Oct-06-08
IMCI 101 January 16th, 2000The purpose of this workshop was to brief participants on clinical IMCI, and to introduce them to Community and Household IMCI (C/HH-IMCI). The definition of Community and Household IMCI is still in its formative stages. Presentations at the IMCI 101 workshop include:
Overview of the Development and History of the IMCI Strategy Michel Pacque (Child Survival Technical Support Project), presented information prepared by prepared by WHO and the World Bank What are major issues affecting child health? Significant progress has been made in the reduction of child mortality, but 10.8 million children under the age of five still die every year. Forty-nine percent of these children die from one of four major causes: respiratory disease, malaria, measles, and diarrheal diseases. What is IMCI? The objectives of IMCI (Integrated Management of Childhood Illnesses) are to significantly reduce global mortality and morbidity in children under five and to contribute to the healthy growth and development of children. IMCI focuses on reducing mortality and morbidity associated with the major causes of disease in children under five: diarrhea, respiratory diseases, malaria, and measles. In traditional, vertical health care programs, national programs conduct a number of disease-specific courses, using separate guidelines and technical materials for each disease. It is up to the health worker to attend all of these courses and then "integrate" these guidelines internally. The IMCI Strategy promotes integration of vertical programs at many levels. Health care providers can attend one training course, rather than an array of disease-specific courses, and provide integrated care for sick children. IMCI engages families and communities by promoting appropriate home care and safe, supportive environments for healthy growth and development. This multi-level integration ultimately benefits children, who receive holistic care as a result of the IMCI strategy. Download
Overview and Development presentation
Presentation of IMCI Guidelines René Salgado (Team leader for Child Health and Nutrition, JSI) WHO/UNICEF provides a training course in the IMCI guidelines. The course lasts for 11 days and combines a large volume of classroom work with hands-on clinical practice. Although doctors may take the course, it is geared toward first-level health care workers, such as nurse-auxiliaries. Course objectives are to teach participants to assess, classify and treat sick children; refer seriously ill children and administer pre-referral treatment; counsel caretakers about danger signs and when to return for follow up care; check immunization status; provide nutrition counseling; and, when appropriate, carry out feeding assessments. Rene Salgado emphasized three key points regarding IMCI. First, misdiagnosis erodes credibility. Second, IMCI is not a "cookie cutter" methodology but rather reflects an advance in sensitivity and holistic treatment of illness. Third, with IMCI there is finally a tool with an internationally agreed-upon standard; it can now be used as an assessment tool. Download
the IMCI Guidelines presentation
Health Systems Strengthening for IMCI Paula Tavrow (QAP) How do "strong health systems" introduce standards? In its broadest sense, a standard is a statement of the degree of quality expected. Standards should be valid, reliable, clear, measurable, and realistic. Strong health systems introduce standards in the way they define the desired quality, work to improve the quality of performance, and monitor the quality. Typically, each level (national, district, facility, and community) has primary responsibility for different activities. For example, developing and adapting guidelines may be primarily the responsibility of the national level, while the district is responsible for communicating these standards, the facility is charged with obtaining client input, and the community provides incentives for following the standards. However, the involvement of multiple levels creates a much stronger health system, as the combined efforts of the various levels achieve greater results. Benefits and Challenges of IMCI IMCI offers numerous potential benefits. IMCI allows more accurate diagnosis, treatment, and referral as well as better patient monitoring and follow up. Because IMCI treats the whole child, there are fewer missed opportunities for immunizations and Vitamin A distribution. IMCI training enables workers to communicate more effectively with caretakers and offer more effective counseling on nutrition and breastfeeding. However, IMCI also poses several challenges. First, providers don’t regularly perform IMCI. Discussions among providers in Uganda, Kenya, and Zambia have revealed that within three months of training, half of providers no longer perform IMCI. The half that do perform IMCI do so rarely. Providers may lack the necessary drugs or equipment to perform IMCI effectively. For example, a provider may not have a watch with which to measure respiration, or may not have the right drugs for each illness. IMCI is very time-consuming, and practitioners don’t always feel they have the time or support from other staff to perfume IMCI. Sometimes, nurses are not allowed to diagnose patients when there are doctors available. Mothers sometimes don’t accept referrals; they want the provider to give the child an injection or medication. Given these considerations, providers often feel like IMCI is a lot of hard work, and the benefits are not always clear. Second, trained providers make many errors in classifying illness, creating a second challenge facing IMCI. Providers who were observed in Kenya, Zambia, and Uganda missed about 1/3 of severe classifications. About 20% to 40% of children get the wrong treatment. Severe illnesses are most frequently misclassified: severe disease, severer malnutrition, and severe dehydration. Why do these errors occur? Providers assume that they know the guidelines and do not use chart booklet. Providers also avoid the chart booklet because it can be cumbersome to use, and providers worry that they will appear incompetent if patients see them referring to it continually. Providers may take shortcuts or rush to clear lines of people waiting, thereby missing key steps. Finally, providers frequently revert to previous training. Third, IMCI Training is costly and requires follow-up. In Uganda, Kenya, and Zambia, the cost of the initial training course ranged from $450 to $750. The large number of people at each facility who require IMCI training multiplies this cost. Not only do all providers who see sick children need IMCI training, but also the facility in-charges need training or orientation in order to be supportive of IMCI. Additionally, without follow-up observation and feedback, performance declines an additional 10-20% Download
the Health Systems Strengthening presentation
Improving IMCI Training with a Computer-Based Program Marina Budeyeva (URC) Potential of Computer-Based Training Computer-Based Training (CBT) is self-paced, offering learners more independence. CBT may be both more cost-effective and a shorter course of study than traditional training. As an added benefit, training programs can be copied and shared among a large number of users. The program can also serve as a reference for up-to-date learning. Features of the IMCI CD-ROM The IMCI CD-ROM developed by the Quality Assurance Project covers both the theory and the clinical practice of IMCI. As many trainees have never used a computer, the program includes a computer-tutorial. The practical portion of the program includes six case studies. Clicking on a case study takes the trainee to an interactive exam room in which trainees can note pertinent information about the patient and answer questions posed by the programs. Uganda Field Test A study team lead by Paula Tavrow field-tested the IMCI CD-ROM in Uganda. The study team sought to assess the effectiveness of Computer-Assisted IMCI Training (CAT) versus standard IMCI training; compare the costs of the two types of training; and assess the acceptability and feasibility of using computers in IMCI training. A cost analysis showed that the cost per trainee of CBT was almost 20-25% less expensive (omitting development and hardware costs). Facilitators found the course less taxing. Participants seemed to prefer the CBT course, even though none of the participants had ever used computers before the training. The study further concluded that new CBT courses might lead to increased knowledge and retention of information. Download
the presentation on Improving IMCI Training
IMCI Complementary Course Development Beth Gragg (World Education) IMCI Complementary Course The IMCI Complementary Course is designed for facilities-based health practitioners with lower levels of literacy. The people who come to these courses generally have a sixth grade education, two years of medical training, little access to reading materials, and little or no in-service training. Because many live in isolated areas, they were frequently overlooked for in-service training although they have large amounts of practical experience. Many received no training, follow-up, supervision, or mentoring after their initial technical training. Field-Based Course Development Process The IMCI Complementary Course was developed using a field-based course development process. This process helps stakeholders understand that training is one part of a continuum, which also includes the selecting appropriate participants; designing appropriate curriculum and program design; and post-testing, following-up and "supporting the vision." Facility-level Site Audits A key part of the development process is the facility-level site audit. The purpose of a facility-level site audit is to find out the literacy level of participants, their access to reading materials, their current practices, and the systems in place to support their work (supervision, available drugs, available equipment, access to reading materials, etc.) Course Design The course design is based completely on learning IMCI objectives, algorithms, and materials. It relies on more participation than reading. Non-formal techniques are used to find out what participants know, build on their current skills, give them practice new skills, and evaluate their learning. The learning is based as closely as possible to the reality of what the health care workers do. It is important to remember that one size does not fit all. The course must be adapted to the IMCI protocol of the country where it is conducted. The course design must respond to the needs of the participants. Proper equipment, drugs, and supervision must be in place, or participants will not be able to apply IMCI skills. Download
the IMCI Complementary Course Development presentation
Process for Adoption and Implementation at Country Level and the Status of Global Roll Out Prepared by World Bank/WHO, Presented by Michel Pacque (CSTS+) The introduction of IMCI to a country typically follows the following steps:
Early implementation of IMCI
IMCI Adaptation
Achievement in IMCI: IMCI Implementation in Africa Thirty-two countries in Africa are currently implementing IMCI, and 12 countries have adopted IMCI as national strategy for child health. Seven countries have initiated the planning for the community component of IMCI. IMCI is included in projects supported by the World Bank in seven countries. Four thousand health workers in 15 countries have been trained in IMCI, and the performance of health workers has improved. IMCI is now introduced in the curricula of medical and paramedical schools in four countries. Fifteen countries have adapted the IMCI guidelines for counseling caretakers. Evidence has shown that IMCI can serve as a catalyst for specific health improvements, such as drug availability, district supervision, and the organization of services. Challenges to IMCI implementation Although the IMCI strategy can boast several successes, there are still challenges to IMCI implementation. Increasing resources are needed to expand IMCI, and care should be taken that scope and coverage are expanded without losing quality. The family and community component of IMCI should be strengthened. IMCI must be adapted to areas of high HIV/AIDS prevalence. IMCI implementation should be coordinated with other initiatives (e.g. Roll Back Malaria) and strategies (e.g. IMPAC). As HIV/AIDS reaches epidemic proportions, IMCI should be adapted to areas of high HIV/AIDS prevalence. Download
the Adaptation Process presentation
An Overview of the Uganda IMCI Impact Study George Pariyo (Johns Hopkins University) Johns Hopkins University and Makerere University, Uganda conducted the Uganda IMCI Impact Study in collaboration with the Ministry of Health. The study was prompted by the need to evaluate the implementation of IMCI and measure its success in changing behavior and decreasing childhood illness and mortality. The study had three objectives:
Study Design The Uganda study was designed to measure changes in mortality, as they are the ultimate test of the effectiveness of a child health activity. Ten districts made up the sampling frame of the study. Six IMCI districts were randomly selected in 1999 from a list of districts that were ready for IMCI and had adequate support to sustain IMCI. Four comparison districts without active plans to implement IMCI were also selected. A baseline was determined using a DHS approach. IMCI implementation was then monitored continuously in the ten districts. When there was adequate IMCI implementation to affect child mortality, the survey was repeated to determine the mortality change and other indicators. Determining what was "adequate" implementation was an important issue in this study. Highlights from Health Facility Survey Preliminary results from the Health Facility Survey in eight districts revealed that workers trained in IMCI were more likely than workers not trained in IMCI to check respiratory rate if a child had a cough or difficult breathing. IMCI-trained workers were also more likely to check for dehydration in children with diarrhea, check weight cards, give correct feeding instructions, and refer children when appropriate. General Observations Low utilization is a general problem. A large proportion of children is still managed by health workers who are not trained in IMCI. Those workers who are trained in IMCI do not strictly follow the IMCI case management algorithm. Facilities lack the drugs and equipment for IMCI. Most facilities have first-line drugs, but lack second-line drugs and drugs for pre-referral treatment. Many facilities lack essential equipment for IMCI, such as chart booklets, laminated forms, and mother’s cards. Levels and Trends in Infant and Child Mortality Both infant and child mortality have steadily decreased in the fifteen years preceding the survey. Several factors were found to be key mortality determinants. Female babies generally experience lower mortality than male babies do. Babies born to younger mothers (under40) experience higher mortality rates than mothers who are forty years of age or older. First-order births are at highest risk for mortality, followed by birth orders seven and higher. Second- and third-order were at lowest risk. Children of mothers who had at least a secondary education enjoy the best probability of survival, while children born to mothers with no education were at the highest risk of death. Download the Uganda IMCI Impact Study presentation
What is the PVOs/NGOs’ Role in the IMCI Initiative Partnership? Alfonso Rosales (Catholic Relief Services) Background During the 1960s collaboration between PVOs/NGOs/NGOs and multilateral agencies was limited and distrustful. During the late 70s and early 80s, "neo-liberal" ideas influenced international organizations to promote a greater role for the private sector in development. In 90s there was a growing disillusionment with multilateral agencies, who were perceived to be competing with each other. Additionally, there was an increasing recognition of inter-sectoral relevance in determining "good health." Nowadays, PVOs/NGOs have an opportunity to form real partnerships with multilateral and bilateral agencies. IMCI Development: a brief history The IMCI strategy was developed in the early 1990s and was promoted by WHO-UNICEF. In 1995, a generic course of "Facility-Based IMCI" was tested in Arusha, Tanzania. In 1997, the First Global Review and Coordination Meeting took place in the Dominican Republic, and the International Agency Working Group (IAWG) was established. PVOs/NGOs have been participating in the IAWG since 1997. PVO role in the IMCI partnership In the health sector, WHO describes a partnership as a means to bring together a set of actors for the common goal of improving the health of populations based on mutually agreed-upon roles and principles. PVOs/NGOs can play a prominent role in the IMCI partnership. PVOs/NGOs can participate in policy development at the global, regional and national levels. Recently there has been a lot of PVO participation in committees. However, we may not be ready for this, because we are not seen as partners and equals, nor do we see ourselves as partners and equals. There are opportunities, but we have to be ready to take them and we have to be pro-active in pursuing them. PVOs/NGOs can offer technical support in the adaptation process and in material development. Because of their presence in the community, PVOs/NGOs are in a position to help strengthen and promote links between health facilities and the community. So far, the emphasis in studies has been on the health facilities. However, PVOs/NGOs may want to explore other ways to improve the relationship between the community and the health facility. Finally, PVOs/NGOs can offer valuable resource support in the national implementation process. Community IMCI: Two paradigms Community IMCI (C-IMCI) is currently in a developmental stage. The international public health community does not share a single, common definition of community IMCI. There are two main paradigms of C-IMCI: IMCI in the Community, and Community-Based IMCI. IMCI in the Community is a top-down approach. It is centered primarily at the health facility. The community is one of three components, but is largely passive. The main focus is on "improving family and community practices" by improving communication from the health facility to the families and the community. The IMCI in the Community approach presents some challenges. This approach relies on the existence of accessible health facilities, and there is currently an access problem. As this approach also relies on effective communication to families and communities, a change in the attitudes and behaviors of the first-level health facility workers and more contact between the first-level health workers and the children’s caretakers is necessary. Improved communication between the health worker and the caretaker could promote appropriate care-seeking behavior and enhance treatment compliance. Community-Based IMCI Community-based IMCI is a horizontal approach that, in contrast to IMCI in the community, is not focused on the health facility but on the community, who implement the approach. This approach defines specific health care roles for home, community, and health facility and facilitates links between the health facility and the community. The main focus of this approach is on strengthening household and community actions to address prevalent childhood diseases. As health facilities are only visited by 17% of the community, resources are not focused on improving the skills of the health facility workers as they are in the IMCI in the Community approach. This approach also has its challenges. Community-based IMCI necessitates a paradigm shift from an "exclusive" public health policy to an "inclusive" one that actively involves the community. We need a global, regional, and national commitment to a community focus; an emphasis on "Home-level" promotion/prevention in the IMCI strategy; and a community IMCI process that includes an introduction phase, early implementation phase, and expansion phase. Is it one or the other? The two approaches actually complement one another. While "IMCI in the Community" improves the quality of services at the health facility," "Community-Based IMCI" improves access and problem-solving capacity at the community level.
Larry Casazza (World Vision)
Suggested Roles of the NGO Community in IMCI Planning and Management Major NGOs within a country should join national-level working groups in order to help influence national IMCI policy. In the districts, NGOs may serve as the focal input of high level expertise. NGOs can develop and sustain supervisory systems, and take an independent role in service evaluation. Service Delivery It is estimated that up to 50% of health care delivery in some countries derives from the NGO sector. NGOs can work to provide
Research and Development Often, NGOs are asked how we do things, especially how we mobilize communities. We do not have enough documentation to meet this need. NGOs should document their efforts and successes in IMCI. Operational research is needed on alternative models of care in small populations. NGOs can test materials and methods in areas of controlled quality. They can also test new approaches, particularly in community action. IMCI should be included in multi-sectional development approaches. Lessons-Learned
Review of the IMCI Component in Child Survival Grant Submissions Nitin Madhav (Technical Advisor, USAID) The Child Survival Grants Program has seen a rise in the number of applications containing an IMCI component. In 1999, 39% of the applications received included an IMCI component. However, several applications were not funded because of program gaps identified in the grant proposals. John Murray, a medical epidemiologist, reviewed the 19 applications that involved IMCI. Those submitting applications involving an IMCI component are urged to read his observations. Anyone with questions about the RFAs or the application process are also urged to contact Nitin Madhav or Ann Hirschey at USAID. Download John Murray’s Review paper |
CSTS+ Project/Macro International
Phone: 301-572-0823
Email: csts@macrointernational.com
