DRAFT Child Health Strategy of DISH II

Future plan

During the first year of the project, great efforts were made in conducting IMCI training and in building-up the capacity of districts and health sub-districts for training and supervision. Although there are variations of coverage of trained health workers and in the capacity of conducting training and supervision among districts, nearly all of the 12 DISH II supported districts now have the capacity to manage IMCI training and supervision with minimal support.

Now that IMCI training and support supervision is well established, for the next eighteen months the project intends to focus on additional child survival interventions, which have the potential to significantly reduce childhood mortality.

These interventions were selected on the basis of discussions with the MOH, partners and districts:

1. Home based management of fever/malaria.
2. Immunisation
3. Infant/child nutrition

• Exclusive breastfeeding
• Complementary feeding
• Growth monitoring/prommotion
• Vitamin A supplementation

1. IMCI case management
2. Prevention of mother to child transmission of HIV

Interventions involving these five program areas can be implemented at the following three strategic points:

• Public health facilities
• Household and community
• Private health sector.

Through a consultative process (in a workshop Kampala, 8^th-9^th May 2001) with MOH and partners, the above program areas and strategies were agreed on and a joint work plan developed.

Improvement in the case management skills of health workers

This involves the following activities of improvement of the quality of services offered by the health system:

1. Curriculum design
• DISH II will work with MOH to incorporate growth promotion, PMTCT and routine Vitamin A supplementation in the current IMCI curriculum or design a separate refresher course curriculum.
• DISH II will work with MOH and other partners to develop the curriculum for a few-days workshop for drug sellers on rational use of drugs, especially treatment of malaria (refer to the role of private sector).
  
  
2. Training of trainers
• DISH II will carryout one mop up Training of trainers to consolidate the district capacity to train their health workers in IMCI. The potential trainers are identified during the standard 11-day IMCI course.
  
  
3. Training implementation
• At least two staff from each health facility will be trained in IMCI (totally 1080) by the end of the project. This is intended to give critical mass to each health facility to implement IMCI.
• IMCI training course should meet the MOH criteria of quality training. At least one of DISH II staff supervises the course to make sure the quality of course.
• DISH II will provide technical and financial supports to the IMCI part of the three months training of nurse aides with a primary aim of improving the quality of the training.
• Adequate training materials will be printed in coordination with the MOH and stocked in each branch office for the districts’ requirements.
• A checklist for the preparation for the course has been developed and is to be distributed to each district IMCI focal persons and DISH trainers.
• Performance assessment tools to be developed to help focus technical supervision.
  
  
4. Technical supervision and continuing education

• Follow-up visits (technical supervision) will be done within 4-6 weeks after training by each district team and DISH trainers. After that, integrated support supervision will takeover and sustain the skills.
• Once the curriculum has been developed, one refresher course for in-charges in health facilities, focusing on counseling skills, rational use of drugs and growth promotion will be organized in each district except Kasese. Selection of the participants for the courses should be based on the result of follow-up visits and discussions with IMCI focal person in each district.
• At the end of training and follow-up visits after training, the importance of on-job training in IMCI and internal supervision in health facilities, especially for nursing aids, will be emphasized.
• Quarterly updated information on child health for health workers will be developed and disseminated to health facilities with dissemination of "Health Matters" and during regular supervision.
• The health facilities which achieve and maintain standards of quality in child health (as well as other areas) will be identified, promoted and rewarded as a part of the Quality of Care Initiative.
5. The role of the private sector
• DISH II will collect further information on current child health services and providers in the private sector At the same time, information related to training private sector health workers will be collected from Uganda Private Midwife Association, Minnesota International Health Volunteers and AFRICARE (training for drug sellers) etc. Based on the information collected, a strategic plan will be developed on how to improve the quality of care provided in the private sector (including drug sellers).
• Following the plan, DISH II will train private health workers in IMCI and drug sellers on child health in a few selected areas. All training and follow-up activities will be documented very carefully.

Improvement in household and community practices

DISH II has worked, to promote exclusive breastfeeding, infant nutrition, growth promotion and Vitamin A supplementation through multi-channel campaigns, training CHWs and equipping them with weighing scales. MOH has also developed a household/community IMCI strategy. DISH II will implement the following activities, in close collaboration with other partners such as BASICS, MOST, CHILD, AFRICARE and CARE:

1. Prioritization of key behaviors, in conjunction with the Ministry of Health, with a likely focus on nutrition, immunization, and malaria
• DISH II works closely with child health division, MOH, in relation to malaria home management
DISH II will specifically promote the following key community and child health practices:
• Give sick children appropriate treatment during illness
• Take children as scheduled to complete immunization before their first birth day
• Recognizing when sick children need treatment outside the home and timely seeking care
• Follow the health workers advice on treatment follow up and referral
  
  
2. Literature review on current knowledge, attitudes and practices related to selected key behaviors and supplementary qualitative research as required
3. Message, media and activity strategy developed in close collaboration with DISH II clinical services component
4. Multi-channel campaigns, including radio, print and interpersonal activities, promoting selected key behaviors
5. In collaboration with BASICS, assist with participatory community activities in selected health sub-districts
6. Development and distribution of "Health Matters", "Olujegere" radio programmes, and centerpiece videos on specific child health topics
7. DISH II will sensitise all districts on PRA approaches for cIMCI and assist the MOH to scale-up PRA in two districts.
8. During IMCI training, the importance of use of child health card will be emphasized for immunization and growth promotion.
9. Support to outreach activities including immunization, Vitamin A supplementation and growth promotion
• DISH II will organize one forum in collaboration with MOH to discuss how to conduct the integrated outreach activities.
• Based on the discussion, DISH II will provide technical support and necessary inputs to improve outreach activities.
  
  
10. DISH will also take advantage of the following opportunities to reach community members and disseminate key messages:
    
    
• Antenatal care visits
• Delivery and postnatal care visits
• Well-child clinic
• Sick child visits
• Outreach services
• Traditional birth attendants
• Existing radio programmes
• Community drama performances
• Community meetings
• Women’s groups meetings
• Church groups meetings
• Child health days
• Market days
• Other educational and entertaining events (e.g. song contests, healthy baby contests etc.)

Improvement in the health systems to deliver child health activities

1. Integrated supervision: Continued DISH II support for implementation of the National Supervision Guidelines; plus strengthening of the child health component with particular regard for IMCI
   
   
2. Quality assurance: Support for the national quality assurance program, as well as specific efforts to improve the organization of work at health facilities

• During follow-up visits district and DISH supervisors will help health unit staff to organize facility to all services together so as to reduce missed opportunities for all child health.
• During the follow-up visits help will be offered to increase availability of immunisation services both at the static and outreach points.
• Health facilities that achieve and maintain standards of quality on child health will be identified, promoted and rewarded. Specific child health related standards include weighing all children coming to the health unit and plot the weight on the child health card, avoiding stock outs of chloroquine, cotrimoxazole and vaccine and appropriate management of sick children according to IMCI.
  
  
3. Drug logistics: Improved availability of IMCI drugs and essential supplies

   • DISH II will support availability of make IMCI drugs in health facilities through working with MOH, districts and sub-districts on stock management.
   • DISH II will advocate to sub-districts to procure essential IMCI drugs.
   • To make sure proper and timely drug distribution from National Medical Stores, district and sub-district to health facilities, training of drug store keepers on drug management will be conducted.

4. HMIS
• DISH II will support the dissemination of the new HMIS guidelines in which IMCI classifications are included.

5. Health Worker Communication Campaign
   
   
• Development of messages encouraging changed attitudes and improved clinical care among health workers
• Secondary audience will be potential clients, thus publicizing improved quality of care
• Job aides to remind health workers of key child health information and procedures

Monitoring and evaluation:

• Quarterly reports on training and supervision, BCC and Health Management/quality assurance
• Quarterly HMIS data from 80 sentinel sites
• DISH Evaluation Surveys ( last one in 1999, next one in 2002)
• Special BCC studies to evaluate reach and impact of messages

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