The impact of the Integrated Child Development Services Scheme in north India

No data, no problem, no action: parenting programs in low-income countries. Making the social-emotional outcomes more visible

BACKGROUND

Parenting programs are delivered in many low income countries in an effort to address the effects of insufficient cognitive stimulation, major social-emotional risk factors related to inadequate caregiver sensitivity and responsiveness, maternal depression, violence and biological risk factors. However, the outcomes of these programs are often untested because of methodological limitations in the existing evaluation tools available for cross-cultural research, and especially those related to social-emotional development and functioning.

METHOD

This study takes an approach that involves organizing data from focus groups collected following caregiver participation in a parenting program, Learning Through Play (LTP) delivered in 11 low income countries. The LTP program has as its aim to increase parent knowledge and influence parental practice regarding the essential components of early development of children aged birth to 6 years. The purpose of systematically organizing focus group data was to illustrate a means by which program developers worldwide can discuss outcomes of program participation, particularly in social-emotional domains that have been overlooked in past studies on parenting programs.

RESULTS AND CONCLUSION

The findings from this study suggest that qualitative outcome data can be organized to make the social-emotional outcomes of participation in parenting programs more visible.

Strategies for integrating primary health services in low- and middle-income countries at the point of delivery

BACKGROUND

In some low- and middle-income countries, separate vertical programmes deliver specific life-saving interventions but can fragment services. Strategies to integrate services aim to bring together inputs, organisation, and delivery of particular functions to increase efficiency and people's access. We examined the evidence on the effectiveness of integration strategies at the point of delivery (sometimes termed 'linkages'), including integrated delivery of tuberculosis (TB), HIV/AIDS and reproductive health programmes.

OBJECTIVES

To assess the effects of strategies to integrate primary health care services on healthcare delivery and health status in low- and middle-income countries.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 3, part of the The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care Group Specialised Register (searched 15 September  2010); MEDLINE, Ovid (1950 to August Week 5 2010) (searched 10 September  2010); EMBASE, Ovid (1980 to 2010 Week 35) (searched 10 September  2010); CINAHL, EBSCO (1980 to present) (searched 20 September 2010); Sociological Abstracts, CSA Illumina (1952 to current) (searched 10 September  2010); Social Services Abstracts, CSA Illumina (1979 to current) (searched 10 September  2010); POPLINE (1970 to current) (searched 10 September  2010); International Bibliography of the Social Sciences, Webspirs (1951 to current) (searched 01 July 2008); HealthStar (1975 to September 2005), Cab Health (1972 to 1999), and reference lists of articles. We also searched the World Health Organization (WHOLIS) library database, handsearched relevant WHO publications, and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials, non-randomised controlled trials, controlled before and after studies, and interrupted time series analyses of integration strategies, including strengthening linkages, in primary health care services. Health services in high-income countries, private public partnerships, and hospital inpatient care were excluded as were programmes promoting the integrated management of childhood illnesses. The main outcomes were indicators of healthcare delivery, user views, and health status.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the risk of bias. The statistical results of individual studies are reported and summarised.

MAIN RESULTS

Five randomised trials and four controlled before and after studies were included. The interventions were complex.Five studies added an additional component, or linked a new component, to an existing service, for example, adding family planning or HIV counselling and testing to routine services. The evidence from these studies indicated that adding on services probably increases service utilisation but probably does not improve health status outcomes, such as incident pregnancies.Four studies compared integrated services to single, special services. Based on the included studies, fully integrating sexually transmitted infection (STI) and family planning, and maternal and child health services into routine care as opposed to delivering them as special 'vertical' services may decrease utilisation, client knowledge of and satisfaction with the services and may not result in any difference in health outcomes, such as child survival. Integrating HIV prevention and control at facility and community level improved the effectiveness of certain services (STI treatment in males) but resulted in no difference in health seeking behaviour, STI incidence, or HIV incidence in the population.

AUTHORS' CONCLUSIONS

There is some evidence that 'adding on' services (or linkages) may improve the utilisation and outputs of healthcare delivery. However, there is no evidence to date that a fuller form of integration improves healthcare delivery or health status. Available evidence suggests that full integration probably decreases the knowledge and utilisation of specific services and may not result in any improvements in health status. More rigorous studies of different strategies to promote integration over a wider range of services and settings are needed. These studies should include economic evaluation and the views of clients as clients' views will influence the uptake of integration strategies at the point of delivery and the effectiveness on community health of these strategies.

India at the crossroads of millennium development goals 4 and 5

The current year marks the completion of two thirds of the period between the adoption of the millennium development goals (MDGs) and the target date of 2015. Although there has been some progress, it is incontestable that much more needs to be done. India contributes to 20% of births worldwide and has the highest proportion of children younger than 5 years. Global progress toward MDG 4 and 5 depends significantly on improvements in maternal and child health indicators in India. Although it has been reported that the country has made substantial progress, the pace has been slow and marred by vast regional variability. Certain states continue to have unacceptably high mortality and morbidity rates. This article provides a context to the current status of maternal and child health in India, highlights the achievements, and uses the available data effectively to emphasize the progress. The authors acknowledge the new initiatives and make recommendations for reinforcing the continuum of care.

Strategies for integrating primary health services in middle- and low-income countries at the point of delivery

BACKGROUND

Strategies to integrate primary health care aim to bring together inputs, organisation, management and delivery of particular service functions to make them more efficient, and accessible to the service user. In some middle and low income countries, services have been fragmented by separate vertical programmes established to ensure delivery of particular technologies. We examined the effectiveness of integration strategies at the point of delivery.

OBJECTIVES

To assess the effects of strategies to integrate primary health care services on producing a more coherent product and improving health care delivery and health status.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (August 2005), MEDLINE (1966 to September 2005), EMBASE (1988 to 2005), Socio Files (1974 to September 2005), Popline (1970 to September 2005), HealthStar (1975 to September 2005), Cinahl (1982 to September 2005); Cab Health (1972 to 1999), International Bibliography of the Social Sciences (1970 to 1999), and reference lists of articles. We also searched the Internet and World Health Organization (WHO) library database, hand searched relevant WHO publications and contacted experts in the field.

SELECTION CRITERIA

Randomised trials, controlled before and after studies, and interrupted time series analyses of integration strategies in primary health care services. Health services in high-income countries were excluded. The primary outcomes were indicators of health care delivery, user views on any measure of service coherence, and health status. We also sought information on comparative costs.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study quality.

MAIN RESULTS

Three cluster randomised trials and two controlled before and after studies were included, with three types of comparison: integration by adding on an additional component to an existing service (family planning); integrated services versus single special services (for sex workers); integrated delivery systems versus a vertical service (for family planning); and packages of enhanced primary child care services (integrated management of childhood illnesses) vs. routine child care. Interventions were complex and in some studies inputs varied substantially between comparison arms. Overall, no consistent pattern emerged. Only one study attempted to assess the user's view of the service provided.

AUTHORS' CONCLUSIONS

Few studies of good quality, large and with rigorous study design have been carried out to investigate strategies to promote service integration in low and middle income countries. All describe the service supply side, and none examine or measure aspects of the demand side. Future studies must also assess the client's view, as this will influence uptake of integration strategies and their effectiveness on community health.

Integrated Child Development Services (ICDS) scheme: a program for holistic development of children in India

The Integrated Child Development Services (ICDS) scheme is the largest program for promotion of maternal and child health and nutrition not only in India but in the whole world. The scheme was launched in 1975 in pursuance of the National Policy for Children. The scheme has expanded in the last twenty-seven years form 33 projects to 5171 blocks. ICDS is a multi-sectoral program and involves several government departments. The program services are coordinated at the village, block, district, state and central government levels. The primary responsibility for the implementation of the program lies with the Department of Women & Child Development at the Centre and nodal department at the states, which may be Social Welfare, Rural Development, Tribal Welfare or Health Department or an independent Department. The beneficiaries are children below 6 years, pregnant and lactating women and women in the age group of 15 to 44 yrs. The beneficiaries of ICDS are to a large extent identical with those under the Maternal and Child Health Program. The program provides an integrated approach for converging all the basic services for improved childcare, early stimulation and learning, health and nutrition, water and environmental sanitation aimed at the young children, expectant and lactating mothers, other women and adolescent girls in a community. ICDS program is the reflection of the Government of India to effectively improve the nutrition and health status of underprivileged section of the population through direct intervention mechanism. The program covers 27.6 million beneficiaries with supplementary nutrition. The program services and beneficiaries has essentially remained the same since 1975. Recently a review of the scheme was held, sponsored by Government of India, which suggested modifications in the health and nutrition component of ICDS scheme to improve the program implementation and efficiency.

Strategies for integrating primary health services in middle- and low-income countries: effects on performance, costs and patient outcomes

BACKGROUND

Integration of primary health care is change to bring together inputs, organisation, management and delivery of particular service functions. Integration has been promoted in the health sector to improve the efficiency of health care delivery. The need for integration arose from perceptions that services were fragmented when delivered through separate vertical programmes. Integration is relevant to the health system at various levels, and this review is concerned with integration at the point of delivery.

OBJECTIVES

To assess the effects of strategies to integrate primary health care services on producing a more coherent product and improving health care delivery and health status, in relation to service cost, outputs, impact and user acceptability.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (August 2000), MEDLINE (1966 to September 2000), EMBASE (1988 to September 2000), Socio Files (1974 to September 2000), Popline (1970 to September 2000), HealthStar (1975 to September 2000), Cinahl (1982 to September 2000); Cab Health (1972 to 1999), International Bibliography of the Social Sciences (1970 to 1999), and reference lists of articles. We also searched the Internet and World Health Organization (WHO) library database, hand searched relevant WHO publications and contacted experts in the field.

SELECTION CRITERIA

Randomised trials, controlled before and after studies, and interrupted time series analyses of integration strategies in primary health care services. Health services in high-income countries were excluded. The primary outcomes were service outputs: productivity and coverage, impact, user acceptability and unit cost.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Four studies were included. There was no consistent pattern of benefit. Integration had a clear positive effect on the outputs in only one study; in another it had similar effects to vertical programme delivery but greater effect than the control group. In the other two studies integration resulted in negative outputs in comparison with vertical programmes, although in one of these integration performed better than the control group.

REVIEWER'S CONCLUSIONS

Few studies of good quality, large and with rigorous study design have been carried out to investigate the evidence to support integration as a style of service delivery. In fact, some studies found greater effects for vertical health care delivery. Policy makers and planners considering integration could introduce strategies, using rigorous study design, to allow further evaluation and increase the base of studies from which to draw evidence.

Impact of Urban Basic Services on immunization coverage in a slum area of northern India

The Urban Basic Services (UBS) programme was launched in some of the urban slums in the major cities of India in the year 1986. The main objective of the Urban Basic Services (UBS) Program is to improve and upgrade the quality of life of the urban poor, particularly the women and children. The major thrust area under the UBS programme includes child survival and development, learning opportunities for women and children, water and sanitation, and community organization. The present study attempts to find out the impact of the UBS Program in terms of the immunization coverage carried out in slums covered by UBS and comparing it with non-UBS slums using the 30-cluster sampling technique as suggested by WHO. The percentage of fully immunized children was higher (16.2%) in the UBS slums compared to 10.9% in non-UBS slums. The immunization coverage of children was slightly better in the UBS slums for BCG, DPT and Oral Polio Vaccines, while for measles it was 18.6% in UBS slums and 11.9% in non-UBS slums. The dropout rates for I to III doses of DPT was much higher (36.4%) in non-UBS slums as compared to 28% in UBS slums. The availability of immunization cards was found to be higher in both mothers (16.7%) and children (22.4%) in UBS slums compared to the non-UBS ones (5.2% and 8.6% respectively). The slums thus covered under the UBS program have done marginally better in immunization but it appears that to assess the overall impact of UBS, all the components of services and not merely immunization should be assessed.