Abstract
Evaluates the integrated management of childhood illness (IMCI) project in Latin America and the Caribbean (LAC). The project is being implemented by the Pan American Health Organization (PAHO) and the Basic Support for Institutionalizing Child Survival Project (BASICS). Midterm evaluation covers the period 3/97-5/00. All three direct partners in the project -- USAID/LAC, PAHO, and BASICS -- can be proud of their accomplishments. The LAC region is serving as the test case for many aspects of IMCI, and in just 3 years the results obtained are substantial. On a policy level, the ability to garner the political commitment at the highest levels of the Ministry of Health (MOH) has been critical to the effective launching of IMCI in Latin America. On a personal level, the dedication, enthusiasm, and optimism of MOH and NGO staff, promoters, and mothers interviewed are proof that IMCI's success will ultimately be decided by individual willingness to change behavior. The evidence obtained during this evaluation is that IMCI can be successfully implemented and managed. More specific achievements are as follows: (1) Seven out of eight countries chosen for the project have adopted the IMCI strategy. (2) IMCI has been incorporated into the MOH's operational plans in Honduras and Peru and into the MOH's Seguro Basico de Salud in Bolivia. (3) The IMCI message has been conveyed undiluted and undistorted to different audiences at different levels. (4) Although in-country training is not part of the regional initiative, its quality is related to the quality of the training manuals and the expertise of the trainers. Over 8,000 people have been trained with manuals adapted from generic materials through the use of regional funds. Those interviewed had good knowledge of IMCI and an integral vision of children's health. As a result, there has been better counseling of mothers, more awareness of mothers and community members of their role in children's health, better diagnosis of pneumonia, more awareness of risk factors, and better referrals by health workers. An often stated but not yet documented consequence has been fewer children's deaths. (5) IMCI tools has been adapted and disseminated both in-country and to other countries. For example, Rational Pharmaceutical Management (RPM), developed by Management Sciences for Health (MSH) with BASICS and PAHO support, was field tested in Bolivia and Ecuador. This tool collects cost data, assesses the role of the private sector, determines the availability of drugs at health centers, and assesses prescribing practices. Also, with project support, the Training Center for Breastfeeding and Nutrition (COTALMA) in Bolivia modified the community IMCI materials that were originally developed by PAHO/UNICEF. With TA from World Education, COTALMA also adapted materials for auxiliary nurses, called complementary IMCI. Additionally, because of the success of the implementation of IMCI in Latin America, two PAHO representatives were invited to present their experience in an upcoming international meeting in South Africa. Finally, Peru and Honduras made their own shortened versions of the clinical IMCI training course (from 11 to 7 days). (6) The project has shown itself able to work under adversity. For example, in Honduras, despite the worst hurricane in the last 25 years (Mitch), the initiative progressed; in Bolivia, a dedicated facilitator works on training activities on her vacation time; and in Peru, after work hours, an entrepreneurial young doctor conducted a thorough study of drug use in a group of clinics. The project shows great promise for making a major contribution to the eventual sustainability of IMCI within nationwide health systems in the target countries. Currently, five different approaches are being pursued to promote sustainability, all with initially promising results, although mostly on a limited and pilot basis: incorporation of IMCI into MOH policies; stimulation of donor support and funding for the expansion of IMCI; incorporation of health issues into activities of the education sector; training of community-based health promoters and mothers in IMCI messages; and incorporation of IMCI into the curricula of nursing and medical schools.