AIDS Care, February 2007; 19(2): 152 158 Formal and informal sector health providers in southern India: Role in the prevention and care of sexually transmitted infections, including HIV/AIDS J. MIGNONE 1, R. G. WASHINGTON 2, B. M. RAMESH 3, J. F. BLANCHARD 4,& S. MOSES 5 1 Faculty of Human Ecology, University of Manitoba, Canada, 2 Institute for Population Health and Clinical Research, St. John s Medical College, Bangalore, India, 3 Department of Community Health Sciences, University of Manitoba, Canada and Karnataka Health Promotion Trust, Bangalore, India, 4 Department of Community Health Sciences, University of Manitoba, Canada, and 5 Departments of Community Health Sciences, Medical Microbiology and Medicine, University of Manitoba, Canada Abstract Healthcare providers (HCPs) play a central role in the provision of prevention and care services for people with sexually transmitted infections (STIs), including HIV/AIDS. However, the degree of readiness for this role through appropriate training and experience is not clear. In the case of both the urban and rural areas of the state of Karnataka, India, primary and secondary healthcare is provided by practitioners who can be categorised into three major groups: qualified allopathic physicians, qualified non-allopathic doctors (homeopathic and Ayurvedic) and registered medical practitioners. In 2002, the India-Canada Collaborative HIV/AIDS Project conducted a study in an urban area and a rural district of the state of Karnataka, collecting information from 998 care providers regarding attitudes, knowledge and practices related to STI care and HIV/AIDS care in particular. This paper analyses and compares the three different types of HCPs with respect to these parameters and discusses implications for STI/HIV/AIDS prevention and care programs. Introduction Healthcare providers play a central role in the provision of prevention and care services for people with STIs, including HIV/AIDS. However, the degree of readiness for this role through appropriate training and experience is not self-evident. In the case of both the urban and rural areas of the state of Karnataka, India, primary and secondary healthcare is provided by practitioners who can be categorised into three major groups: qualified allopathic physicians, qualified non-allopathic doctors (homeopathic and Ayurvedic) and registered medical practitioners (RMPs). Sexually transmitted infections and HIV/ AIDS-prevention and care programs must understand the distinct practice modalities, knowledge and training needs of these practitioners. To this end, in 2002, the India-Canada Collaborative HIV/AIDS Project (ICHAP), a collaborative HIV-prevention and care program operating in Karnataka, conducted a study in the Hubli-Dharwad Municipal Corporation (HDMC) area and in the Bagalkot district of the state of Karnataka. (Population Research Centre & JSS Institute of Economic Research, 2003). With approximately five million persons infected with HIV, India now has the second largest absolute disease burden globally (UNAIDS/WHO, 2004). The prevention and control of STIs, including HIV/AIDS, has proven to be an immensely complex public health and social challenge. As part of this effort, the role of primary and secondary HCP is extremely relevant. Nonetheless, few assessments have been conducted of their professional readiness. As Hawkes and Santhya (2002) indicate, there is a strong and prevalent system of indigenous medical care in India and a multitude of different providers in the formal and informal sectors. It is estimated that there are 390,000 qualified allopathic doctors registered with medical councils in India and that there are 650,000 providers of other systems of medicine (Bhat, 1999a). Qualified allopathic physicians are graduates from medical colleges and Correspondence: Dr. Javier Mignone, PhD., Assistant Professor, Faculty of Human Ecology, University of Manitoba, Buhler Research Centre, 715715 McDermot Ave, Winnipeg, Manitoba, R3E 3P4, Canada. Tel: /1 (204) 975 7722. Fax: /1 (204) 975 7783. E-mail: mignonej@ms.umanitoba.ca ISSN 0954-0121 print/issn 1360-0451 online # 2007 Taylor & Francis DOI: 10.1080/09540120600780542
Role of informal healthcare providers in India 153 universities that are registered with the medical councils in India. Qualified non-allopathic doctors are graduates of medical colleges in traditional systems of medicine, mostly homeopathic and Ayurvedic and are registered by the state. There are 241 colleges in India that offer government accredited medical degrees in these disciplines (Mudur, 2001). The third group is that of registered medical practitioners (RMPs), who generally do not have any formal medical training. In rural areas, the most common first contact with a practitioner is with non-allopaths and RMPs. This is also the case in urban areas, although it is proportionally less common. The utilisation of different types of HCPs by a large number of the population (Bhat, 1999b) highlights the need to engage these practitioners in STI/HIV/AIDS-related primary and secondary prevention initiatives. The objectives of our study were to gather information to assess the degree to which the different types of HCPs are utilised to provide services for STIs and HIV/AIDS, to develop a comparative understanding of how the different types of providers proceed to diagnose and treat illness, as well as provide preventive services and to gauge the level of knowledge of STI/HIV/AIDS among these practitioners, as well as their need and willingness for further training. Methods To enumerate the HCPs, a comprehensive list of STI/HIV care providers in eight cities/towns of and in rural areas of Bagalkot district was prepared. A questionnaire was administered to all of the HCPs listed. Of these, we were unable to contact 15%, 9% were available but were not interviewed due to being out of town or on holiday and 4% refused to be interviewed. The questionnaire collected information on the type of facility, the number of patients received during the month prior to enumeration, the number of STI patients received, training needs in the area of STI/HIV/AIDS and care providers perceptions and knowledge regarding STI/HIV/ AIDS. The questionnaire was also used to screen the HCPs for inclusion in a second part of the study. All care providers who received five or more STI patients in the month prior to enumeration were included in a more detailed study of their practices in the management of STI/HIV/AIDS. A further questionnaire was then used to collect information on the actual diagnostic and treatment care practices of these providers. Of the 1,417 HCPs listed, information was collected from 998 (72% response rate). Based on their qualifications, HCPs were initially grouped into Table I. Health care providers-characteristics Allopaths Non-Allopaths RMPs N/998 (% of total HCP in each group) 503 (50.4) 421 (42.2) 74 (7.4) Female (%) 27.1 20.7 4.1 * Male (%) 72.8 79.3 95.9 * Average age of HCP 47.6 39.1 44.2 * Place of practice: (%) Residence 13.5 16.6 23.0 n/s Private clinic 50.7 69.8 74.3 * Private hospital 27.0 9.3 2.7 * Medical college hospital 9.5 14.0 0.0 * Govt health centre 3.6 1.0 0.0 * Govt hospital 10.5 1.7 1.4 * Urban (%) 54.9 39.9 5.2 * Rural (%) 14.8 59.3 25.9 * Average number of patients per month 628 440 347 * Maintain records of patients (yes): (%) 70.3 40.1 13.5 * Information maintained: (%) Diagnosis 65.7 55.9 60.0 n/s Treatment 60.9 56.5 60.0 n/s Lifestyle/behaviour 7.4 10.0 10.0 n/s HIV status 7.4 4.7 10.0 n/s Saw patients with STI last month (yes): (%) 50.0 51.0 41.0 n/s Average number of male patients with STI last month 2.3 1.9 1.2 n/s Average number of female patients with STI last month 2.6 1.4 0.5 n/s Average number of patients with STI last month 4.8 3.2 1.6 n/s Average number of males referred for HIV testing last month 12.4 2.5 0.9 * Average number of females referred for HIV testing last month 33.4 3.0 1.7 * * /Significant at 0.05.
154 J. Mignone et al. four categories: Allopathic, homeopathic, Ayurvedic and RMPs. Of all of the HCPs surveyed, 89% were from urban centres and 11% from rural villages. Finally, 180 of the 998 HCPs reported receiving five or more STI patients in the prior month and were thus administered a further questionnaire. For the purpose of the results reported below, the types of care providers were re-grouped into three categories: qualified allopathic, qualified non-allopathic (Ayurvedic and Homeopathic) and non-qualified practitioners (RMPs). Descriptive statistical analyses were conducted comparing characteristics of these three categories of practitioners. Results Of the 998 HCPs who participated in the study, 503 (50.4%) were qualified allopathic, 42 (42.1%) were qualified non-allopathic and 74 (7.4%) were nonqualified practitioners (Table I). The main difference across groups was that allopaths, aside from practicing in private clinics or residences, also practised in hospitals, both public and private. To a lesser extent, non-allopaths practised in private hospitals but RMPs were essentially relegated to practising in their private clinics or residences. Allopaths averaged 628 patients per month (58% female), non-allopaths 440 (62% female) and RMPs 347 (52% female). The maintenance of records has particular relevance for the treatment and prevention of STIs. Seventy percent of allopaths indicated that they maintained records of their patients, whereas only 40% of non-allopaths and 14% of RMPs reported doing so. As shown in Table I, approximately half of HCPs in the three groups indicated having seen patients with STIs in the last month, although allopathic physicians averaged almost five per month compared to three for non-allopathic practitioners and two for RMPs. An important difference across groups emerged in the number of males and females referred for HIV testing in the last month. Allopathic practitioners referred markedly higher numbers, averaging 12 males and 33 females per month, compared to only 2.5 and three respectively for non-allopaths and only one and two respectively for RMPs. Allopathic physicians (Table II) appeared to be more prone to inform patients about why they were recommending HIV testing (60%, compared to 43% and 32%) and in providing some explanation for this referral. A similar pattern held when the test results were negative. Allopathic practitioners were less likely to refer HIV-positive patients (37%, compared to 44% and 64%) but were more likely to recommend additional testing (28%, compared to 8% and 16%). A marked difference across groups was that when test results were negative, 32% of allopathic physicians would recommend additional tests after three months, compared to only 16% of nonallopathic practitioners and 8% of RMPs. The percentage of HCPs advising condom use was quite low across all groups, with only 28% of allopaths doing so, 32% of non-allopaths and 24% of RMPs. These figures were comparable when the question was asked in the context of what they perceive their role to be in the prevention of STI/HIV/AIDS, with only 26% of allopaths, 16% of non-allopaths and 20% of RMPs considering that it is part of their role to promote condom use. Only 26% of allopaths, 11% of non-allopaths and 7% of RMPs considered counselling to be part of their role. However, health education was considered part of their role by large proportions of all three groups (80% of allopaths, 84% of non-allopaths and 76% of RMPs). The treatment of STI patients was not considered to have a role in the prevention of HIV/AIDS in any of the three groups. Between 80% and 85% of HCPs across the three groups indicated they used disposable needles. However, only 19% of allopaths, 15% of nonallopaths and 10% of RMPs used proper sterilisation techniques. A marked difference was observed in the wearing of gloves, where 73% of allopaths mentioned their use, compared to 62% of non-allopaths and only 35% of RMPs. Table III focuses on information provided by HCPs about their knowledge on STI/HIV/AIDS and on training interests. Eighty-six percent of allopathic physicians, 63% of non-allopaths and 50% of RMPs indicated they had a lot or some knowledge about AIDS. This gradient persisted in some questions that inquired about specific knowledge of HIV/AIDS, although more often than not the results were quite similar across the three groups. The gradient was most apparent when HCPs were asked if it is possible for a person with HIV to have no symptoms: 95%, 75% and 60% of allopaths, nonallopaths and RMPs respectively responded in the affirmative. Similarly, to the question if it is possible for a person with HIV to have no symptoms and a negative blood test, 82%, 55% and 32% of allopaths, non-allopaths and RMPs respectively responded in the affirmative. Answers to the self-rated knowledge question were cross-tabulated with what could be considered the most difficult question about HIV/AIDS: Is it possible for a person with HIV to have no symptoms and a negative blood test? (Table IV). Of the practitioners who rated themselves as knowing about HIV/AIDS, 20% of the allopaths, 50% of the nonallopaths and the majority of the RMPs gave the wrong answer. This suggests an overestimation of
Table II. Perceived role of HCPs in providing HIV/AIDS information and advise to patients Allopaths Non-Allopaths RMPs N/998 (% of total HCP in each group) 503 (50.4) 421 (42.2) 74 (7.4) What do you tell patient after recommending HIV testing? (%) Nothing 39.8 57.3 68.0 * Need for right diagnosis 54.7 40.9 32.0 * Implications of result 3.3 0.5 0.0 * Other 7.9 0.9 4.0 * If test indicates HIV-positive, what does HCP do? (%) Nothing 3.0 3.6 4.0 n/s Refer 36.8 44.1 64.0 n/s Recommend additional test 27.7 8.2 16.0 * Start treatment 17.0 22.7 16.0 n/s Reveal only to patient 14.3 9.1 4.0 n/s Reveal only to family 20.1 31.4 16.0 * Reveal to both patient and family 7.0 0.9 0.0 * If test indicates HIV-negative, what does HCP do? (%) Nothing 23.4 16.0 16.0 n/s Refer 2.7 4.1 0.0 n/s Recommend additional test after 3 months 31.9 16.0 8.0 * Reveal only to patient 7.6 9.6 8.0 n/s Reveal only to family 3.6 1.5 0.0 n/s Reveal to both patient and family 1.5 0.9 0.0 n/s Precaution HCP takes to protect themselves or prevent patient to patient HIV transmission: (%) Use disposables 79.7 85.5 84.9 n/s Proper sterilisation 18.7 15.0 9.5 n/s Wearing gloves 73.4 61.8 35.1 * Advising condom use 27.8 31.8 24.3 n/s Counselling 7.0 5.0 4.1 n/s Universal precautions 14.7 1.9 1.4 * Savlon wash and drying 41.0 33.3 20.3 * Advising not to donate blood 4.6 3.8 0.0 n/s Avoiding contact with blood 12.7 19.2 23.0 * Isolation 2.0 2.4 2.7 n/s Surgical precaution 8.5 2.4 1.4 * Wearing spectacles 5.2 0.0 2.7 * Waste management 3.2 1.0 0.0 * Decontamination 2.8 0.7 0.0 n/s Role of HCP in prevention of STI/HIV/AIDS: (%) Counselling 25.6 11.2 6.8 * Health education 79.6 84.3 75.7 n/s Treat HIV persons humanely 3.6 3.3 2.7 n/s Spread message of condom use 26.0 15.5 20.3 * Detection of HIV infection 4.2 1.0 1.4 * Treatment of STI patients 4.0 0.7 0.0 * */Significant at 0.05. Role of informal healthcare providers in India 155 self-rated knowledge among the three groups, but to a larger extent among non-allopaths and RMPs. Thirty-two percent of allopaths had ever attended specific STI/HIV/AIDS-related in-service training, while only 8% of non-allopaths and 5% of RMPs had done so. Seventy-five percent of allopaths, 83% of non-allopaths and 82% of RMPs indicated that they were interested in receiving training for STI/ HIV/AIDS management and 46%, 51% and 67% respectively expressed that they were willing to pay for such training. Of the 998 practitioners studied, 180 (18%) indicated that they had seen five or more STI patients in the last month: 153 allopaths, 24 qualified non-allopaths and three RMPs. These high-volume STI practitioners were administered a second questionnaire for a more detailed study of their practice patterns and management of STI/HIV/ AIDS. Due to the low number in the RMP group, only results pertaining to the other two groups were analysed. The general characteristic of this follow-up group was quite similar to that of the overall sample. An important difference was in their reported maintenance of patient records: 78% of allopaths in the follow-up group reported maintaining patient records compared to 70% of those of the overall
156 J. Mignone et al. Table III. HCP s knowledge about STI/HIV/AIDS and training interests Allopaths Non-Allopaths RMPs N/998 (% of total HCP in each group) 503 (50.4) 421 (42.2) 74 (7.4) Ever attended STI/HIV/AIDS training (%) 31.5 7.6 5.4 * Duration of last training in days 3.4 2.4 2.0 n/s Interested in training for STI/HIV/AIDS management (yes) (%) 75.0 83.3 82.4 * Willingness to pay for STI/HIV/AIDS training (%) 46.4 51.3 67.2 * How much do you know about AIDS? (%) A lot/some 86.1 63.4 48.6 * A little/none 13.9 36.6 51.4 * Most common mode of spread of HIV in your area: (%) n/s Unprotected sexual contact 13.8 8.8 4.1 Illegal sexual contact 7.2 10.2 10.8 Sexual contact 72.2 75.5 83.8 Untested blood transfusion 0.4 0.5 0.0 Infected blood transfusion 0.6 1.2 0.0 Blood 2.2 0.5 0.0 Unsterilised instruments 3.4 1.4 0.0 Infected mother to child 0.0 0.2 0.0 What can a person do to avoid getting HIV/AIDS? (%) Abstain from sex 6.2 6.4 5.4 n/s Use condoms 79.0 72.2 66.2 * Limit sex to one partner/stay faithful to one partner 46.8 40.1 43.2 n/s Limit number of sexual partners 17.8 13.1 17.6 n/s Avoid sex with prostitutes 39.4 51.5 59.5 * Avoid sex with persons who have many partners 2.6 1.9 0.0 n/s Avoid sex with homosexuals 1.0 0.2 1.4 n/s Avoid sex with persons who inject drugs intravenously 5.0 1.7 0.0 * Avoid blood transfusions 24.6 19.0 8.1 * Avoid injections 13.3 7.4 2.7 * Avoid sharing razors/blades 8.6 15.9 20.3 * Avoid kissing 1.0 0.7 2.7 n/s Avoid mosquito bites 0.4 0.2 0.0 n/s Can people reduce risk of HIV by having one sex partner who has 95.8 93.8 86.3 * no other partners? (Yes) (%) Can people protect themselves from getting HIV by using a condom 88.0 86.0 82.4 * every time they have sex? (Yes) (%) Is it possible for a person with HIV to have no symptoms? (Yes) (%) 94.8 74.6 59.5 * Is it possible for a person with HIV to have no symptoms and 82.2 55.1 32.4 * a negative blood test? (Yes) (%) Can HIV be transmitted from a mother to a child? (Yes) (%) 98.4 93.1 86.5 * */Significant at 0.05. sample. In addition, 67% of the non-allopath followup group reported maintaining records compared to only 40% of the overall sample. Qualified allopaths in the follow-up group showed similar overestimation of knowledge as that of the overall sample of allopaths. However, among non-allopaths, the follow-up group showed more accurate estimation of knowledge compared to the overall group. There were no appreciable differences between both qualified allopaths and qualified non-allopaths in the follow-up group compared to that of the overall sample in relation to having attended STI/HIV/AIDS training programs, to being interested in attending training and in willingness to pay. Discussion Several important practice characteristics were identified that are important to HIV prevention program planning. In terms of place of practice, all three groups practised in private residence or clinics. However, it was mainly allopaths who also practised in public or private hospitals. This highlights the relevance of proper enumeration of HCPs in private practice when organising training or intervention programs. The recruitment of HCPs for training programs should originate in their places of practice, rather than through institutional mechanisms. The proper maintenance of patient records is a valuable tool from a primary care perspective. The generally poor record maintenance observed is an
Role of informal healthcare providers in India 157 Table IV. HCPs self-rated knowledge of HIV/AIDS crosstabulated with a knowledge question Specific Knowledge Question Correct (%) Incorrect (%) Total p value Allopaths Self-rated Knows a lot/some 359 (72) 70 (14) 429 B/0.01 Knows a little/none 51 (10) 18 (4) 69 Total 410 88 498 Non-Allopaths Self-rated Knows a lot/some 162 (39) 103 (25) 265 B/0.01 Knows a little/none 69 (17) 84 (20) 153 Total 231 187 418 RMPs Self-rated Knows a lot/some 13 (18) 23 (31) 36 B/0.01 Knows a little/none 11 (15) 27 (36) 38 Total 24 50 74 issue of concern, signaling an area that would require program intervention. An important difference across groups emerged in the number of males and females referred for HIV testing in the last month. Allopathic practitioners referred markedly higher numbers, compared to non-allopaths and RMPs. The reasons for this difference merit further investigation, given its implications for prevention and treatment of HIV/AIDS. Allopathic physicians were more prone to inform patients about why they were recommending HIV testing and in providing some explanation for referral. In cases when the test was positive, allopathic practitioners were less likely to refer the patient but were more likely to recommend additional testing. This suggests that allopaths consider themselves more capable of treating HIV-positive patients. When training allopaths and non-allopaths, the former may require more training for the treatment of HIV/AIDS patients, whereas the latter may require better information about referral issues. The number of HCPs advising condom use was low across all groups. Allopaths were even less likely than non-allopaths to promote condom use, although RMPs were the least likely to suggest condom use. On the other hand, the majority of practitioners across the three groups considered health education as part of their role. This suggests that all three types of practitioners are resistant to talking openly with their patients about issues related to STI/HIV/AIDS. The reasons for this merit further investigation and need to be addressed in training programs for HCPs. The study provided an interesting glimpse into knowledge of HCPs on STI/HIV/AIDS and on their training interests. In general, there was a gradient suggesting that allopaths had more knowledge, followed by non-allopaths, and finally RMPs. In terms of knowledge of ways to prevent HIV/AIDS, comparative results showed very little variability across groups, although in most cases the gradient persisted, with somewhat higher knowledge among allopaths. These findings suggest that HCPs in general require more specific training on STI/HIV/ AIDS and that, across the three groups, the RMPs are the most in need. The central role that RMPs play as primary HCPs in rural areas emphasises the particularly urgent need for STI/HIV/AIDS training of these practitioners in non-urban settings. Few HCPs reported having received any specific STI/HIV/AIDS in-service training but it was encouraging that the majority of allopaths, non-allopaths and RMPs indicated that they were interested in receiving training for STI/HIV/AIDS management and roughly half across the three groups expressed that they were willing to pay for such training. Only a relatively small proportion of HCPs saw the majority of STI/HIV patients. This finding has a number of implications from a programmatic perspective. Training programs for STI/HIV/AIDS prevention and treatment should start with those who see the majority of STI/HIV patients. Although these high-volume STI/HIV/AIDS service providers are clearly important, they do not appear to have any more specific training than the majority of practitioners. It was encouraging, though, that almost 80% of high-volume allopaths and almost 90% of high-volume non-allopaths indicated that they were interested in STI/HIV/AIDS training. Some possible limitations of the study should be considered. One is that of recall bias, particularly among non-allopaths and RMPs, who were less likely to keep proper records of patients. It is not clear however if the bias would be towards overreporting or under-reporting. Social desirability bias could have affected some answers towards more positive responses. Nonetheless, the worst case would be that the results are underestimating the need for STI/HIV/AIDS training and capacity building across the three groups of practitioners. The rigorous enumeration of providers and the relatively high response rates provide reasonable assurance that the results of this study are representative of all HCPs in the study region. Being one of the first studies in India to assess the knowledge and perceptions of RMPs (Rego et al., 2002) with respect to STI/HIV/AIDS and the only one that we know of that compares knowledge and service practices across the spectrum of HCPs, it has provided much needed initial information.
158 J. Mignone et al. The issue of involving differently qualified HCPs in STI/HIV/AIDS training programs is not without controversy. The Medical Council of India is resistant to the idea of providing training to nonallopaths in general and particularly to RMPs. However, the reality in the study region is that only half of practitioners in the urban settings are allopaths and that three-quarters of practitioners in rural areas are non-allopaths. In India, 75% of the formal health infrastructure is concentrated in urban areas, where only 27% of the population lives (Patil et al., 2002). Another study of STI patients (Population Research Centre & JSS Institute of Economic Research, 2003) suggested that the majority of people in this region first seek treatment with nonallopathic doctors because of easier accessibility and lower costs. This reality cannot be dismissed if STI/ HIV/AIDS-prevention and treatment programs are to be effective and to have the reach that is necessary to have impact on a large scale. Acknowledgements Dr. Mignone was supported by a Canadian Institutes for Health Research (CIHR) post-doctoral fellowship. Dr. Blanchard holds a Canada Research Chair Tier II from CIHR. Dr. Moses holds a CIHR Investigator Award. References Bhat, R. (1999a). Characteristics of private medical practice in India: A provider perspective. Health Policy and Planning, 14, 26 37. Bhat, R. (1999b). Private medical practitioners in rural India: Implications for health policy. Report submitted to the Indian Institute of Management, Ahmedabad. Hawkes, S., & Santhya, K.G. (2002). Diverse realities: Sexually transmitted infections and HIV in India. Sexually Transmitted Infections, 78, i31i39. Mudur, G. (2001). Indian doctors decry proposal to teach traditional medicine. British Medical Journal, 323, 1090. Patil, A.V., Somasundaram, K.V., & Goyal, R.C. (2002). Current health scenario in rural India. Australian Journal of Rural Health, 10, 129135. Population Research Centre & JSS Institute Of Economic Research (2003). Study of socio-demographic and behavioural characteristics of patients attending STD care services and STD care providers, Hubli-Dharwad Municipal Corporation Area and Bagalkot District, Karnataka, 2002. Report 130. Dharwad, India: ICHAP. Rego, A., Nadkarni, V., & Vasundhra, D. (2002). HIV/AIDS in India: A critical review of selected studies (19902000) Report submitted to the Gender and Reproductive Health Research Initiative. New Delhi, India: CREA. UNAIDS/WHO (2004). Epidemiological fact sheets on HIV/ AIDS and sexually transmitted infections: 2004 update. Geneva: UNAIDS/WHO/UNICEF.