Regional Community IMCI Partnership

UNF/PAHO Partnership Final Report Empowering Local Communities to Improve Children's Health in Ten Latin American Countries 2003-2007 WHO-RLA-01-223

An Integrated Approach to Improve Family and Community Health Practices

UNF/PAHO Partnership Final Report Empowering Local Communities to Improve Children's Health in Ten Latin American Countries 2003-2007 WHO-RLA-01-223

An Integrated Approach to Improve Family and Community Health Practices

United Nations Foundation for International Partnerships United Nations Foundation

Child and Adolescent Health Unit, Family and Community Health Area Pan American Health Organization/World Health Organization

Washington, D.C. March 2007

Table of Contents

List of Abbreviations …………………………………………………………………………………..4

Executive Summary…………………………………………………………………………………….5

1.0 Background …………………………………………………………….………………….....7

2.0 Scope and Justification ……………….……………………………………………………8

3.0 Achievement towards Meeting Objectives and Indicators ……………….……....9

4.0 Highlights and Accomplishments ……………………………….…………….………..15

5.0 Ownership, Sustainability, Scaling-up and Capacity Building……………………. 19

6.0 Telling the IMCI Story – Country Examples…………………………………………… 20

7.0 Budget and Administrative Issues……………………………………………………… 23

8.0 Future Perspectives……………………………………………………………………….. 24

Acknowledgements…………………………………………………………………………………...25

Annexes………………………………………………………………………………………………… 26

Annex 1: Approved Community IMCI Projects using ARC and UNF Funds, 2001-2006 Annex 2: New Community IMCI Initiatives and Results at the Country Level Using UNF Funds, January 2006-January 2007 Annex 3: Selected Country Examples of Expansion and Institutionalizing the Community Component of the IMCI Strategy at the National Level, as of January 2007 Annex 4: Key Family Practice Household Baseline and Post Surveys, as of January 2007 Annex 5: Technical Documents and Materials Developed, as of March 2007 Annex 6: Community IMCI Fact Sheets, Technical Documents and Publications, as of March 2007

3 List of Abbreviations

ARC American Red Cross

CDC Centers for Disease Control and Prevention

CHW Community Health Worker

ICC Interagency Coordinating Committee

IHP International Health Program

IFRC International Federation of Red Cross/Red Crescent Societies

IMCI Integrated Management of Childhood Illness

KFP Key Family Practices

KPC Knowledge, Practice and Coverage

MDG Millennium Development Goals

MOH Ministry of Health

NGO Non-governmental Organization

ONS Red Cross Operating National Societies

PAHO Pan American Health Organization

PNS Participating National Society

PVO Private Voluntary Organization

RC Red Cross

UNICEF United Nations Children Fund

UNF United Nations Foundation

UNFIP United Nations Foundation for International Partnerships

WHO World Health Organization

Executive Summary

In January 2000, a five-year Partnership between the Pan American Health Organization (PAHO) and the American Red Cross (ARC) was signed to implement the community component of the Integrated Management of Child Illness (IMCI) strategy. This work supported the health program of the Red Cross Operating National Societies (ONS) and Ministries of Health in eleven countries (Bolivia, Colombia, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Nicaragua, Peru, and Venezuela). Because of early Partnership success, in January 2003, a matching grant agreement between the American Red Cross, the United Nations Foundation/United Nations Fund for International Projects (UNF/UNFIP), and PAHO was signed leveraging funds from ARC to further support and scale-up community IMCI activities through a complementary project titled Empowering Local Communities to Improve Children's Health in Ten Latin American Countries. The ARC portion of the Partnership ended in January, 2006. UNF/UNFIP then provided PAHO with a one-year an extension with additional funds to continue activities up to January 31, 2007.

The Partnership was used as a foundation to expand PAHOs collaboration with the wider Red Cross Movement including the International Federation of the Red Cross (IFRC) and National Red Cross Operating Societies (ONS). A Memorandum of Understanding was signed between PAHO and IFRC in May 2002, to further support community IMCI activities. In April and October 2002, in Antigua, Guatemala, and Santa Cruz, Bolivia, respectively, PAHO participated in several tripartite consultations. This work created the momentum for the Ministries of Health, National Red Cross Operating Societies, PAHO Country Offices, American Red Cross, Canadian Red Cross, International Federation of Red Cross, other agencies and international and national institutions, and NGOs, to institutionalize the methodology of community IMCI into official country plans and policies.

Key elements of this work supported community IMCI activities implemented by the ONS and Ministries of Health with support from community leaders and networks, community health workers (CHW), non- governmental organizations (NGOs), families and other social actors and institutions. It promoted the use of the WHO/UNICEF Key Family Practices for the prevention of common childhood illnesses as the primary intervention to change behaviors at the family and community level. It also strengthened the integrated case management of illness, especially diarrhea and pneumonia, with the goal of bringing children closer to the health system and generating community resources to improve the quality of care. This work contributed to reducing morbidity and mortality rates in children less than five-years of age.

The Partnership successfully built on existing community-based programs at the district level, promoted equitable access to services, improved access to quality health care at the health facility level, strengthened local capacity and ownership, and made the best and most cost-effective use of scarce resources. The goal was to meet Partnership objectives and provide the leadership and technical support to make the community component of the IMCI strategy a national programming strategy; moving beyond a pilot activity by scaling up coverage to the national level and carrying forward the basic principles of primary health care to contribute to reaching the Millennium Development Goal 4.

Many accomplishments were achieved; three stand out as the most salient: 1) the design and implementation of an innovative social-actor community model, 2) the transformation of community IMCI from a training course to part of a national strategic plan of action, and 3) the improvement of case management knowledge and changing behaviors among caretakers. The design and implementation of community projects by social actors was empowering because groups not traditionally working in health became involved in the promotion of the key family practices at the family and community level.

The community mobilization component engendered by the social-actor community model was one of the most innovative elements of the Partnership and will sustain actions in the future. The identification of risk factors and associated causes of death lead to a selection of effective preventive interventions by the communities. The ONS and Ministry of Health capacity to provide quality, sustainable services to children in vulnerable communities dramatically increased during Partnership implementation. It did not require expensive overhead and other capital costs to achieve success.

From January 2003, to January, 2006, UNF provided resources, coupled with ARC funds, to support thirty- two community IMCI projects in ten countries. Project activities created links between the health services, social actors, and the family and community to ensure an integrated approach. Millions of children, mothers and fathers were beneficiaries of Partnership activities. Over 350 community-based organizations and institutions, international agencies, and NGOs, collaborated in the implementation of community projects and expansion plans. Over 14,000 people were trained in different planning, case management and community teaching courses, and 35 new technical guidelines, tools and materials were developed and used at the national and community level. Twenty-three baseline-and seven follow-up household key family practice surveys were carried out to collect indicators to document behavior change in selected sites.

From the period January, 2006 to January, 2007, UNF supported seven countries (Bolivia, Colombia, Guyana, Peru, Paraguay, Nicaragua and Honduras) in the expansion of community IMCI activities and documentation of evidence and best practices. A University Extension Course in Community Health and IMCI was established in 2006. Two community IMCI effectiveness studies in Honduras and Peru were held to document evidence on the effectiveness of the social-actor community model. The research will attempt to demonstrate the impact of community IMCI initiatives implemented in selected areas of interventions.

The Partnership provided a unique opportunity for the countries to undertake new challenges and lead a comprehensive, integrated approach to meet the Millennium Development Goals. Country partners assumed a leadership role, established IMCI coalitions at the community, district and national levels, and worked collectively to expand and institutionalize key family practices and effective case management into daily life at the local level and in institutional policies at the national level. However, while there is extensive research on the effectiveness of health-care interventions, there is less evidence on the process of their implementation, cultural appropriateness, cost-effectiveness and effects on health inequalities, all of which are important considerations for policy-making. There is still a need to evaluate how interventions are implemented and which factors help or hinder their success to scale-up interventions. New approaches are also required to link community actions with health services and health systems to scale-up efforts based on a primary health care model.

The ARC/UNF/PAHO Partnership worked at the family and community level to increase the coverage of community-level interventions using a combination of outreach services and family and social actor participation. As documented in the following report, this work was instrumental in sustaining actions after the Partnership ended.

6 1.0 Background

he Integrated Management of Childhood Illness (IMCI) is a global initiative spearheaded by the World THealth Organization (WHO) and Member Countries to reduce morbidity and mortality of the most common and preventable childhood illnesses. The American Red Cross (ARC) hosted the First Red Cross and Red Crescent Conference on IMCI in Washington, D.C., in October, 1998, to highlight the important role the Red Cross Movement could have in support of the IMCI strategy.

In January, 2000, the American Red Cross (ARC) and the Pan American Health Organization (PAHO) signed an agreement to establish a new regional Partnership. The innovative, five-year (2000-2005) Partnership complemented the work of Ministries of Health and the ARC International Health Program working through Red Cross Operating National Societies (ONS) in eleven countries (Bolivia, Colombia, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana [included in 2004], Honduras, Nicaragua, Peru, and Venezuela) to improve local capacities to deliver low-cost, high-impact health services (see Figure 1).

Figure 1 In January 2003, a matching fund Regional Community IMCI Partnership agreement between the American 2000-2007 Red Cross and the United Nations • Bolivia Foundation/United Nations Fund for • Colombia International Projects (UNF/UNFIP) • Ecuador • El Salvador with PAHO was signed leveraging • Guatemala funds from ARC to support and scale- • Guyana up community IMCI activities through • Honduras a complementary project titled • Nicaragua Empowering Local Communities to • Peru Improve Children's Health in Ten • Dominican Latin American Countries. In January Republic 2006, UNF/UNFIP provided PAHO an Pan American Health• Venezuela Organization 2004 extension with additional funds up to January 31, 2007.

Purpose and objectives are outlined below:

UNF/UNFIP 2003-2006 Framework

• Purpose To improve the health and quality of life of children less than 5 years of age and their families living in vulnerable communities in ten countries. • Strategic Objective To contribute to the reduction of mortality from diseases and health problems targeted by IMCI in children under 5 years of age.

Objective 1: To increase the capacity of the Red Cross National Societies, Ministries of Health and other community sectors to provide quality, sustainable community IMCI services to children in vulnerable communities and change health seeking behaviors of the caretakers.

Objective 2: To increase the ARC capacity to support the Red Cross Movement in providing quality, sustainable community IMCI services to children in vulnerable communities.

Objective 3: To develop innovative strategies for community participation and implement new tools on community IMCI costing, long distance education and operational research, and provide evidence that community IMCI works.

2.0 Scope and Justification

In the Region of the Americas, families and communities perform strategic health functions, especially in areas where governments and social systems do not reach. Families and communities constitute a critical safety net and source of support and protection for the health and well-being of citizens. As such, they need to be empowered, supported, and strengthened. At the same time, health and social systems must collaborate with families and communities to maximize the impact of health and development interventions. It is this crucial partnership that will enable the achievement of an ambitious health agenda for the new millennium.

The Child Survival Series in The Lancet challenged the world to reach full coverage with interventions that will increase a child’s chance for survival and healthy development. The series argued that we need to intervene, not only through the health system but also at the household level promoting interventions which can be effectively delivered. Going beyond the household to increase the coverage of community-level interventions could prevent almost half of childhood deaths. The Neonatal Survival Series in The Lancet also argued that many newborn deaths could be averted with a combination of outreach services and improved family and community care.

The social-actor community model developed by the Partnership and implemented by Member Countries promoted a bottom-up approach with early involvement of all community members in identifying local health requirements based on epidemiological data, in setting priorities and interventions, in planning programs, and in taking concrete actions. It works at the national, local, and household levels to increase the coverage of community-based interventions by using a combination of outreach services, family, and social actor participation (see Figure 2). This work strengthened links between communities and health services, promoted community participation and empowerment to address child health problems, and supported inter- sector coalitions to sustain actions.

At the core of the community component is a set of key family practices that promotes growth and development, prevents disease, provides home care for a sick child, and improves care seeking and compliance with the advice of a health worker. It also strengthens the integrated case management of illness, especially diarrhea and pneumonia, bringing children closer to the health system and community

8 resources which improved the quality of care. These interventions reached the most vulnerable, including indigenous population groups.

Figure 2

Strengthening collaboration between the The Partnership maximized the potential health sector, family and community of the Red Cross organizational structure NGOs and volunteer network, Ministries of ++++++++ Health, country-level NGOs, and Universities Caritas Mayor international organizations including Volunteers UNICEF, USAID, the World Bank, IFRC, =Faith-based org. JCIs Schools and enhanced sustainable linkages CHW between ONS activities, governmental Health services National Child Health Plans, and social Family CHW networks in each country. The Partnership increased the capacity of PAHO to deliver Effective health Family and Other sectors community system community-based IMCI activities through Pan American Health Organization 2004 non-governmental organizations (NGOs) and civil society, preventing deaths by concentrating interventions in local areas with infant mortality rates greater than 40 per 1000 live births. These actions contributed significantly to increasing children’s access to trained health professionals and giving them the chance to grow into healthy, productive adults.

Figure 3 - Conceptual Framework, Regional Community IMCI Partnership

The conceptual framework outlined below was developed at the beginning of the Partnership to guide the implementation of community IMCI activities, especially linking actions between families and communities, social actors and health services. The fundamental premise was to create a dialogue among all actors in the community through integrated actions between the Ministry of Health and Red Cross. In this fashion, local capacity and sustainability of activities with other civil society organizations and other social actors would occur (Figure 3).

3.0 Achievement towards Meeting Objectives and Indicators

Over the course of the Partnership, participating countries made significant advances implementing activities at the national, community, and especially household levels promoting key family practices and improving case management. As in any massive regional effort, each country followed its own pace within a constantly changing context of

9 social, economical and political variables. The rate of progress was partly influenced by the stability of national teams in respective country MOHs and ONSs. Leadership initiatives by national teams to institutionalize community IMCI activities into district and national plans demonstrated the commitment, motivation and enthusiasm of these groups to make positive changes.

During the 2006-2007 period, the Partnership using UNF funds provided financial assistance to seven countries (Bolivia, Colombia, Guyana, Honduras, Nicaragua, Paraguay and Peru) in the area of community IMCI and national scaling-up of the IMCI strategy. Most of this work was directed to training local leaders in the key family practices, developing strategic plans for expansion, adapting new tools and guidelines for local and national use, documenting evidence, and holding advocacy workshops to plan for sustainable actions at the national level. Based on the logical frameworks included in the UNF/PAHO Project, all objectives, indicators and expected results were accomplished (most were exceeded). The following section outlines Partnership accomplishments based on objectives, indicators and expected results, described in the logical framework of the UNF/PAHO project. …After community IMCI Objective 1: To increase the capacity of the Red Cross training we went out to National Societies, Ministries of Health and community inform our neighbors. Now mothers take their children to sectors, to provide quality, sustainable community IMCI Health Centers. If you would services to children in vulnerable communities and change have seen how they use to fill health seeking behaviors of caretakers. the Centers with mothers with their children. This way ¾ Progress achieved towards the first Partnership objective we prevent them from dying - included: 1) technical proposals developed by ONS, MOH and other Sr. Felipe Cháchez, local networks; 2) Red Cross staff and volunteers, and MOH Presidente Neighborhood personnel trained in IMCI clinical case management and community Organization, Bolivia courses, key family practices, and other health programming and management courses; 3) implementation of community projects focusing on interventions in the family; 4) participation in local and national public health coalitions; 5) enhanced relationship between the ONS and the MOH; and 6) application of community mobilization techniques using social actor networks.

Table 1. First UNF/PAHO Objective, Activities, Indicators and Progress Achieved Empowering Local Communities to Improve Children's Health in Ten Latin American Countries, 2003-2007 Objective 1: To increase the capacity of the Red Cross National Societies, Ministries of Health and other community sectors to provide quality, sustainable community IMCI services to children in vulnerable communities and change health seeking behaviors of the caretakers Activities Indicators and Progress Achieved 1. Develop community IMCI projects that -100% of families in selected project areas received improved health incorporate the IMCI strategy and key care attention and information on the key family practices in ten family practices countries, Accomplished

2. Increase the role of community-based -100% of the population in selected project areas received health providers in the promotion of key education information on IMCI prevention in ten countries, family practices Accomplished 3. Develop methods for participatory -Increased community participation in primary health care issues and community assessment and planning decision-making in ten countries, Accomplished -Number of communities using project-training materials as part of strategic community plan (local actors and key family practices), Accomplished (32 community sites in 10 countries) -Number of countries generating self-income or including IMCI as item in local government budgets (8 countries – Bolivia, Colombia, El Salvador, Guyana, Honduras, Nicaragua, Perú, Venezuela)

10 Note: In 2003, the Partnership included two additional objectives to the original Regional Community IMCI Project with ARC: 1) to increase not only the capacity of Red Cross but also of other community sectors, and 2) to change the health seeking behaviors of the caretakers. The decision to include other community sectors was strategic. The Partnership realized that in several countries a limited number of Red Cross Volunteers and community health workers were available to provide the necessary coverage to reach 100% of the families in selected communities. The involvement of other social actors was included to build medium and long-term strategies to develop and implement plans to increase coverage of skilled community workers, increase outreach services and family-community care, strengthen links between communities and health services, and promote community participation and empowerment.

The ONS and MOH capacity to provide quality, sustainable community services to children in vulnerable communities was dramatically increased during Partnership implementation. Survey results showed a change in health seeking behaviors of caretakers in selected communities that finished their initial plan of action. One of the most successful achievements was recorded in the district of Chao, Peru, where the malaria risk was reduced dramatically over a two year period. In an unexpected development, cases of malaria dropped almost 99 percent between 2002 and 2004. Public health workers credit the decline to IMCI’s success in getting Chao’s citizens active on issues of public health. Other results include:

Changes in Practices that Ensure Adequate Care at Home - Figure 4 illustrates that 4% more homes gave more or an equal amount of breast milk to children with diarrhea, and that 5% more households used oral rehydration solution to treat diarrhea. An additional 2% of men accompanied their wives to seek assistance at health services in cases of children with a cough and accelerated breathing, 6% more families left their children under the supervision and care of adults, and 4% and 14% more households knew how to prevent accidents caused by burns and swallowing of medication at home, respectively.

Figure 4. Changes in practices related to adequate health care of children at home, in rural and peri-urban localities participating in Regional Community IMCI Partnership activities in Honduras, Peru, Bolivia, and El Salvador, 2003- 2005

Changes in Practice of Seeking Assistance outside the Home: Figure 5 illustrates in selected community sites 29% more families recognized the warning signs of diarrhea; 31% more knew the risk of death signs in a child; and 12% more could cite the danger signs of pneumonia. Most importantly, 6% more children with a cough and rapid breathing were taken to health services.

11 Figure 5. Changes in the recognition of danger signs and use of health services for children with a cough and rapid breathing in rural and peri-urban localities participating in Regional Community IMCI Partnership activities in Honduras, Peru, Bolivia, and El Salvador, 2003-2005

Note: Although it might be difficult to attribute direct change to particular aspects of the Partnership methodology, especially in communities that received multiple interventions promoted by other initiatives (NGOs, etc), the community’s perception of this change is strongly attributed to the IMCI activities implemented. Additionally, it is important to understand that the results presented above must be interpreted as a process of behavior change overtime which requires sustained actions and follow-up taking into account the amount of time exposed to the message and educational activities held in each community.

In many of the participating community sites various social networks were created to involve as many local actors as possible to produce a multiplying effect of volunteers delivering one common message. These activities included home visits by community health workers (CHW) and Red Cross volunteers. It also involved dissemination of innovative messages to hard to reach families through local opinion leaders such as mother’s support groups, neighborhood organizations, and teachers. The Partnership increased community participation in primary health care issues and community mobilization around child health needs. Many districts and communities are generating self-income and including IMCI as a line item in local government budgets. These are Bolivia, El Salvador, Nicaragua, Peru, Venezuela, Colombia, Guyana and Honduras. Furthermore, several government health policies, NGOs and USAID child health projects in Bolivia, Dominican Republic, Ecuador, El Salvador, Honduras, and Peru, adopted the community IMCI methodology developed by the Partnership.

Communities are using training materials developed by the Partnership to complement strategic community plans (local actors and key family practices). Interestingly, the majority of countries have produced local adaptations of Partnership materials and developed new instructional brochures and guides to promote key family practices tailored to their own language and customs. Many community IMCI projects included a component to improve information collection at the district level. All projects implemented a strong

12 monitoring and evaluation component, although there were some deficiencies in following-up with the various activities implemented by local social actors.

Objective 2: To increase the ARC capacity to support the Red Cross Movement in providing quality, sustainable community services to children in vulnerable communities.

¾ Progress achieved towards the second Partnership objective included: 1) the American Red Cross became a regional actor and leader in community IMCI activities in Latin America and supported selected ONSs by funding key staffing positions to provide public health leadership, technical assistance, and program coordination; and 2) lessons learned by the American Red Cross through their partnership with PAHO provided essential technical information and experience for future community health programming.

The American Red Cross (ARC), through its partnership with PAHO and UNF, increased its capacity to support the Red Cross Movement to provide quality and sustainable community services to children in vulnerable communities. PAHO contributed to the Partnership with technical expertise and leadership. This combined effort resulted in quality interventions and sustainable activities. Local partnerships established between the public health sector and Red Cross volunteers encouraged the community to solve problems using local assessment and planning tools and involving multiple social actors. This approach generated unexpected grassroots actions and community movements eager to expand the community IMCI experience to new regions and a larger country population base.

Activities, indicators and results for the second ARC/UNF/PAHO objective and logical framework have been easily achieved (Table 2). There is clearly increased coordination between the government health system, community leaders and Red Cross chapters to improve quality of life and health care in participating countries. The number of community members and Red Cross volunteers trained in key family practices and other relevant community level-training activities has surpassed by far the original expected goal of 1,000 in ten countries.

Table 2. Second UNF/PAHO Objective, Activities, Indicators and Progress Achieved Empowering Local Communities to Improve Children's Health in Ten Latin American Countries, 2003-2007

Objective 2: To increase the ARC capacity to support the Red Cross Movement in providing quality, sustainable community services to children in vulnerable communities. Activities Indicators and Progress Achieved • Develop and implement strategies to promote and -Increased coordination between the government health sustain IMCI within the Red Cross Movement system, community leaders and Red Cross chapters to improve quality of life and health care in ten countries, Accomplished -Number of community members and Red Cross volunteers trained in the key family practices and in other relevant community level training activities, Over 14,000 trained -ARC and ONS participation in country Interagency Coordinating Committees (ICC) in ten countries, Accomplished

Objective 3: To develop innovative strategies for community participation, develop and implement new tools on country IMCI costing, long distance education, and provide evidence that community IMCI works.

…For me as a public ¾ Progress achieved towards the third Partnership objective authority it’s important to included: 1) a social-actor community model was developed and know how many women in my implemented to increase the number of skilled community community are pregnant, workers and to expand coverage and outreach promoting key family how many of them have practices, 2) a new tool for community IMCI costing was developed. completed their control, This instrument uses a software program to classify and summarize and…those who have not expenses by social actors by activity and timeframe, and produces graphics completed it to go urgently to and reports to better analyze information for decision making, 3) in the health services.. collaboration with CIDA Canada, a new long-distance clinical IMCI course was Mayor - Yarecoya, developed using an internet platform, and 4) Publications: a series of 17 Huancane, Peru Community IMCI Fact Sheets were published in Spanish and English, numerous technical documents and guidelines were created and published, country case studies were developed, a series of baseline and post surveys to measure behavior change at the community level and two community IMCI effectiveness studies were implemented to document Partnership results. Five publications are pending completion and submission to peer-reviewed international public health journals.

Table 3. Third UNF/PAHO Objective, Activities and Progress Achieved Empowering Local Communities to Improve Children's Health in Ten Latin American Countries Project, 2003-2007

Objective 3: To develop innovative strategies for community participation, develop and implement new tools on community IMCI costing, long distance education, and provide evidence that community IMCI works. Activities Indicators and Progress Achieved 3.1 To develop innovative strategies for community -The social-actor community model designed and participation implemented by the Partnership was shown to be low- cost, easily replicable, able to be scaled-up in other institutions, and sustainable using local resources. 3.2 Develop long distance education training and -In collaboration with CIDA Canada, a new long-distance advocacy packages for all community sectors clinical IMCI course was developed using an internet platform 3.3 Understand cost aspects required for the community -During 2004, a new tool for community IMCI costing was component developed. This instrument uses a software program to classify and summarize the expenses of social actors by activity and timeframe, and produces graphics and reports to better analyze information for decision making (Figure 6). 3.4 Evidence that community IMCI works -A series of 17 Community IMCI Fact Sheets and technical documents and guidelines were created, country case studies were developed; a series of baseline and follow-up surveys to measure behavior change at the community level and two community IMCI effectiveness studies were implemented to document evidence. Five publications are pending completion and submission to peer-reviewed international public health journals.

Figure 6 - Community IMCI Costing Tool, Regional Community IMCI Partnership

4.0 Highlights and Accomplishments

Major Innovative Accomplishments

¾ The social-actor community model was developed and implemented to increase the number of skilled community workers and to expand coverage and outreach promoting key family practices. This work strengthened links between communities and health services, promoted community participation and empowerment to address child health problems, and supported local inter-sector coalitions to sustain local actions. The key was to involve the Ministries of Health and national and local governments long-term, using experiences and lessons learned to change policies and enact legislation. For example, in Bolivia, largely due to the Partnership, community IMCI has become part of the national health policy to support the government’s Zero Malnutrition Initiative, and a national working group has been established which focuses on community IMCI with participation from the Ministry of Health, Red Cross, PAHO, UNICEF, USAID, and several NGOs in the country.

¾ The Partnership achieved a regional transformation of public health work at the community and the family levels by:

o Emphasizing coordinated work and an integrated approach with the health sector in the communities and sharing knowledge about health practices with other social actors not formally involved in public health has given rise to a new type of community mobilization o Strengthening social mobilization around changes in health behaviors using key family practices and community case management of disease

15 o Strengthening national child health programs, national IMCI policies, and health systems and services o Implementing our work with an emphasis on equity–the most vulnerable and high-risk areas were targeted for interventions with a special focus on indigenous populations o Forging partnerships and innovative networks to strengthen local capacity and provide technical cooperation for expansion and sustainability

¾ The Partnership generated local and national capacity building and promoted sustainability:

o The community and family were empowered and trained to make their own decisions and take actions on the health and prevention of common childhood illnesses with improved home care and health seeking behavior and the promotion of quality of care by providers o The Ministries of Health, National Red Cross Operating Societies, PAHO Country Offices, American Red Cross, Canadian Red Cross, International Federation of Red Cross, other agencies and international and nationals institutions, and NGOs, institutionalized the methodology of community IMCI into official country plans and policies o Health workers, Red Cross volunteers, local leaderships, schools, community clubs, Church, local and national governments, etc., were trained to improve the health of the child and pregnant woman o Community and family member awareness of health problems was increased - social actors in the community enhanced demand for preventive health services, such as vaccinations, prenatal care, growth monitoring, reproductive health and nutrition counseling o Community IMCI interventions were promoted through inter- sectoral committees and achieved a high level of synergy among sectors (many municipal governments bought into an integrated vision of health and took a leadership role in fostering inter-agency participation) o The incorporation of community IMCI activities in national and municipal strategic planning, annual operating plans, and budgets was achieved in most countries.

¾ Many accomplishments were achieved. Three stand out as particularly salient :

1. The design and implementation of an innovative social-actor community model 2. The transformation of community IMCI from a 3-day training course to part of Member Country national strategic plans of action in child and community health. 3. The improvement of case management knowledge and changing behaviors using key family practices among caretakers to fight underlying causes of diseases and mortality.

Over the course of the Partnership, countries made significant advances implementing activities at the community and national levels, especially at the household level, where key family practices and improved case management were promoted. One

16 major achievement of the Partnership was the expansion and incorporation of the social-actor community model into national health systems and other organizational projects. The design and implementation of community projects by social actors (including the health sector) was empowering because groups not traditionally involved in health became involved in the promotion of the key family practices at the family and community level. The identification of risk factors and associated causes of death lead to a selection of effective preventive interventions in the communities. This approach was very successful at generating a surprising number of participants eager to expand community IMCI to new areas and to a larger population base. Working in tandem with traditional community health workers, social actors identified and solved child health problems collectively. Health prevention activities spearheaded by municipal governments and schoolteachers in some of the project sites attest to the potential of this strategy. Family and community- oriented services, including adoption of improved care practices and appropriate care seeking for illness, were important aspects of community mobilization and empowerment.

Building National and Local Capacity

¾ Thirty-two community IMCI projects in ten countries were approved and completed using ARC and UNF funds (see Annex 1). Country final reports were developed. Over 350 community-based organizations and institutions, international agencies, and NGOs collaborated in the implementation of community projects and expansion plans. As of January, 2007, over 14,000 people were trained in various planning and management, prevention, evaluation, and case management training courses.

¾ New UNF-sponsored Community IMCI Initiatives and Results in Seven Countries in 2006-2007 are outlined in Annex 2. The variations and innovations developed and implemented demonstrate the continued dynamism and sustainability of the community IMCI effort.

¾ A University Extension Course in Community Health ..In my Educational Center and IMCI was established in 2006. The training forms part we take advantage of of the capacity-building efforts with local clinicians carried different moments, such as out by the Regional Community IMCI Partnership. The first the salute to the flag, to talk university extension course was held with 40 health personnel about the vaccine practices, from Tacna, Peru. Nurses from the Ministry of Health, the hygiene and danger signs Peruvian Social Security, and local universities participated in with parents and students … the course. The course objectives are: 1) increase the skill and Prof. Lucia Loza, (teacher) abilities of participants in community health and IMCI with a Hugo Banzer Suarez Educational Center, Bolivia special focus on engaging local actors in the promotion of key family practices, and 2) contribute to the institutional strengthening of community health programs in the Ministry of Health, the Peruvian Social Security, and the Regional Council of Nurses. The course methodology consists of a series of six modules. Each module requires three days to complete. The methodology is dynamic and interactive with workshops, small group discussions and presentations as well as lectures. Topics include:

• Conducting local diagnostics of the community health situation • Promoting key family and community health practices • Community planning and identifying and organizing with local actors • Interviewing/talking with mothers • Creating linkages with clinical IMCI components • Monitoring/evaluation and conducting research within the community IMCI framework

The certificate extension course forms part of an ongoing and collaborative process in the Region. Plans are being made to expand the curriculum to the Javeriana University in Bogota, Colombia, and schools in Ecuador, Nicaragua and Bolivia in 2007.

Expansion and Scaling-up

¾ One major achievement of the Partnership was the expansion and incorporation of the social-actor community model into national health systems and policies (see Annex 3)

¾ In April 2006, a Regional Workshop was held in Bolivia entitled “Results, Lessons Learned and Future Perspectives in the Regional Community IMCI Partnership within the Context of the Millennium Development Goals”. The workshop was attended by 72 participants from 10 countries representing 15 different institutions, including Ministries of Health, local governments, PAHO country offices, National Red Cross Operating Societies, American Red Cross, NGOs, universities, etc. The workshop objectives were to: 1) present results and interventions achieved in the Regional Community IMCI Partnership, 2) discuss lessons learned, and 3) plan next steps and future actions to sustain achievements, scale-up and strengthen the institutionalization of the community component of the IMCI strategy into national policies and programs.

Monitoring and Evaluation

¾ As of January, 2006, 23 Baseline Household Surveys and Seven Follow-Up Household Surveys (five with controls) were conducted. Community survey results showed a change in behavior at the community and health facility level. Health seeking behaviors of caretakers in selected communities showed an increase in demand of consultations for diarrhea and respiratory infections in children under five years old, increased immunizations rates, increased prenatal care and skilled birth attendance, and increased percentage of children receiving Vitamin A. Annex 4, outlines the survey site and dates. Survey results emphasized the importance of involving social networks, local leaders, and active community participation at all levels. Final country survey reports are available.

¾ Extensive monitoring and supervisory visits were held every six months using standardized forms reporting on progress indicators, achievements and obstacles. Results were used at the local and national levels for planning and documentation.

Tools and Materials

¾ Annex 5 outlines a listing of 35 Technical Materials and Documents developed by the Partnership. Many countries developed local adaptations of these materials and prepared new instructional brochures and guides to promote key family practices tailored to their own language and culture.

Lessons Learned and Publications

¾ Annex 6 outlines a listing of published Community IMCI Fact Sheets and Proposed Publications.

¾ Quantitative and Qualitative Community IMCI Effectiveness Studies in Honduras and Peru were carried out in 2006, to document the results of the social-actor community model. The research demonstrated the impact of community IMCI initiatives implemented in the regions of San Luis, Honduras and Chao, Peru. In Honduras, the San Luis area was the project site for a series of community interventions coordinated by the Honduran Red Cross, local municipalities, and the Ministry

18 of Health. Community IMCI activities were carried out in 27 communities in the San Luis region. Two community-based surveys were implemented as part of the project’s evaluation. The first was conducted in August 2004, as a baseline measurement and the second in December 2005, as a follow- up.

In Peru, the region of Chao in the Department of La Libertad, was the site of a community IMCI intervention involving Red Cross volunteers, 22 local health committees, and a wide and diverse network of social actors. Household-level surveys included a baseline in August 2004, and a follow-up in December of 2006. Preliminary results have demonstrated positive effects of the community IMCI interventions with local families. More interviewed mothers now report being able to successfully identify the danger signs of the most common ailments affecting children under 5 years of age in Chao: acute respiratory infections and dangers episodes of diarrhea.

Furthermore, appropriate health seeking behavior also was improved. A regression analysis of child respiratory illness and family response demonstrated that those families exposed to IMCI messages were 11% more likely to seek clinic care than those who had not been exposed to IMCI. These exploratory findings will be triangulated and enriched with qualitative data gained from interviews with key informants in 8 participating communities. PAHO is presently coordinating a thorough review of the results with the goal of publishing scientific articles on the Community IMCI experiences in Honduras and Peru.

5.0 Ownership, Sustainability, Scaling-up and Capacity Building

Member Countries, through their partnerships with PAHO and UNF, increased capacity to support and provide quality and sustainable community services to children in vulnerable communities. Participating countries could not have obtained the results in the logical framework without ARC and UNF financial support, Ministry of Health participation, and PAHO/WHO technical cooperation. Red Cross Operating National Societies increased their local capacity, leadership and programming skills participating in local and national coalitions composed of representatives from Ministries of Health, PAHO, UNICEF, World Bank, USAID, NGO, other sectors, etc.

The Partnership made special efforts to increase the knowledge and experience of MOH, ONS and ONG personnel in the following areas:

• Promotion of key family practices and social-actor community model at the household and community level • Visibility and importance of the IMCI strategy (advocacy) • Planning, project management, administration of funds and preparation of reports • Improved case management skills at the health facility and household level • Interagency collaboration with other national and international organizations • Participation in the development of new tools, field-tests and training • Supervision of activities and problem solving • Use of indicators to measure results and logical framework • Monitoring and evaluation • Scaling-up and expansion of project activities • National child heath programming and changing institutional policies

19 6.0 Telling the Community IMCI Story - Country Examples

• Our experience in the town of Chao, Peru, shows that community IMCI can have a real effect on parents’ knowledge about child health. A survey held in 2004, showed that 95% of mothers now know that babies should be breastfed exclusively for the first six months, compared with only 34% two years ago. Three-quarters know how to treat a child’s infection versus just over half before community IMCI was introduced. And 90% of mothers have kept their children up-to-date on their vaccines, compared with 58% in the past. In an unexpected development, cases of malaria dropped almost 99% between 2002 and 2004. Achieving results such as these requires the involvement of a wide range of actors to help raise awareness and encourage behavior change. In Chao, as elsewhere, this has meant involving everyone from the mayor and the police to the Red Cross, labor unions, mother´s clubs and schools. Training teachers to include maternal and child health themes in their classrooms has proved a particularly effective way of reaching parents through their kids.

• In Cotahuma, Bolivia, the community IMCI strategy demonstrated impressive gains in the key family practice indicators. This area is a poor, predominantly Aymara-speaking peri-urban region of La Paz. The community IMCI strategy served as a catalyst to bring together a dynamic array of local organizations with the goal of improving inter-sectorial cooperation in addressing community health needs. Partners included the Ministry of Health, the Ministry of Education through local schools, Red Cross Volunteers, Neighborhood Councils, the Local Popular Health Councils, Community Health Promoters, and the Deputy Mayor’s Office. All sectors collaborated in promoting essential behavioral changes at the family, community and health service levels. Extensive training was held in community IMCI with representatives from all partners and random community surveys documented the results. The baseline (April 2003) and follow-up (November 2005) surveys revealed that the percentage of fully vaccinated children increased from 31% to 47%, while the proportion of mothers who exclusively breastfeed a child less than six months old increased from 44% to 58%. In addition, the number of mothers who could identify at least two danger signs in a diarrhea episode increased from 9% to 22%, while the proportion that recognized danger signs in pregnancy went from 16% to 24%. A great deal of the success of this interventions was credited to community health workers in Cotahuma who brought healthy messages directly to mothers and who encouraged the health clinics to become more engaged in community work.

• Bolivia, El Salvador, and Peru - The Regional Community IMCI Partnership introduced easy-to-understand strategies and methodologies for working with groups and social networks. In each intervention site a participatory diagnosis was carried out and coordination strategies proposed between the various actors involved in improving child health. Each group pledged to devote time and resources to implement the strategy. For example, health services committed to increasing access to vaccines and reaching out to pregnant women; educators

20 pledged to teaching key family practices in schools and involving parents in promoting good hygiene and nutrition; local governments agreed to improve access to water and sanitation; Red Cross volunteers and grass roots organizations invested their time and other resources in community out reach to disseminate positive messages and promote collaboration. In an attempt to “quantify” such involvement, the Partnership implemented a method to measure the level of participation of each group in each country. Numerical values were assigned depending on the degree of intensity of each individual actor in the partnership. The following localities were classified as scoring high in terms of participation (ratings of more than 20 points): two sites in El Salvador, three sites in Bolivia, and one in Peru. The composition of social actors at each site varied. In El Salvador, for example, involvement of community health workers prevails; in Bolivia, members of the Red Cross and school teachers carried most of the weight; while in Peru, members of grass roots organizations and local governments had a greater presence. This suggests that the success of the Partnership depended on the geographical, political, and social context where it was implemented. It also emphasized the inherent adaptability and flexibility of the strategy.

• In November 2006, a community IMCI effectiveness study in Honduras consisted of a closer examination of a subset of 8 communities that demonstrated the marked clustering of both positive and negative health behaviors (regarding the promoted key family practices) as measured in the first round of surveys. In each of the eight selected communities, locally trained surveyors conducted 25 interviews with a questionnaire of approximately 150 items. In an attempt to triangulate and enrich the survey results, qualitative research was also carried out. Sixteen focus groups lasting approximately one-hour each were conducted. Focus group material was transcribed and analyzed using the qualitative software Atlas TI. Key informant interviews were also completed with a small group of experts identified in each community. The interviews were transcribed and analyzed. Preliminary results showed a statistically significant impact in many of the healthy behaviors and key family practices promoted by the Partnership. In a meta-analysis of all participating communities there were significant decreases in the number of randomly surveyed households practicing unhealthy behaviors. Local actors and community groups provided community level interventions that promoted disease prevention through good hygiene and the survey results demonstrate program effects. Figure 7, for example, illustrates the impact made on household level hygiene with 17% less families storing trash in the home. It was also revealed that 33% fewer households kept animals in the residence and 15% less families had unsafe toilet and latrine facilities.

Figure 7

Increase in Healthy Household Behaviors - San Luis, Honduras (N=300) Baseline No Trash in 62% 8/2004 House 79% Endline 12/2005

No Animals 44% in House 77%

45% Safe Toliet 60%

0% 20% 40% 60% 80% 100% Percentage of Households in San Luis Practicing Healthy Behaviors

The promotion of safe motherhood and messages encouraging exclusive breast feeding were also important components of community level interventions in San Luis. The quantitative evaluation

21 demonstrates the impact of these efforts. Figure 8 illustrates the increase in the adoption of key family practices that are essential to healthy communities and children. As shown in the graph the percentage of families with skilled attendance at last birth increased by 15%. In addition, 15% more women in the villages of San Luis took iron during their last pregnancy, and 6% more mothers exclusively breastfeed their babies for at least six months. All results were deemed statistically significant by external evaluators.

Figure 8

Increase in Healthy Practices in San Luis, Honduras (n=300)

Last Birth at 47% Skilled 62% Attendant

Given Iron at 56% Baseline 8/2004 Prenatal 71% Endline 12/2005

Exclusively 11% Breastfeed 19% to 6 Months

0% 20% 40% 60% 80% 100% Percentage of Households in San Luis Practicing Healthy Behaviors

Peru - The Regional Community IMCI Partnership strengthened local organizations, actors, and social networks by involving the community from the beginning to promote capacity building and sustaining actions in their areas. It also encouraged the achievement of private goals and legitimacy by encouraging ownership of the training methodologies. Social actors invested their own time and resources in efforts to reach their own goals and those of the Partnership. The empowerment of actors directly involved in health mobilization revealed an important source of unconventional economic and financial resources that are found in the community and in entities other than health facilities. These are determinants to meet the objective of reducing infant and maternal mortality. This element has not been estimated from an economic standpoint, but it should be considered as an additional achievement of the Regional Community IMCI Partnership intervention. A calculation of the mobilization of unconventional resources (non-cash or non-financial in nature) within the community is an economic estimate of the resources contributed by the community and the social networks. A methodology for the estimate of unconventional resources mobilized was designed and implemented in Chao, Peru. The estimate obtained demonstrated a significant capacity to mobilize these resources—both financial and in kind. In terms of the analyzed activities in Chao, for every financial unit directly contributed by the Project, an additional 8.8 units of resources were mobilized by community partners.

• In Medellin, Colombia, a unique weekly radio broadcast entitled “For the Health of the Children” was created to spread the message of key family practices and to promote the community IMCI strategy throughout the Department. This innovative mass media campaign was created in collaboration with the

22 Universidad Pontifica Bolivariana and featured a diverse array of presentations by maternal and child health and community health experts. The station, Radio Bolivariana, broadcasts the program twice weekly on Saturday afternoons and Sunday mornings. Over 100 transmissions were produced throughout the year, the majority live broadcasts with local experts as guests. Telephone calls from listeners are a large part of the program, with advice and consultations presented over the air. Topics covered a wide range of important child health issues and included the recognition of childhood illness danger signs, the importance of vaccines, the use and abuse of common medicines, child abuse, accident prevention, mother and child nutrition, child growth and development, and parenting skills. Each 30-minute program had a potential audience of over 5 million people in 16 municipalities in the Department of Antioquia.

7.0. Budget and Administrative Issues

PAHO Finance and Budget Office will send UNF/UNFIP a final copy of the standard financial forms reflecting expenditures incurred during the life of the project. During the reporting period, six PAHO staff stationed in Washington, D.C., one regional consultant, and ten country staff provided services in support of the Partnership implementation, as described below:

Washington (in-kind services): 1. Christopher Drasbek Regional IMCI Advisor 25% time 2. Florencia Behrensen Administrator 15% time 3. Mariana Bellino Secretary 10% time 4. Jose-Anibal Rivera Document Distribution 5 % time 5. Marcela Gieminiani Publication and Design 10% time 6. Thomas Harkins Technical Assistant 20% time

Regional (ARC/UNF supported): 7. Luis Gutierrez Regional Technical Support 100% time

Country (in-kind services): 8. Reynaldo Aguilar Nicaragua 15% time 9. Ramon Granados El Salvador 10% time 10. Cecilia Michel Dominican Republic 10% time 11. Luis Amendola Honduras 15% time 12. Martha Mejia Bolivia 15% time 13. Luis Seoane Guyana 10% time 14. Bernardo Sanchez Paraguay 10% time 15. Miguel Davila Peru 15% time 16. Martha Saboya Colombia 10% time 17. Soledad Perez Venezuela 10% time

8.0 Future Perspectives

It has been over 11 years since IMCI was introduced into the Region of the Americas. Much has been learned through the adaptation and implementation process in the countries. Over the last six years a regional transformation has occurred based on principles of primary health care that has increased the coverage of community-level interventions using a combination of outreach services and family and social actor participation. The challenge now is to scale-up these efforts to expand the coverage of household and community interventions that will reduce child mortality, promote the healthy growth and development of young children and support community-level case management of childhood illness contributing to the Millennium Development Goals (MDGs).

Important work is still required to link community actions with health services and health systems to scale-up efforts based on primary health care such as: 1) improving mechanisms for delivery of cost-effective interventions to the underserved populations, 2) expanding primary health care efforts which incorporates evidence- based interactions for maternal, neonatal and child health, and 3) ensuring that these interventions are universally accessible requiring a strong government steering role (advocacy, leadership and policy formulation) and government funded social protection in health. Additionally, while there is extensive research on the effectiveness of health-care interventions, there is less evidence on the process of their implementation, cultural appropriateness, cost-effectiveness and effects on health inequalities, all of which are important considerations for policy-making. There is still a need to evaluate how interventions are implemented and which factors help or hinder their success to scale-up interventions.

The Child Survival series in The Lancet challenged the world to reach full coverage with interventions that will increase a child’s chance for survival and healthy development. The series argued that we need to intervene, not only through the health system but also at the household level promoting interventions which can be effectively delivered; these include breastfeeding, oral rehydration therapy, education on complementary feeding, and others. These interventions could jointly prevent more than one-third of all deaths. To achieve this challenge and help countries achieve the MDGs, a dramatic increase in political will, human and financial resources, and effective partnerships are required. Member Countries, PAHO, ARC, IFRC, NGOs, civil society, private sector, multi-lateral and bi-lateral organizations, and other partners must make commitments and collectively play a leading role to meet this challenge and set new directions advocating for child and maternal survival.

24 Acknowledgements

The Pan American Health Organization/World Health Organization wishes to thank everyone at the regional, country and community levels who made this Partnership possible (American Red Cross Headquarters and United Nations Foundation; participating Red Cross Operating National Societies, Red Cross volunteers, American Red Cross Health Delegates, Ministries of Health, PAHO National IMCI Consultants, NGOs, communities, families, social networks, and other national and international organizations); including Dr. Gina Tambini, Area Manager, Family and Community Health, Pan American Health Organization; Dr. Yehuda Benguigui, Unit Chief, Child and Adolescent Health, Pan American Health Organization; and Mr. James Hill, PAHO External Relations Officer, Governance, Policy and Partnerships, Pan American Health Organization. Special recognition is extended to Mrs. Andrea Gay, Senior Program Officer, United Nations Foundation and Mr. Derrick Deanne, Coordinator, Governing Bodies and External Relations, WHO/GER, who provided important technical and managerial leadership.

25 Annex 1. Approved Country Community Projects using ARC and UNF Funds

Regional Community IMCI Partnership 2001-2006

Country and Project Name Community Site Bolivia Proyecto de salud comunitaria de las Enfermedades Distrito de Salud # 5 Cotahuma Ciudad de la Paz Prevalentes de la Infancia Proyecto de Salud AIEPI Comunitario: "Juntos podemos San Cristobal - Pailaviri POTOSI salvar a los niños y mujeres" Proyecto de Salud AIEPI Comunitario Pucarita – Cochabamba Proyecto de Salud AIEPI Comunitario Quillacollo Proyecto Regional AIEPI Comunitario CRA/OPS/UNF Ciudad de El Alto en Municipio de El Alto "Luchando juntos por la salud infantil y materna de El Alto" Colombia Promoción de las prácticas clave en Comuna Cuatro y Pasto Corregimiento Cabrera de Pasto Dominican Republic Proyecto Regional de AIEPI Comunitario Sabana Grande de Boya Proyecto Regional de AIEPI Comunitario La Caleta Proyecto Regional de AIEPI Comunitario Madre Vieja Norte Ecuador Proyecto AIEPI Comunitario "Promoción de prácticas claves" Columbe, Colta Chimborazo Proyecto AIEPI Comunitario "Promoción de prácticas claves" Pujili, Cotopaxi Proyecto AIEPI Comunitario "Promoción de prácticas claves" Tena, Napo Proyecto AIEPI Comunitario "Promoción de prácticas claves" Bolivar El Salvador Proyecto Regional de AIEPI Comunitario Municipio de Santiago Texacuangos Proyecto Regional de AIEPI Comunitario Municipio de Nejapa Proyecto Regional de AIEPI Comunitario Municipio de Panchimalco

Información, educación y asistencia preventiva en Municipio de Tejutla, San Marcos Comunidades del Municipio de Tejutla, San Marcos Manejo y atención integrada a niño sano y enfermo Municipio de San Antonio San Marcos comunitario Honduras Proyecto de Movilización Comunitaria para la Salud Infantil Yamaranguila, Departamento de Intibuca Municipio de Yamaranguila Proyecto de Movilización Comunitaria para la Salud Infantil Copan Ruinas Municipio Copan Ruinas Proyecto de Movilización Comunitaria para la Salud Infantil San Luis, Santa Barbara Municipio San Luis Nicaragua Atención Integrada de Enfermedades Prevalentes de la Managua Infancia, AIEPI - Componente AIEPI Comunitario Atención Integrada de Enfermedades Prevalentes de la Waspam Infancia, AIEPI - Componente AIEPI Comunitario AIEPI Comunitario San Carlos, Rio San Juan

26 Peru Proyecto AIEPI Comunitario "Promoción de prácticas claves" Chao – Trujillo Proyecto AIEPI Comunitario "Promoción de prácticas claves" Alto Nanay - Santa Clara – Iquitos Proyecto AIEPI Comunitario "Promoción de prácticas claves, Huancané 2002" Amigos de los niños para verlos crecer sanos y felices Provincia de Juamanga - Ayacucho

Proyecto AIEPI Comunitario "Promoción de prácticas claves, Huancané 2004" Venezuela Promoción de la salud en niños y niñas a nivel comunitario en Municipio Andrés Eloy Blanco, Estado Lara el desarrollo de prácticas saludables para el crecimiento y desarrollo a través de AIEPI y la atención integral a la mujer en el Municipio de Andrés Eloy Blanco. Prevención de Enfermedades Prevalentes de la Infancia en Municipio Crespo, Estado Lara niños menores de cinco años en el Municipio de Crespo Promoción comunitaria de la salud y atención oportuna de Barrio Primero de Diciembre, Municipio Barinas, niños y niñas y madres a partir de la atención integral en el Estado Barinas Municipio de Barinas

27 Annex 2. New Community IMCI Initiatives and Results at the Country Level using UNF Funds, January 2006-January 2007

Empowering Local Communities to Improve Children's Health in Ten Latin American Countries

BOLIVIA • Locations: Departments of Potosí, Chuquisaca, Pando, Oruro, La Paz, Santa Cruz and Cochabamba - 161 Municipalities throughout the country were prioritized.

• Partners: Bolivian Ministry of Health, in conjunction with the Vice Ministry of the Department of Traditional and Intercultural Medicine, Bolivian Red Cross, Bolivian Ministry of Education, Federation of Associated Municipalities, the Universities of La Paz, Cochabamba, Sucre, and Santa Cruz, UNICEF, FAO, CARE, Plan International, Caritas, and numerous local NGOs and community-based groups.

• Activities and Results: The community component of the IMCI strategy forms an integral part of the national “Zero Malnutrition” initiative in the Ministry of Health. In 2006, a multisectorial effort, supported in part by the Partnership, resulted in holding 122 community IMCI training workshops. Over 4,600 health and education personnel, community leaders, members of mothers groups and peasant unions, and local-level health promoters, were trained in community IMCI. Extensive follow-up after training visits were carried out. Ninety-seven (60%) of the 161 targeted municipalities were incorporated into the strategy. Local education materials were produced on the key family practices including recognition of the danger signs of child illness, infant and child nutrition and feeding practices, immunizations, and promoting prenatal care. A monitoring system in six priority departments was established. Clinical IMCI training in medical and nursing schools was strengthened. A strategic plan to link these efforts in an integrated community/health services strategy implemented by local leaders and clinical staff was developed.

• Notable Innovations: The integration of the community IMCI effort in Bolivia with the national “Zero Malnutrition” initiative was a singular achievement and resulted in broad support for the strategy across diverse governmental and civil society sectors. The strategy in Bolivia was linked with supplemental feeding for the poorest children in the country, many of whom are indigenous and live in marginal urban slums or remote rural areas. The community IMCI component effectively promoted the engagement of health personnel with community leaders and members, and provided the context to address maternal and child health problems to organize municipalities around child health issues in a dynamic and synergistic manner.

COLOMBIA • Locations: Santa Fe de Bogotá (Department of Cundinamarca), Pasto (Department of Nariño) and Medellin (Department of Antioquia)

• Partners: Colombian Ministry of Health, Colombian Institute of Family Welfare (ICBF), Local Government of Pasto, Secretaria de Salud de Bogota, The Health Division of Colombian Family Security Institution (Colsubsidio), Colombian Red Cross, Universidad Javeriana and Convenio Andres Bello, Universidad Pontifica Bolivariana, and the Unversidad de Antioquia.

• Activities and Results: Country actions strengthened the capacity to expand the community IMCI component by training regional and national level facilitators. Thirty regional level facilitators were trained in the community IMCI strategy. These facilitators served as regional focal points for national

28 activities. In addition, forty national level facilitators were trained in IMCI case management with a focus on preventing neonatal deaths. In the Department of Medellin, these actions were accomplished in 90 of the 125 municipalities. A total of 235 health personnel were trained to be promoters of key family practices in their neighborhoods. Educational materials were developed for mother’s groups. A methodological guide for implementing the strategy with an emphasis on promoting community participation was developed. Results at participating health facilities showed vaccination coverage rates increased. In the Department of Nariño, Municipality of Pasto, activities were focused in three communities (Ipiales, Samaniego, and Yacuanquer). Household baseline and follow-up surveys were carried out to document results. The regional government recently passed official resolutions supporting the community IMCI component and designated local funds for its continued implementation.

• Notable Innovations: A weekly radio program promoting the key family practices and community IMCI was an innovative component of the activities in Antioquia. The program was developed and implemented by staff at the Universidad Pontifica Bolivariana and featured 30-minute broadcasts with local maternal and child health experts. Listeners were able to call in with questions and receive advice and consultation directly from community health experts on topics ranging from childhood illness danger signs to accident prevention and child abuse. At the national level, the Partnership facilitated advocacy efforts for the appropriation of funds to continue the clinical and community components of the IMCI strategy. Also, the involvement of the private health sector with the participation of the ICBF supported the rapid and widespread adoption of IMCI at both the clinical and community levels.

GUYANA • Locations: Pomeroon-Supenaam (Region 2) and Upper Takutu-Upper Essequibo (Region 9)

• Partners: Guyana Ministry of Health and the American Red Cross

• Activities and Results: Guyana is one of the few Caribbean countries using the IMCI strategy as it addresses issues of limited human resources and difficulties accessing populations in remote areas. With the success of the clinical IMCI component introduced in 2001, the Ministry of Health, with technical and financial support from the Partnership, moved towards expansion of the initiative through the introduction of the community IMCI component in Regions 2 and 9. In Suddie (Region 2), a three and a half day community IMCI workshop was held with 34 regional health managers, doctors, nurses, auxiliary nurses, community health workers and members of community groups (school teachers and youth groups). The main topics covered included a review of community IMCI framework, actions to coordinate local actor participation in promoting the key family practices, and other health promotion and prevention issues including the recognition of danger signs. A 2007 plan of action was developed to expand this work in the Regions.

• Notable Innovations: As most technical resources for community IMCI are available in Spanish, materials had to be first reviewed for appropriateness to the Guyanese context and then translated into English. Special emphasis was placed on HIV/AIDS prevention due to the higher prevalence of the infection in the country (a generalized HIV epidemic exists in Guyana).

HONDURAS • Locations: San Luis, Department of Santa Barbara

• Partners: Honduran Ministry of Health, American Red Cross, Honduran Red Cross, Canadian Red Cross, and the Municipality of San Luís

29 • Activities and Results: Local community leaders were trained in key family practices, community health promoters trained in the community component of the IMCI strategy, and clinicians in four health centers trained in clinical IMCI including management of health services, management of newborn complications and emergency obstetric procedures, and attention to underweight children.

• Notable Innovations: A community IMCI effectiveness study was conducted in 8 communities in the San Luís region. The investigation included both quantitative and qualitative components (see Section 6.0 Telling the IMCI Story – Country Examples).

NICARAGUA • Locations: Municipalities of Dolores (Carazo), Tipitapa (Managua), San Isidro and Sébaco (Matagalpa), San Rafael and El Cuá (Jinotega), Villanueva and Cinco Pinos (Chinandega)

• Partners: Nicaraguan Ministry of Health (MINSA), Ministry of Education, Sports and Culture, Nicaraguan Communal Movement (MCN), Caritas Nicaragua, Nicaraguan Red Cross, and the Nicaraguan Network of Mayors.

• Activities and Results: In each of the municipalities above, 10 communities were selected to receive community IMCI training. In these communities, 10 health promoters were then selected for facilitator training and then assigned a group of 10 brigadistas to train. In total, over 80 health promoters trained 800 brigadistas. A grand total of 14,000 people were then trained in community IMCI, or attended educational events staff by the facilitators. In each municipality, three community IMCI public events promoting key family practices were held and brigadistas organizied home visit campaigns to provide education messages directly with the households. Neighborhood education sessions on child health were held and youth groups formed to discuss the relationships between community health and hygiene. The promotion of community IMCI neonatal activities further distinguished the efforts of this work. A workshop was held with 25 MINSA and MCN personnel in Managua to train staff in the neonatal component of the strategy. The high proportion of neonatal mortality in infant deaths in Nicaragua and throughout the region makes this a valuable advancement. A workshop was also held in Villanueva, Chinandega (Department of Leon) with MINSA and PAHO training 35 midwives and nurses from 17 surrounding communities. The two-day workshop emphasized the recognition and identification of danger signs in pregnancy and childbirth and neonatal resuscitation techniques. A national alliance - the Nicaraguan Community Health IMCI Network - was created to promote the strategy. In addition, in several communities (El Cuá and San Rafael) the strategy formed a local alliance with Ministry of Health’s Reproductive and Sexual Health Program. These advocacy efforts in support of community IMCI catalyzed the development of new national health policies promoting community health.

• Notable Innovations: These activities were part of the strategic goal to consolidate community mobilization around maternal and child health efforts. In many cases, the promoters and brigadistas made periodic visits to local health centers to coordinate their activities with health personnel, provide education and counseling to patients, and to promote clinic outreach work in their communities. The larger goal is to facilitate greater integration and to strengthen community/health services relations.

PARAGUAY • Locations: Communities of Curuguaty, Caaguazú, Santani, Hernandarias, Minga Guazú, and Villa Ygatimí

• Partners: Paraguayan Ministry of Public Health and Social Welfare, Community Based Organizations, Canadian Agency of International Development (CIDA), and Plan International.

30 • Activities and Results: 180 community leaders and health promoters were trained in key family practices and the community IMCI strategy. Local committees were established in each site to coordinate activities and to encourage sustainability between municipalities, schools and local NGOs. Information, education, and communication materials were designed according to the local situation and for specific community needs. A National Steering Committee was formed to guide community IMCI efforts in the country. This group also oversees and encourages the coordination of community and clinical IMCI activities, and plans and advocates for more support at the local, regional, and national levels.

PERU • Locations: Lima, Cajamarca, La Libertad, Arequipa, Tacna, Cutervo, Jaén, Chota and Sullana

• Partners: Peruvian Ministry of Public Health, Canadian Agency of International Development (CIDA), Peruvian Red Cross, Caritas Peru, Pathfinder International, Community Based Organizations (Prisma, Wawa Wasi-MINDES) neighborhood clubs, mothers groups, unions, and school councils.

• Activities and Results: Activities in Peru were implemented under the “Prevention and Control of Priority Communicable Diseases Strategy” as part of the Peruvian National Program on Child Health. Community IMCI workshops were conducted with local governmental officials, community leaders, and teachers in several towns and regions. Sessions covered key family practices, how to organize community health issues, and how to evaluate community progress. Teachers were encouraged to include the key family practices into their curriculum. Local leadership in the towns of Cutervo, Chota, and Jaén were encouraged to assign the strategy top priority. Activities began with a site survey and needs assessment which were then analyzed and followed-up by training sessions for clinicians, teachers, health promoters, and local government officials. Home visits were carried out to promote the key family practices, look for danger signs and to develop community-health services linkages. The Partnership collaborated with the Peruvian Pediatric Society to publish a Key Family Practice Guide for journalists and other members of the media.

• Notable Innovations: A University Extension Course in Community IMCI forms part of the capacity building efforts for local clinicians. The first extension course trained 40 health personnel from Tacna, Peru. Nurses from the Ministry of Health, the Peruvian Social Security, and local universities participated in the course. Future courses are being planned. The certification is recognized throughout the country. A community IMCI effectiveness study was conducted in four communities in the Chao region.

31 Annex 3. Selected Country Examples of Expansion and Institutionalizing the Community Component of the IMCI Strategy at the National Level. As of January 2007

Regional Community IMCI Partnership

Bolivia: A National IMCI Coalition (Mesa de Trabajo AIEPI) is established. The coalition, headed by the Ministry of Health and the Bolivian Red Cross, includes UNICEF, PROSIN (Ministry of Health and USAID), PROCOSI (a coalition of 27 NGOs), Plan International, and COTALMA (a local health care network). The local PAHO Office incorporated the model into other national health programs. The mayor of the El Alto city, serving almost one million population requested funds from the Belgian Cooperation to implement community IMCI activities using the Partnership methodology. The new government is using the Partnership social-actor community methodology to increase national coverage in support of the Zero Malnutrition Initiative. Colombia: The Health Division of Colombian Family Security Institution (Colsubsidio), Ministry of Health and Social Protection, PAHO/Colombia, Colombian Institute of Family Well-being (ICBF), University of Javeriana and Convenio Andres Bello and Pontifica Bolivariana, established a country partnership to promote the IMCI strategy and strengthen the community IMCI component in the country. Dominican Republic: A National IMCI Coalition is established with the Ministry of Health, Dominican Republic Red Cross, PLAN International, and the National Center for Childhood (Consejo Nacional por la Niñez, CONANI). El Salvador: A National IMCI Coalition is established with the Ministry of Health, El Salvadorian Red Cross, ISSI, CARITAS-CMMB/BMSF, PHR Plus and USAID. The Salvadorian Red Cross is expanding the Community IMCI methodology to local chapters and strengthening a national technical working group with Red Cross allies (Canadian Red Cross and Italian Red Cross) to include the IMCI strategy in the projects currently being financed by these partners. Guyana: In coordination with PAHO, UNICEF, Ministry of Health and local ONS, the country is expanding community IMCI efforts to a national scale using a national strategy platform. PAHO/Guyana is exploring with PAHO/Suriname the possibility of establishing a Technical Cooperation Committee (TCC) to share country experiences and maximize resources in the IMCI strategy. Honduras: The Hondurans Red Cross (HRC) has introduced the IMCI methodology into national health programs. World Bank funds are expanding activities to other communities. Local municipalities and mayors are organizing themselves under the Regional Environmental Council (Consejo Regional Ambiental) and forming a National Association of Municipalities (Mancomunidad de Municipios) to expand the Community IMCI methodology in the government sector. The Canadian Red Cross is planning a new 5-year project to strengthen community IMCI and incorporating the social actor community model. Nicaragua: A National IMCI Coalition is established with the Ministry of Health, Nicaraguan Red Cross, and the Movimiento Comunal Nicaraguense. The Canadian Red Cross is planning a new 5-year project to strengthen community IMCI and incorporating the social actor community model. Nicaragua’s Ministry of Health decided to incorporate several aspects of the community IMCI methodology in its current AIN-C methodology as part of its national health program in selected SILAIS. Paraguay: With recent personnel changes in the Ministry of Health, IMCI is being prioritized in the country, especially the family and community component which was on-hold for many years due to the last administration’s policies. Expansion activities are underway in three Departments and in the indigenous population group with the National Health Commission. Peru: A National IMCI Coalition is established with the Peruvian Red Cross, the Ministry of Health (DGPROMSA, DGSP), Ministry of Education, NGOs (Catalyst, CARE, and Prisma), Wawa Wasi-MINDES, and Caritas, to scale-up community IMCI activities. The CIDA-Canada financed project with PAHO called Prevention and Control of Priority Communicable Diseases will incorporate the community IMCI social actor model into country project sites and within national child health programming. Venezuela: The National IMCI Coalition between the Ministry of Health and Venezuelan Red Cross is strengthening the expansion of the Community IMCI methodology through the Barrio Adentro (13,000 health workers) and Casas Comunitarias (10,000 community centers) national initiatives. The national strategy called Mothers’ Program of Health will soon be officially launch incorporating the community component of the IMCI strategy in all national programs directed at the family and community levels.

32 Annex 4. Key Family Practice Household Baseline and Post Surveys. As of January 2007

Regional Community IMCI Partnership

Country Site Date Bolivia Cotahuma April 2003; post Nov 2005 Colombia Urban Pasto April 2004 Rural Pasto April 2004 Dominican Republic Sabana Grande de Boya November 2003 La Caleta November 2003 Madre Vieja Norte November 2003 Ecuador Pujilí June 2002 Chimborazo June 2002 Tena-Napo June 2002 El Salvador Texacuangos June 2003; post Oct-Nov 2005 Nejapa June 2003; post Oct-Nov 2005 Panchimalco June 2003; post Oct-Nov 2005 Guatemala OPS/ARC October 2003 IFRC October 2003 Honduras Yamaranguilla January 2002 San Luis August 2004; post Nov-Dec 2005 Copan Ruinas August 2004 Peru Ayacucho April 2004; post Nov 2005 Chao September 2002 Nicaragua Managua January 2002; post Jan 2006 San Carlos January 2002 Waspam January 2002 Venezuela Crespo October 2003

33 Annex 5. Technical Documents and Materials Developed. As of March 2007

Regional Community IMCI Partnership

One important element of the Partnership was the development of technical materials for the community component of the IMCI strategy. The table below outlines a list of documents created. Many countries produced local adaptations and prepared new instructional brochures and guides to promote key family practices tailored to their own language and customs.

Document Purpose Content Language Advocacy 1. Video Advocacy and promotional Salvar a los Niños – El poder de la Spanish message about community familia y la comunidad English IMCI, fund raising 2. DVD Documenting evidence in AIEPI Uniendo Spanish Chao, Peru using the social- Redes…construyendo Salud actor community methodology 3. Partnership Promotional Advocacy Project description and promotion Spanish Brochure 4. Partnership Promotional Advocacy Project promotion and brand Spanish Poster 5. IMCI Strategy Advocacy Forum to meet with senior Agenda, working group sessions, Spanish Workshop decision makers to advocate planning for IMCI strategy Training 6. Community Local Actors A series of guides providing a Child health strategy and IMCI, key Spanish Guides: description of the community family practices, role of local actor English - Guide for Red Cross - component of the IMCI participation Volunteers strategy and actions which - Guide for Health Providers can be taken by individual - Guide for Local actors to use their influence Coordinators – Red Cross and role in the community to and Community Health affect change Workers - Guide for Leaders of Grassroots Organizations - Guide for Teachers and Schools - Guide for Training Facilitators of Community Health Workers - Guide for Mayors and Local Government - Junior Chamber International Chapters (JCI) - Indigenous Population Guide 7. Community Local Actors CD- Electronic versions (PDF and - Red Cross -Volunteers Spanish ROMs word files) of the Community - Health Providers Local Actors guides. The - Local Coordinators – Red Cross purpose is to help facilitate and Community Health Workers countries to adapt materials to - Leaders of Grassroots local language and customs, Organizations

34 and introduction of their local - Teachers and Schools logos and reprint - Training Facilitators of Community Health Workers - Mayors and Local Government - Conducting Baseline Surveys for Key Family Practices

8. Community Health Worker Training tool to teach Seven teaching modules Spanish Training Course (CHW) – generic community health workers Portuguese version 2003 and promoters IMCI (adapted English in each country) 9. Community Health Worker Training tool to teach Three teaching modules Spanish Training Course (CHW) – revised community health workers generic version 2007 and promoters IMCI techniques, including more emphasis in promotion and prevention, growth and development, key family practices, and nutrition areas 10. Local IMCI Community Planning tool to assist CHW Two modules Spanish Organizational Guide and local actors to develop local plans of action 11. University Extension Increase skills of participants Six modules, working group Spanish Community IMCI Long-Distance in community health with sessions, small group discussions, Course - Draft focus on engaging local presentations actors in key family practices and contribute to institutional strengthening 12. Clinical IMCI Long-Distance Using an internet platform to Training modules, monitoring with Spanish Course - Draft expand training opportunities tutors, worksheets to health and university personnel Implementation 13. Guidelines for Preparing Aimed at local health Objectives, methodology, operating Spanish Community IMCI Projects coordinators and Red Cross sequence, financial and normative and MOH officials. issues 14. Local Coordinators Guide -To outline project Information on planning, Spanish management and roles with organizations, responsibilities, Red Cross and MOH local processes for successful project coordinators management, participation of local -Guidelines and agenda to actors hold management and planning workshop completed. 15. Guidelines for Conducting Provide methodological tools Discussion how to conduct Spanish Community Participatory to local coordinators from Red assessments and project profile Diagnostic Assessment Cross and Ministry of Health development 16. Key Family Practices Card To outline WHO/UNICEF key A description of the key family Spanish family practices for prevention practices by component English at the community level Portuguese 17. Workshop Guidelines for Strengthen local planning in a What is participatory planning, Spanish Participatory Local Planning participatory fashion working group guidelines, how to (guidelines and agenda identify common problems and completed) establish solutions

35 18. Guidelines for Social Provide an overall framework Background of social communication Spanish Communication Strategy for to strengthen social and methodologies, country Partnership Development and communication activities examples, worksheets Behavior Change 19. Social Communication - To provide health education Simple examples to implement Spanish Community and Household Key messages promoting behavior behavior change based on family Family Practices Guidelines change at the household level practices for prevention of disease. Simple methodology aimed at community members (e.g. Red Cross, mothers clubs, churches, local youth groups, teachers, community leaders, etc.) that help to identify local networks, referral mechanisms as well as key and supporting health education messages for the family practices. 20. Suggested Interventions to To provide community leaders List of key family practices and Spanish Improve Key Family Practices at a suggested list of ideas to suggested practical interventions for the Community Level implement community implementation at the community practices level 21. Clinical Neonatal Training Training tool to teach Training modules and facilitator guide Spanish Course physicians and nurses in English clinical neonatal work Monitoring and Evaluation – Evidence and Reporting 22. Guidelines for Conducting Provide a standardized Introduction, sample size, training Spanish Baseline Surveys for Key Family guideline to conduct baseline agenda, questionnaires, analysis, Practices surveys to measure behavior etc. change of key family practices 23. Translation to Spanish of To provide evidence of cost Research evidence and country Spanish “Family and community practices effective interventions to examples that promote child survival, change behaviors for 12 key growth and development. A family practices. To serve as review of the evidence”. WHO reference during participatory 2004 planning workshops, helping to identify how to best invest resources in priorities chosen by the community 24. Costing Tool Software program developed Complete methodology, analysis to classify and summarize the package, graphics and report making expenses of local actors by to use for decision making activity and timeframe 25. Final Sub Regional and To disseminate country Complete Reports. Spanish Regional Workshop Reports experiences & lessons ¾ San Pedro de Sula, learned among participating Honduras countries. ¾ Lima, Peru Includes country ¾ Santa Cruz, Bolivia presentations, technical presentations, working groups analysis and results 26. Final Local Projects Reports To share lessons learned and Epidemiological data, country and Spanish & Successful stories successful experiences in community examples English

36 implementing community IMCI activities with multiple social actors, including Red Cross and Ministry of Health. Includes project’s description, objectives, results & lessons earned. 27. Guidelines for Monitoring Second up-dated version of Complete guidelines including Spanish and Evaluation original guidelines to monitor indicators project activities in intervention sites Indicators, process, tables, etc. 28. Regional Community IMCI To share best practices and A series of 17 Fact Sheets with Spanish Partnership Fact Sheets of lessons learned country examples and study results English Lesson Leaned and Best Practices 29. Community IMCI A database of articles List of articles, authors and short Spanish Bibliography published over the past seven abstracts English years regarding community primary health care 30. Study on Family and To document information Methodology, data tables, Spanish Community Practices in the Care collected in the community conclusions and recommendations of Children less than Five Years participatory analysis to of Age – Bolivia 2003 prioritize community actions 31. Community Project Provide a framework to report Project summary with its objectives Spanish Evaluation Report on final project and strategies. Analysis of results and lessons learned

Annex 6. Community IMCI Fact Sheets, Technical Documents and Proposed Publications, Best Practices and Lessons Learned As of March 2007

Regional Community IMCI Partnership

Fact Sheets: • In Chao Viru, Peru, we improved the health of our children using a community IMCI framework • How have community and family interventions using key family practices changed behavior in the rural and peri- urban areas of Latin America? A epidemiological review of pre-and post household surveys indicators • In some sites they’re called partnerships, associations, or networks - In San Luis, Honduras we call it community IMCI • System of monitoring and evaluation community IMCI to effectively measure outputs at the health services and community levels • Community IMCI made dramatic changes in the culture of institutions, organizations, and families resulting in better health and reduced illnesses • Community IMCI institutionalized new technical and managerial approaches, government policies, and social networks based on the delivery of key family practices to prevent illness • Future perspectives and scaling-up the community component of the IMCI strategy to sustain actions • Community intervention using case management practices in the home and family to contribute to the reduction of neonatal and child mortality to reach the MDGs • Conceptual framework of the community IMCI participatory methodology • Participation of other sectors outside the health component and the institutionalization of the IMCI strategy at the national level • Community IMCI: A review of country successes • Working with social networks to meet the MDGs • Why the Red Cross National Societies prioritized community IMCI in the Strategy 2010 • Why do social actors participate in community IMCI in Latin America? • Communication in favor of social change: A conceptual model for healthy family practices

Technical documents and guidelines: • Systematization of community IMCI experiences in Chao Viru, Peru • Systematization of community IMCI experience in San Luis, Honduras. • Economic estimates of the mobilization of funds and additional resources from social networks in Chao, Peru • Systematization of community IMCI experience in Peru - Perspectives of the national network final report and analysis of household surveys to improve family and community indicators to change care-seeking behaviors - Findings from selected countries • Monitoring and evaluation of the community component of the IMCI strategy – A practical guideline

Proposed articles (Working titles) • Epidemiological perspectives of promoting key family practices at the family and community level in rural and suburban areas of Latin America – Contributing to the MDGs; Velasquez, A; Drasbek, C; et. al. • Economic estimates of mobilizing extra budgetary resources from networks outside the health sector – Experiences in Chao, Peru; Tejada, D. • Social participation in the IMCI Strategy in the Latin America Region, Velasquez, A; Drasbek, C; et. al. • Effectiveness of the Community IMCI Strategy in Honduras and Peru Social Actors and Key Health Practices in Cotahuma, Bolivia; Aroyo, J; Harkins, Tom; Drasbek, C; et. Al. • The Health Effects of Consensus Building: Experiences with Community IMCI in Chao, Peru and San Luis, Honduras; Velasquez, A. • Social Capital and health behavioral change: An exploration of a community integrated management of childhood illness initiative in San Luis, Honduras, Mc Question, M; Quijano, A; Drasbek, C; Harkins, Tom; et. al.