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SudanMarch - April 2003
IMCI Health Facility Survey
World Health OrganizationRegional Office for theEastern Mediterranean
Federal Ministry of HealthRepublic of Sudan
OBJECTIVES
1
! To assess the quality of outpatient care, including both clinical and counselling care, provided to sick children aged 2 months up to 5 years old at health facilities implementing the IMCI strategy;
To describe organizational and other “healthsystems support” elements influencing the quality of care and identify major constraintsto it;
! To measure key indicators of quality care to monitor progress of the IMCI strategy at health facilities; and
! To recommend further approaches to improving the quality of outpatient child health services.
!
2
METHODOLOGY
3
SELECTION OF HEALTH FACILITIES
Systematic, random selection of 66 health facilities from a list of 136 facilities in8 States in urban and rural areas and bytype of facility:
! implementing IMCI; and
! with estimated daily caseload ofat least 2 cases below 5 years old
4
DISTRIBUTION OF HEALTH FACILITIES IN THE SAMPLEBY LOCATION AND TYPE
2
32
6
3
1112
Hospitals
No
. o
f fa
cilit
ies
Health centres Dispensaries
0
5
10
15
20
25
30
35Urban
Rural
5
SURVEY FINDINGS
6
1. Sample characteristics
2. Quality of clinical care
3. Factors influencing care
7
1. SAMPLE CHARACTERISTICS
! Case management observations:364 children aged 2 months up to5 years old
! Gender of cases: 46.7% female
! Age: 54.3% under 2 years old
! Caretakers interviewed: 350
! Mother caretakers: 82.6%
8
CASES MANAGED BY TYPE OF HEALTH PROVIDER (N = 364)
Nurses3%
Medical Assistants77%
Doctors20%
9
2. QUALITY OF CLINICAL CARE
! ASSESSMENT
! Classification
! Treatment and advice
! ASSESSMENT
10
DISTRIBUTION OF MAIN CONDITIONS IDENTIFIED IN THE SAMPLE (N = 364)
Acute respiratoryinfections
Fever
Diarrhoeal diseases
Anaemia
Eye infections
Ear problem
Severe malnutritionand Very low weight
Needing urgent referral
Percentage of all cases0 20 40 60 80 100
63
57
30
17
11
9
7
4
11
INTEGRATED ASSESSMENT (1) : MAIN TASKS AND INDEX
5.9 out of 10 tasks
Child weight taken and checkedagainst growth chart
Child checked for 3 main symptoms(cough, diarrhoea and fever)
Child checked for 3 generaldanger signs
Child road-to-health card asked for
Child checked for palmar pallor
WHO Index of integratedassessment
75%
60%
53%
45%
21%
9%
Child vaccination status checked
12
INTEGRATED ASSESSMENT (1): MAIN TASKS AND INDEXTRAINED vs UNTRAINED
Child vaccination status checked
Child weight taken and checkedagainst growth chart
Child checked for 3 main symptoms(cough, diarrhoea and fever)
Child checked for 3 generaldanger signs
Child road-to-health card asked for
Child checked for palmar pallor
WHO Index of integratedassessment
79%
71%
63%
58%
28%
10%
6.6
62%
23%
19%
0%
0%
5%
3.4
Trained
Untrained
outof 10tasks
13
PERFORMANCE OF SELECTED TASKS:TAKING TEMPERATURE AND WEIGHT
48
14
82
53
Temperaturetaken
Temperaturetaken correctly
Weighttaken
Weight takencorrectly
Perc
en
tag
e o
f ca
ses
in w
hic
h t
ask
do
ne
0
10
20
30
40
50
60
70
80
90
100
Temperature Weight14
PERFORMANCE OF SELECTED TASKS: TAKING TEMPERATURE AND WEIGHTTRAINED vs UNTRAINED
4 0
55
46
0
10
20
30
40
50
60
70
80
90
100
Perc
en
tag
e o
f ca
ses
in w
ho
m t
ask
do
ne
61
18
91
55
Temperaturetaken
Temperaturetaken correctly
Weighttaken
Weight takencorrectly
Trained
Untrained
Temperature Weight15
PERFORMANCE OF SELECTED ASSESSMENT TASKS: ARI (N = 228) AND DIARRHOEA (N = 109)
76
57
76
57
51
69
33
0
10
20
30
40
50
60
70
80
90
100 Acute respiratory infections (ARI)
Diarrhoea
Respiratoryrate
counted
Respiratoryrate
countedcorrectly
Duration of diarrhoeaepisode
asked about
Presenceof blood instool asked
about
Somethingto drinkoffered
Abdomenskin
pinched
Abdomenskin
pinchedcorrectly
Perc
en
tag
e o
f ca
ses
in w
ho
m t
ask
do
ne
ARI Diarrhoea16
SELECTED ASSESSMENT TASKS: ARI AND DIARRHOEATRAINED vs UNTRAINED
0
10
20
30
40
50
60
70
80
90
100
Respiratoryrate
counted
Respiratoryrate
countedcorrectly
Duration of diarrhoeaepisode
asked about
Presenceof blood instool asked
about
Somethingto drinkoffered
Abdomenskin
pinched
Abdomenskin
pinchedcorrectly
89
77
88
6964
82
41
15
33 33
13
4
21
4
Perc
en
tag
e o
f ca
ses
in w
ho
m t
ask
do
ne
Trained
Untrained
ARI Diarrhoea17
ASSESSMENT OF FEEDING PRACTICES:CHILDREN LESS THAN 2 YEARS OLD (N = 189) AND OLDER CHILDREN
WITH VERY LOW WEIGHT AND/OR ANAEMIA (N = 36)
Assessed for feedingpractices
Not assessed
76%
24%18
ASSESSMENT OF FEEDING PRACTICES IN THE TARGET GROUPTRAINED UNTRAINEDvs
Child 2 years old or older with verylow weight and/oranaemia assessed
35
7
30
0 0 0
Child under2 years oldassessed
Both groupsassessed for
feeding practices
0
10
20
30
40
50
60
70
80
90
100 Trained
Untrained
Perc
en
tag
e o
f ca
ses
in w
ho
m t
ask
do
ne
19
2. QUALITY OF CLINICAL CARE
! Assessment
! CLASSIFICATION
! Treatment and advice
! CLASSIFICATION
20
AGREEMENT OF PROVIDER'S CLASSIFICATIONS WITH SURVEYOR'S CLASSIFICATIONS ON MAIN CONDITIONS
72
56
50
38
37
36
33
25
21
46
Very severe febrile disease ormalaria N=65
Very severe disease/severepneumonia or pneumonia
Dysentery N=8
Severe malnutrition or verylow weight N=26
Mastoiditis or acute or chronicear infection N=27
Diarrhoea with severe or somedehydration N=11
Severe or non-severe persistentdiarrhoea N=10
Complicated or uncomplicatedmeasles N=4
Severe anaemia or anaemiaN=61
TOTAL AGREEMENT ONALL CLASSIFICATIONS ABOVE
Percentage of matching classifications
0 20 40 60 80 100
21
AGREEMENT ON CLASSIFICATIONSTRAINED UNTRAINEDvs
Very severe febrile diseaseor malaria
Very severe disease/severepneumonia or pneumonia
Dysentery
Severe malnutrition orvery low weight
Mastoiditis or acute orchronic ear infection
Diarrhoea with severe orsome dehydration
Severe or non-severepersistent diarrhoea
Complicated oruncomplicated measles
Severe anaemia or anaemia
AGREEMENT ON OVERALLCHILD CLASSIFICATIONS
Percentage of matching classifications
71
59
50
43
30
50
43
0
23
0
49
77
40
20
75
0
0
14
0
49
Danger signs
Trained
Untrained
No cases seen
No cases seen
0 20 40 60 80 100
22
2. QUALITY OF CLINICAL CARE
! Assessment
! Classification
! TREATMENT AND ADVICE
23
MANAGEMENT OF SEVERE CASES NEEDING URGENT REFERRAL (N = 14):SEVERE CASES IDENTIFIED AND REFERRED
Severe cases identifiedand referred
43%
Severe cases missedand/or
57%not referred
All the 6 children correctlyreferred out of the 14 severe
cases were identifiedby IMCI-trained providers
24
PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTIC TREATMENT(N = 80 CASES WITH "IMCI CONDITIONS" NEEDING ORAL ANTIBIOTICS)
7368
33
Prescribedoral antibiotics
Prescribedrecommendedoral antibiotics
Prescribedantibioticscorrectly
0
10
20
30
40
50
60
70
80
90
100
Perc
en
tag
e o
f ca
ses
with
an
IM
CI co
nd
itio
nn
eed
ing
an
tib
iotics
25
PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTIC TREATMENT FORIMCI CONDITIONS (1)
TRAINED UNTRAINEDvs
71 70
38
82
55
00
10
20
30
40
50
60
70
80
90
100
Prescribedoral antibiotics
Prescribedrecommendedoral antibiotics
Prescribedantibioticscorrectly
Trained
Untrained
Perc
en
tag
e o
f ca
ses
with
an
IM
CI co
nd
itio
nn
eed
ing
an
tib
iotics
26
PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTICS FORIMCI CONDITIONS (2)
TRAINED UNTRAINEDvs
0
10
20
30
40
50
60
70
80
90
100
63
92
73
54
17
67
17
0
Correct dose Correctfrequency
Correctduration
CORRECTPRESCRIPTION
Trained
Untrained
Perc
en
tag
e o
f ca
ses
giv
en
a r
eco
mm
en
ded
an
tib
iotic
27
CARETAKER CORRECT KNOWLEDGE ABOUT ORAL ANTIBIOTIC TREATMENT (IMCI CONDITIONS)
TRAINED UNTRAINEDvs
49
59
45
25
0
11
22
CORRECTKNOWLEDGE
0
10
20
30
40
50
60
70
80
90
100
0
Correct dose Correctfrequency
Correctduration
Trained
Untrained
Perc
en
tag
e o
f ca
reta
kers
of
case
s g
iven
are
com
men
ded
an
tib
iotic
28
CARETAKER'S POTENTIAL COMPLIANCE WITH PROVIDER'S ADVICE ONDURATION OF ORAL ANTIBIOTIC TREATMENT
SHOULD CHILD GET BETTER BEFORE COMPLETING TREATMENT COURSE
Other / don't know12%
Would continue but reduce dose1%Would stop treatment
22%
Would continue as advised65%
29
RATIONAL USE OF DRUGS:CASES NOT NEEDING ANTIBIOTICS GIVEN NO ANTIBIOTICS (N = 254)
Cases correctly prescribedno antibiotics
63%
Cases prescribed antibioticsbut not needing them
37% 30
74
26
26
74
0
20
40
60
80
100
Pe
rce
nta
ge
of ca
se
s n
ot n
ee
din
g a
ntib
iotic
s
Given no antibiotics Given antibiotics but not needing them
RATIONAL USE OF ANTIBIOTICSTRAINED UNTRAINEDvs
Trained Untrained31
PRESCRIPTION OF RECOMMENDED ORAL ANTIMALARIAL TREATMENT(N = 62)
74 74
27
Perc
en
tag
e o
f ca
ses
with
mala
ria
Prescribed oralantimalarials
Prescribedrecommended
oral antimalarials
Prescribed antimalarialscorrectly
0
10
20
30
40
50
60
70
80
90
100
32
76 76
41
69 69
22
0
10
20
30
40
50
60
70
80
90
100 Trained
Untrained
PRESCRIPTION OF ORAL ANTIMALARIAL TREATMENTTRAINED UNTRAINEDvs
Prescribed oralantimalarials
Prescribedrecommended
oral antimalarials
Prescribed antimalarialscorrectly
Perc
en
tag
e o
f ca
ses
with
mala
ria
33
43
78 76
41
56
100
56
22
Correct dose Correct frequency Correct duration CORRECTPRESCRIPTION
0
10
20
30
40
50
60
70
80
90
100 Trained
Untrained
Perc
en
tag
e o
f ca
ses
giv
en
an
tim
ala
rials
PRESCRIPTION OF ORAL ANTIMALARIALSTRAINED UNTRAINEDvs
34
Correct dose Correct frequency Correct duration CORRECTKNOWLEDGE
0
10
20
30
40
50
60
70
80
90
100 Trained
Untrained
CARETAKER CORRECT KNOWLEDGE ABOUT ANTIMALARIAL TREATMENTTRAINED UNTRAINEDvs
3538
43
24
0
22
0 0
Perc
en
tag
e o
f ca
ses
giv
en
an
tim
ala
rials
35
ADVICE ON ORSTRAINED UNTRAINEDvs
0
10
20
30
40
50
60
70
80
90
100 Trained
Untrained
Perc
en
tag
e o
f ca
ses
giv
en
ORS
72
4440 40
0 0 0 0
Correct amountof water to
prepare ORS
Correct adviceon when
to give ORS
Correct advice onhow much ORS to
give each time
CORRECTADVICEON ORS
36
CARETAKER KNOWLEDGE ABOUT ORS PREPARATIONAND ADMINISTRATION
TRAINED UNTRAINEDvs
79
35
56
28
73
9
27
9
Knows correctamount of waterto prepare ORS
Knowswhen togive ORS
Knows howmuch ORS to
give each time
CORRECTKNOWLEDGEABOUT ORS
0
10
20
30
40
50
60
70
80
90
100 Trained
Untrained
Perc
en
tag
e o
f ca
ses
giv
en
ORS
37
24 26
17
49
Cases with eyeinfection given
tetracyclineointment (N =41)
Cases needingVitamin A given
Vitamin A(N =46)
Cases needingvaccine given
it or toldwhen/where
0
10
20
30
40
50
60
70
80
90
100
Perc
en
tag
e o
f elig
ible
ch
ildre
n
Cases withanaemia
prescribediron (N = 55)
OTHER CURATIVE AND PREVENTIVE TREATMENTS AND OPPORTUNITIESFOR IMMUNIZATION FOR NON-REFERRED CASES
38
CASES GIVEN ADVICE ON HOME CARE BY PROVIDER ANDCARETAKER KNOWLEDGE
Signs to takechild back
immediately
ALL THREEHOME CARE
RULES
Continue feedingGive extra fluids
4138
20
12
48
79
62
0
10
20
30
40
50
60
70
80
90
100
Perc
en
tag
e
Advised by provider
Known by caretaker
39
ADVICE ON HOME CARE GIVEN BY PROVIDERTRAINED UNTRAINEDvs
5249
26
15
51 0 0
Advised to giveextra fluids
Advised tocontinue feeding
Advised on signsto take child
back immediately
ADVISED ONALL THREE HOME
CARE RULES
Trained
Untrained
0
10
20
30
40
50
60
70
80
90
100
Perc
en
tag
e o
f ca
ses
40
CARETAKERS ADVISED ON SIGNS TO RETURN IMMEDIATELYAND KNOWING ABOUT THEM
32
21
25
21
19
14
5
32
5
70
18
4
2
1
SIGNS FOR ALL:Becomes sicker
Unable to drink
FOR NO FEVER:Develops a fever
FOR NO PNEUMONIA:Develops difficult breathing
Develops fastbreathing
FOR NO DEHYDRATION:Has blood in stools
Drinks poorly
0 20 40 60 80 100
Percentage of cases
Caretaker advised
Caretaker knowing
41
CARETAKERS GIVEN AGE-APPROPRIATE ADVICE ONFREQUENCY OF FEEDING
Given no or incorrect advice76%
Given correct advice24%
42
52
21 20
10
Has a mosquitobednet
Has a treatedmosquito bednet
Child sleptunder bednetprevious night
CHILD SLEPTUNDER TREATED
BEDNET PREVIOUSNIGHT
0
10
20
30
40
50
60
70
80
90
100
Perc
en
tag
e o
f ca
reta
kers
in
terv
iew
ed
MOSQUITO BEDNETS AND THEIR USE (N = 350)
43
USE OF HOME CARE CARD AND COMMUNICATION TECHNIQUES
34
5
26 25 23
Home carecard used(N = 347)
Home carecard and
communicationtechniques
used (N = 347)
Card heldproperly
Picturespointed at
Caretakerunderstanding
checked
0
10
20
30
40
50
60
70
80
90
100
Perc
en
tag
e o
f ca
ses
Details on communication techniques(N = 118 cases in whom card used)
44
USE OF HOME CARE CARD AND COMMUNICATION TECHNIQUESTRAINED UNTRAINEDvs
Home carecard used
Home carecard and
communicationtechniques
used
Card heldproperly
Picturespointed at
Caretakerunderstanding
checked
0
10
20
30
40
50
60
70
80
90
100
Perc
en
tag
e o
f ca
ses
Details on communication techniques(cases in whom home care card used)
44
7
26 25 23
0 0 0 00
45
Trained
Untrained
3. FACTORS INFLUENCING CARE
! Drug availability
! Availability of supply for IMCI
! Availability of supply for immunization
! Availability of supply for malaria laboratory
! Availability of other supply
! Supervision
46
6
12
4
5
8.7
2.6
Essential oraltreatments
Non-injectabledrugs
Pre-referralinjectable drugs
0
2
4
6
8
10
12
14
Ind
ex
Index if all key drugs availablein all facilities
Mean no. of key drugs availablein the facilities surveyed
INDEX (MEAN) OF DRUG AVAILABILITY (N = 66 FACILITIES)(Availability of at least 1 treatment course)
47
94
91
89
88
79
45
15
Working baby scale
Source of clean water
Working timing device
Supplies to mix ORS
Thermometer
Working adult scale
Working nebulizer
0 20 40 60 80 100
Percentage of the 66 facilities in which item available
AVAILABILITY OF SUPPLY AND EQUIPMENT FOR IMCI
48
92
77
32
17
36
1. Needlesand syringes
Safety boxto dispose
of usedneedles and
syringes
2a. Functioningrefrigeratorwith correcttemperature
2b. Coldbox and
all icepacksfrozen
AVAILABILITY OFSUPPLY AND
EQUIPMENT FORIMMUNIZATION
(1 AND 2)
0
10
20
30
40
50
60
70
80
90
100
Perc
en
tag
e o
f th
e 5
3 f
aci
litie
s in
wh
ich
ite
m a
vaila
ble
AVAILABILITY OF SUPPLY AND EQUIPMENT FOR IMMUNIZATIONAT 53 FACILITIES PROVIDING IMMUNIZATION SERVICES
49
AVAILABILITY OF KEY SUPPLY AND EQUIPMENT FOR MALARIALABORATORY
77
77
70
68
62
Giemsa
Slides
Functioning microscope
Lancets to prick finger
ALL 4 ITEMS FORMALARIA LABORATORY
0 20 40 60 80 100
Percentage of the 66 facilities with the items available50
AVAILABILITY OF IMCI RECORDS, COUNSELLING CARDS,CHART BOOKLET AND OTHER RECORDS
88
77
77
70
65
65
41
IMCI chart booklet
Mother home carecounselling card for
provider use
IMCI recording forms
Road-to-health cards
IMCI daily register
Vaccination register
Drug stock cards
0 20 40 60 80 100
Percentage of the 66 facilities in which item available51
SUPERVISION IN THE 66 FACILITIES VISITED
50
11
26
15
2
Received atleast 1 supervisory
visit in the past6 months
Casemanagementobserved in
past 6 months
Hassupervisory
book
Last visit'srecommendations
recordedon the book
Clinicalsupervisiondone and
findings recorded
0
10
20
30
40
50
60
70
80
90
100
Perc
en
tag
e o
f all
66
faci
litie
s
52
CONCLUSIONS
535555
CONCLUSIONS
54
1. Better clinical performance of staff trained in IMCIthan those untrained
IMCI training can improve quality ofoutpatient child care
2. Very low clinical performance of staff not trainedin IMCI
Issue of pre-service training standards
3. Weak health systems support elements
Major constraint to delivery ofquality child care services and
IMCI implementation
55
RECOMMENDATIONS
TO FURTHER IMPROVE
OUTPATIENT CHILD
HEALTH SERVICES
56
POLICY: EQUITABLE ACCESS TODRUGS AND SERVICES
Consideration should be given to protecting
children below 2 years old, especially in poor
families, by issuing a policy and establishing
mechanisms to provide affordable drugs to them
States should commit to making key drugs
regularly available to the health facilities where
IMCI-trained staff work, to make the most of the
substantial investment placed in IMCI training
57
TRAINING: BASIC SKILLS AND SKILLREINFORCEMENT
Consideration should be given to strengthening
pre-service training curriculum of medical
assistants and introducing the IMCI outpatient
care approach as a way to develop basic skills
The Federal level and States concerned should
jointly plan to develop and commit adequate
human resources to follow up visits after IMCI
training, to conduct them on a timely basis and
according to standard methodology
58
SUPERVISION: MALARIA LABORATORYAND ROUTINE SUPERVISION
Close supervision by Federal and State levels with
quality control of malaria microscopic diagnosis
should be carried out regularly to improve the
quality of malaria laboratory diagnosis
A training package on supervision of child health
services should be developed. Supervisors
responsible for routine supervision should be
trained in child health supervisory skills and
involved in IMCI follow-up visits
59
The Italian Cooperation
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