assuring access to
necessary drugs, commodities, and when necessary, to trained
providers.
2. Interface Between the home and outside services: Two
critical steps relate home care to outside-the-home care (the
horizontal dotted line is crossed in two different places).
These steps are seeking outside care and providing continued care
after the outside-the-home consultation.
The behaviors required will vary according to the disease. For
all diseases, however, the public health actions available to
influence these behaviors include defining indications for
seeking outside care, providing effective information through
improved communications strategies, assuring the availability of
drugs and supplies for continued treatment, and improving the
relationship between health services and communities/families.
3. Case management outside the home: Increasing access to
high-quality disease management outside the home must be a basic
objective of child survival programs. For severely ill children,
such care can determine survival. Outside-the-home health
services are many and varied, and the framework recognizes this
diversity by indicating broad divisions of both community and
health facility services. In the community, there may be a
formal sector (physicians, nurses, pharmacists, community health
workers, and drug sellers) providing western-oriented services
and, in the informal sector (traditional healers, local sages,
fakirs, and so on), providing traditional or hybridized
treatments and advice. Similarly, diversity may exist in health
facilities, with government (public) and non-government (private)
facilities and health workers existing in close proximity.
Research on health care seeking behavior has shown that mothers
often use multiple services in the course of a single illness
episode. While acknowledging this diversity, the framework
indicates that "quality care" should be held to an accepted
standard, such as that promoted by the WHO/UNICEF "sick child"
algorithm.
Quality care in the community: If the child is attended in the
community, the provider must provide quality services with the
participation of the caretaker. The combination of care by the
community health worker and on-going care by the caretaker often
leads to improved health. If improvement does not occur,
referral from community providers to facilities may be required.
The definition of quality care varies by the type of provider,
with each type of provider aware and respectful of the limits of
their case management capabilities. The relevant public health
actions include training, supervision, incentives, community
participation, commodity support, IEC, and monitoring and
evaluation.
Quality care in the health facility: For the child seen at a
facility, the health worker must provide quality care, including
effectively advising the caretaker. The combination of facility
treatment and subsequent home care lead to improved health and
survival of the child. The health worker may recommend
follow-up, and must effectively communicate indications for
seeking additional care if the condition worsens. In the case of
severe illness, the health worker may refer the child to a
higher-level health care facility. The caretaker must have
access to that facility and must act on the referral. Referral
facility staff must be trained, motivated, and able to provide
quality care.
This framework for integrated management of childhood illness
acknowledges that most of the care of childhood illness occurs
outside of health facilities, and that caretaker recognition of
illness and provision of care are critical components of the
Pathway to Survival. In addition, the framework recognizes that
the pathway involving health facility services may be more
heavily utilized by children with severe illness and that for
these children quality care, follow-up, and referral by health
workers are also critical. Consequently, the pathway must be
examined in its entirety, with the intention of addressing the
most critical constraints to improved child health and survival.
The framework has, at the international level, facilitated the
formulation of more effective national disease control policies
and child survival programs.
Conclusion
The pathway has proven to be a robust tool to date. It answers
the question, "What do children die from?" differently from the
answers that led to vertical, disease-specific programs, and
forces us to think more in terms of behavioral and health systems
research and interventions. Technological advances have helped
bring about a reduction of under-five mortality rates; in most
parts of the world, further progress will be made by only by
adopting the kind of approach suggested by the pathway.
by Ronald Waldman, M.D., M.P.H., Technical Director, BASICS
Project. (This document is available on the BASICS web site at:
www.basics.org )
* * *
L i t e r a t u r e R e v i e w s
THE REVOLUTION OF INCLUSION
Frances Cairncross, The Death of Distance; How the Communications
Revolution Will Change Our Lives, Harvard Business School Press,
Boston, MA, 1997.
The author, a senior editor of The Economist, presents a "must
read" summary of how electronic communications has already
reduced distance between peoples, classes, and cultures, and
gives us a peek into an even more startling future.
Distance, location, company size, improved communications,
specialized information, proliferation of new ideas, work
location, and many other traditional factors will change, but so
will privacy rights, income stability, and most of our pat
notions about life. Ms. Cairncross states that reducing the costs
of communications is the "single most important force shaping
society in the first half of the next century."
Telephone, television, and computers remain the heart of the
communications revolution, but they will all be rolled into one
technology and anyone who masters the technique of dealing with
this will be included in the new distanceless world. This means
that people in the developing world can also be integrated into
the "revolution of inclusion," but only if someone makes it
happen.
But, for all of this to happen many barriers have to be overcome:
regulatory, political and financial. Who's to say that these
forces for maintaining the status quo will buy into the possible
changes?
* * *
O r g a n i z a t i o n s
BASICS
BASICS (Basic Support for Institutionalizing Child Survival) is
an innovative five-year international public health project
funded by the United States Agency for International Development
(USAID). USAID has been a leading partner in the global effort
to meet the challenge of child survival, and BASICS is the
largest USAID program in this field.
BASICS provides both technical leadership and practical field
programs for reducing infant and childhood illness and death
worldwide. The project operates programs in Africa, Asia, Latin
America, and in the New Independent States (NIS). BASICS provides
these countries with cost-effective child survival interventions
and serves as a technical resource to those around the globe that
design and implement child survival health programs. The project
also collaborates with a wide range of nongovernmental
organizations, other donors, and public health institutions in
the following six programmatic areas:
* sustaining immunization programs
* integrating effective case management of childhood illnesses
* strengthening the link between nutrition and health
* promoting and sustaining health behaviors
* improving techniques for monitoring and evaluation
* establishing public/private partnerships
The project's Operations Division plans and implements all BASICS
country and regional activities. Field activities are staffed
with long-term advisors and locally hired staff and consultants.
Technical assistance is provided to the country operations
through regional offices.
The project operates long-term and periodic programs in 30-40
developing countries and assists USAID Missions with short-term
programs in additional countries.
BASICS country and regional programs reflect the project's six
priority areas. They also address specific diseases, such as
control of diarrheal disease (CDD), malaria, and acute
respiratory infections (ARI).
All BASICS country operations seek to strengthen the systems that
support primary health care programs. Operations officers set up
programs to train health workers, improve communication
strategies for health, and strengthen health information systems.
They simultaneously work to make changes in health policy that
will have a long-lasting impact on child health.
The BASICS Technical Division has developed an innovative
model-the Pathway to Child Survival-that identifies the wide
range of factors, inside and outside the home, that play a
critical role in children's well-being. The Pathway was
developed jointly by BASICS, USAID, and the U.S. Centers for
Disease Control and Prevention (CDC), and it guides the thinking
and activities of project staff who work alongside national and
local health authorities around the world.
For additional information about BASICS, contact the Information
Center at:
1600 Wilson Blvd., Arlington, VA USA 22209
E-mail to mailto:infoctr@basics.org. Or check the web site at;
www.basics.org
* * *
V I T A P r o j e c t s
SATELLITE CAPACITY SHARING AGREEMENT
Two satellite companies, SatelLife and Consorcio Sat have joined
VITA to share excess capacity in their satellites for developing
country communications. VITA has been organizing a consortium of
satellite providers to ensure plenty of capacity for
communications.
SatelLife is a Boston, MA non profit organization that manages a
program called HealthNet that brings medical information to
health practitioners in developing countries and permits them to
communicate with their peers around the world; it uses HealthSat
II in remote areas of the world. PoSAT-1 is owned by a Portuguese
company and uses the satellite for health & welfare traffic for
Portuguese military units serving in Angola, Bosnia, and
Mozambique. VITA uses PoSAT-1 in Tanzania, Ireland, the Republic
of Congo, and Antarctica.
For more information, contact mailto:jsedlak@vita.org
VITA INTERNET "ACTION" CONFERENCE PLANNED
VITA will initiate a moderated electronic discussion conference
starting in March 1998. This conference will focus exclusively on
using email for critical health, education, disaster and other
information for people in the rural areas of developing
countries. It will result in definite action plans!
How will this be different from the other Internet conferences
that deal with developing country communications? We want to do
more than simply discuss or share ideas and/or experiences; we
want to actually bring schools, health facilities, businesses,
commerce, transportation and other activities in rural areas into
the mainstream of development! This conference will help shape
what author Frances Cairncross describes as the "Revolution of
Inclusion" in her book Death of Distance: How the Communications
Revolution Will Change Our Lives.
Between now and the start-up of the conference, we need your
advice and comments on how the conference should be organized.
Our plan is to select several key topics for discussion and then
conduct short-term conferences by small panels of experts on each
particular topic. At the end of each panel discussion, we will
then open the conference results for comments from
non-participants for another definite period of time. At the end
of the conference an action plan will be created.
Sample topics: "Real Time v. Store & Forward Communications"
"Email access to the WWW"
"Effective cost/time use of the Internet"
"
Please: 1) comment or make suggestions on the above; 2) suggest
topics for discussion, and 3) indicate your willingness to
participate by sending your name, title and organizational
affiliation and your email address to mailto:VITAlink@vita.org.
You will receive notification soon about the first discussion
topic and how to participate.
* * *
A n n o u n c e m e n t s
HELPING SMALL BUSINESSES IN TRANSITION AND DEVELOPING COUNTRIES
The World Association of Industrial and Technological Research
Organizations (WAITRO) is holding an international seminar in
Warsaw, Poland on Oct 13-16, 1998. The conference is sponsored by
the Danish International Development Assistance (DANIDA) and the
International Development Research Centre (IDRC) of Canada.
Small businesses worldwide face serious problems because they
cannot easily access, absorb, adapt and exploit new technologies
and business techniques. The purpose of the meeting is to review
best practices and to share experiences between participants. The
meeting expects to attract managers from transition economies and
developing countries.
For more information contact: mailto:waitro@dti.dk or
http://waitro.dti.dk.
* * *
HOW TO JOIN VITA'S ELECTRONIC FORUM
VITA's free, public, online discussion forum, DEVEL-L, provides
for the exchange of ideas and information on a wide range of
issues and topics related to technology transfer in international
development; for example, technologies, communications in
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Please do not send these messages to VITA or to DEVEL-L.
* * *
DevelopNet News is an electronic newsletter published monthly by
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VITA specializes in information dissemination and communications
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