In 1990, acute respiratory infections (ARIs) caused 33% of global mortality among under-5-year-olds.(a) Bacterial pneumonia, which can be treated with antimicrobial agents, accounted for most of these deaths (1). WHO recommends case management as the main strategy for reducing child mortality associated with such infections (2). This involves a simple standard plan for the management of children having a cough and/or respiratory difficulty, resulting in the early diagnosis and treatment of pneumonia.(b) Field trials have shown convincingly that the strategy is feasible and effective in reducing child mortality (3-6). Many developing countries have drawn up plans for introducing national ARI control programmes, and WHO, UNICEF, UNDP and approximately 60 countries recently resolved to launch a global programme using case management as the main strategy (7).
Because of the shortage of physicians in rural areas, ARI control programmes have to train nonphysician health workers in case management (7). In previous field trials, paramedical workers (PMWs) and village health workers (VHWs) have been trained to provide this service in villages (3, 5, 6). In a field trial in Gadchiroli, India, traditional birth attendants (TBAs) were trained in the case management of pneumonia (4). The present article assesses TBAs as providers of case management in ARI control and compares them with other types of community-based health workers.
Subjects and methods
The field trial was carried out in Gadchiroli, a remote underdeveloped part of central India, by the Society for Education, Action and Research in Community Health (SEARCH), a voluntary organization. Extreme poverty, a female literacy rate of only 11%, and poor means of communication characterize the area. In the villages, health care is provided by traditional healers and private medical practitioners as well as by government paramedical workers, of whom there are 2 per 3000 people.
A census and a baseline survey were conducted in an intervention area of 58 villages and in a control area of 44 villages with populations of 48 377 and 34 856, respectively, and a system of reporting vital events and causes of death was established (4). The inhabitants of the intervention area received extensive education, by means of audiovisual aids, on the signs and symptoms of pneumonia in children and on when to seek care; and health workers were trained to give case management.
Initially, only PMWs and VHWs were involved. The 30 PMWs in the intervention area were trained after it had been agreed with the government that the case management of pneumonia would be an extra responsibility for them and that no additional wages or incentives would be given. A total of 25 male VHWs, i.e., 1 per 2000 people in the intervention area, were selected and trained by SEARCH. Their customary duties were to maintain population registers, record vital events, and treat minor ailments such as scabies, wounds, aches and pains. They were paid on a part-time basis by SEARCH but no targets or incentives were given for the management of pneumonia. The PMWs and VHWs worked independently of each other in defined but overlapping populations.
In six sessions, each of 1.5 hours, both groups were trained to follow the standard plan of case management suggested by WHO (16). For a child with a cough or breathing difficulty this included the following:
- taking a history; - counting the respiratory rate using a wrist-watch; - looking for referral indications and, if they were present, referring the child; and - diagnosing pneumonia and treating with sulfamethoxazole + trimethoprim syrup if the respiratory rate exceeded 50 per minute (age-specific criteria for the respiratory rate were subsequently introduced, as recommended by WHO).(c)
Both groups of workers were provided with sulfamethoxazole + trimethoprim syrup and with paracetamol and salbutamol tablets. …