republic of tajikistan quality of child health services in...

HUMAN DEVELOPMENT SECTOR UNITCentral Asia Country Unit | Europe and Central Asia Region

Republic of Tajikistan

Quality of Child Health Services in Tajikistan

THE WORLD BANK

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

World Bank Report Number 62870-TJ

ON THE COVER Family Medicine Doctor and under-five patient in Tajikistan

HUMAN DEVELOPMENT SECTOR UNITCentral Asia Country Unit

Europe and Central Asia Region

Republic of Tajikistan

Quality of Child Health Services in Tajikistan

THE WORLD BANK

June, 2011

iiiHuman Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK

Table of Contents

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

Acronyms, Abbreviations and Tajik Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Chapter 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Chapter 2. Key Survey Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Quality of Clinical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Health Systems Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Chapter 3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Chapter 4. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

iv Quality of Child Health Services in Tajikistan

AnnexesAnnex 1: Objectives of the Study and Survey Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Annex 2: Descriptive Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Annex 3: List of Surveyed PHC Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Annex 4: IMCI Priority Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Table of FiguresFigure 1: Trends in Tajikistan’s Infant Mortality Rate 1990-2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Figure 2: Leading Causes of Post-Neonatal Mortality in Tajikistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Figure 3: Tuberculosis and Measles Vaccine Coverage for Children Aged 12-23 Months . . . . . . . . . . 5

Figure 4: Assessment of Danger Signs by Regions (N=300 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Figure 5: Assessment of Weight against Growth Chart by Regions (N=300) . . . . . . . . . . . . . . . . . . . . . 9

Figure 6: Integrated Assessment: Main Tasks and the WHO Index (N=300) . . . . . . . . . . . . . . . . . . . 10

Figure 7: Rational use of Antibiotics by Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Figure 8: Vaccines Availability in Primary Health Care Facilities (N=70) . . . . . . . . . . . . . . . . . . . . . 14

Figure 9: Availability of Basic Equipment and Supplies in the Facilities (N=70) . . . . . . . . . . . . . . . 15

Figure A1: Cases Seen by Health Care Providers’ IMCI Training Status . . . . . . . . . . . . . . . . . . . . . . . 22

List of TablesTable 1: Leading Causes of Child Mortality in Tajikistan by Region (2001-2002) . . . . . . . . . . . . . . . 4

Table 2: Comparison of Selected Indicators by Family Doctors Previous Specialization . . . . . . . . . . 13

Table A1: Sampling Frame and Survey Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Table A2: PHC Facilities Visited . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Table A3: Health Care Provider Type and IMCI Training Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Table A4: Characteristics of the Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Table A5: Study PHC Facilities by Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

vHuman Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK

Acknowledgments

This report was prepared by a World Bank team with support from the Global Alliance for Vaccines Initiative (GAVI) Trust Fund. Wezi Msisha (Task Team Leader, Health Specialist, ECSH1) led the preparation of the report. The team mem-bers from the World Bank included Sarvinoz Barfieva (Operations Officer, ECSH1), Gabriel Francis (Program Assistant, ECSHD), Gulnora Kamilova (Program Assistant, ECCUZ), Shoira Zukhurova (Team Assistant, ECCTJ), Ivdity Chikovani, Maya Kherkheulidze, Natia Rukhadze, and Ketevan Chkhatarashvili (Curatio International Foundation). Editorial services were provided by Rosemarie Esber.

This report would not have been possible without techni-cal support from the WHO and UNICEF Tajikistan. We especially would like to acknowledge the support we received from, Salima Kasymova (National Program Officer, WHO Tajikistan) and Dr. S. Kurbanov (UNICEF, Tajikistan).

We also extend our thanks to Dr. S. Rhakmatuloev (Head of Maternal & Child Health Department [MCH], Ministry of Health, Tajikistan), Dr. S. Rakhmatullaeva (Deputy Head of MCH Department, Ministry of Health, Tajikistan), Dr.

M. Atoev (Director, Center of Pediatrics and Pediatric Surgery, Tajikistan), Dr. Z. Nabiev, Dr. Vakhidov (Center of Paediatrics & Pediatric Surgery, Tajikistan), and Dr. Z. Kasimova (CBHP Project Implementing Unit).

The report has benefited greatly from the peer reviewer comments (on both the concept note and the draft report) provided by Aparnaa Somanathan (Economist, EASHD), Mariam Claeson (Program Coordinator, SASHN), Salima Kasymova (National Program Officer, WHO Tajikistan), and Son Nam Nguyen (Senior Health Specialist, ECSHD). The comments and guidance received from Charles Griffin (Sr. Advisor, ECAVP) were also very useful.

This task was undertaken under the guidance of Tamar Manuelyan Atinc (former Sector Director, ECSHD), Mamta Murthi (Acting Sector Director, ECSHD ), Abdo Yazbeck (former Sector Manager, ECSH1), Daniel Dulitzky (Sector Manager, ECSH1), Motoo Konishi (Country Director, ECCU8), Chiara Bronchi (former Country Manager, ECCUTJ), and Marsha Olive (Country Manager, ECCUTJ).

vi Quality of Child Health Services in Tajikistan

Acronyms, Abbreviations and Tajik Terms

ADB Asian Development Bank

ARI Acute Respiratory Illness

CPD Continuous Professional Development

DPT Diphtheria Polio Tetanus

FM Family Medicine

GBAO Gorno-Badakhshan Autonomous Oblast

IMCI Integrated Management of Childhood Illness

IMR Infant Mortality Rate

Jamoat A local self-government unit, usually a rural sub district

MCH Maternal and Child Health

MDG Millennium Development Goals

MICS Multiple Indicator Cluster Survey

MOH Ministry of Health

NNS National Nutrition Survey

Oblast A province

ORT Oral Rehydration Therapy

PHC Primary Health Care

Rayon A rural district

RRP Rayons of Republican Subordination

TLSS Tajikistan Living Standards Survey

U5MR Under Five Mortality Rate

UNDP United Nations Development Program

UNICEF United Nations Children’s Fund

USAID United Sates Agency for International Development

WHO World Health Organization

1Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK

1. The Government of Tajikistan has identified Primary Heath Care (PHC), and Maternal and Child Health (MCH) as top priorities in its first Comprehensive National Health Sector Strategy (2010-2020). Poor child health outcomes in Tajikistan are related to systemic health sector issues, including the financing and quality of health services, as well as poverty, rural residence, and access to clean water. Tajikistan’s Millennium Development Goal (MDG) target for a two-thirds reduction in child mortality requires an infant mortality rate (IMR) of 29.6 and the under-five mortality rate (U5MR) of 39.3 by 2015.1 The most recent estimates place the IMR at 52 per 1,000 live births and the U5MR at 61 per 1,000 live births.2

2. To reduce its high infant and child mortality rates as well as develop PHC, the Government of Tajikistan introduced the Family Medicine model of practice in 2001, and the Integrated Management of Childhood Diseases (IMCI) strategy in 2000. This World Bank study was undertaken in 2010 to assess the quality of outpatient health care services for sick children aged two months to five years at primary health care (PHC) facilities in Tajikistan. The specific focus of this study is on the quality of care delivered by PHC pro-viders who were retrained over the last several years as Family Medicine practitioners. The team employed the standardized WHO/UNICEF IMCI survey methodology to evaluate the quality of care delivered to sick children attending outpatient facilities. The study was conducted in 19 districts in Khatlon region, Sogd region, the Rayons of Republican Subordination (RRP), and Dushanbe City.

3. The study findings which closely mirror those of the 2009 WHO/UNICEF IMCI survey will be of great concern to the Ministry of Health and should provide the impetus to take immediate remedial actions. Of the sample 300 sick children brought to the PHC facilities by a caretaker, only 46 percent were assessed for the basic three danger signs: inability to drink, vomiting, and convulsions. Providers should have screened 100 percent of these sick children for these seri-ous symptoms, according to the IMCI guidelines. Only 4 percent of sick children were appropriately screened at the RRP’s primary health centers. This shocking finding sharply decreased the overall average. Nonetheless, the other regions scores ranged from 46 to 64 percent, still a poor showing for an indicator that should be consistently 100 percent. Even

Executive Summary

1 UNDP (2005) Investing in Sustainable Development: Tajikistan MDG Needs Assessment.

2 UNICEF State of the World’s Children Report 2011.

though most children were weighed at the clinic, in only 27 percent of the cases did providers check the child’s weight against standard growth charts. This simple step is essential to reveal long-standing health problems, particularly malnutri-tion. Ten tasks should routinely be performed on every child presenting at a clinic, according to the IMCI guidelines. Our findings show that overall, on average, only 6.9 tasks were performed, and the RRP facilities had the worst performance in most instances.

4. On accuracy of diagnosis, the findings were equally troublesome. Providers appropriately referred ten sick chil-dren to a higher-level facility for treatment. Of the remaining 290 in the sample, only 49 percent were correctly diagnosed. Only 42 percent of children needing an antibiotic left the facility with one. While 24 percent of children not needing an antibiotic left the facility with one, or a prescription for an antibiotic. Only 8 percent of children who should have received a first dose of an antibiotic at the facility during the visit actually received it. The treatment of children with diar-rhea was better. Of the children needing oral rehydration salts, 84 percent of them received a first treatment at the facility, but only 22 percent with anemia received an iron supplement at the facility.

5. The study also finds that supervision of PHC workers is irregular, and training does not seem to be performed system-atically to improve children’s health outcomes. For example, in the Sogd region, no IMCI-trained nurse worked in any of the 20 PHC facilities surveyed, even though they play a key role in the provision of child health services. For the majority of indicators examined, no statistically significant differences were found between providers retrained in the six-month Family Medicine program and those who were not. The cur-rent Family Medicine retraining program does not seem to improve the use of the IMCI guidelines for acute child health care services. These findings indicate the need to improve the overall training of Family Medicine practitioners in the basic management of sick children following the IMCI clinical guidelines, particularly because Family Medicine practitioners are often the first point of contact between sick children and the health care system.

6. Two main issues are highlighted by this study. Firstly, the quality of primary health care services provided to children is lacking in many areas, irrespective of the PHC provider’s type of training. Second, is that the family medicine and IMCI training programs and methods require further enhancement to ensure that the service quality for children improves. Some

2 Quality of Child Health Services in Tajikistan

of the findings of this survey may be due to the staff facing constraints that could be relieved with additional resources in all PHC facilities to ensure the availability of essential drugs, antibiotics and vaccines in all PHC facilities. However, train-ing and incentives to provide appropriate care to sick children should be revisited urgently. The existing approach is not serving children or their parents well. While many determi-nants of infant and child mortality lie outside the health care system, it is vital that when a sick child comes in contact with the medical care system that it should perform well on behalf of the child.

7. In light of these findings, several actions must be taken by the Ministry of Health and its development partners to improve the current state of affairs. Of immediate concern are the following: (i) ensure the availability of essential antibiotics and vaccine stocks in all first-level primary health care facili-ties, with a special focus on PHC facilities in the RRP; (ii) undertake a closer assessment of factors contributing to poor performance in PHC facilities in the RRP and other poor per-forming rayons and implementing the appropriate solutions; (iii) provide intensive on the job training on correct child growth monitoring and nutrition to reinforce the skills and knowledge of primary health care workers; and (iv) improve

the system of routine supervision and support of primary health care providers to identify problems and reinforce their adherence to recommended clinical practice guidelines.

8. Medium-term actions to implement include: (i) under-take an independent and external evaluation of the Family Medicine re-training programs to ensure adequate and rel-evant content and training methods, with special attention to MCH; (ii) provide continuous skills improvement training for the trainers of Family Medicine providers at the four main post-graduate training centers; (iii) improve methods of paying primary health care providers through further develop-ment of the current per capita system, including exploring the use of incentive payments to Family Medicine practitioners to improve quality of services, and (iv) improvement of the current system of quality assurance in primary health care facilities.

9. Improving the country’s system of PHC is within the reach of the Tajikistan Ministry of Health. With careful planning and coordination, the MoH can successfully implement these recommendations, which will result in much needed service improvements for sick children and their health outcomes.


CHILD MORBIDITy & MORTALITy1.1 Globally, the majority of under-five mortality is attributed to a few commonly occurring and preventable childhood ill-nesses. These diseases, which often occur concurrently, are pneumonia, diarrhea, malaria, measles and HIV. In many cases, childhood diseases are worsened by under-nutrition, which contributes to approximately 35 percent of child deaths, and 11 percent of the total global disease burden.3

1.2 Tajikistan’s infant and child mortality rates are still quite high. Current estimates place the infant mortality rate (IMR) at 52 per 1,000 live births and the under-five mortality rate (U5MR) at 61 per 1,000 live births,4 compared to an IMR of 65 per 1,000 live births and an U5MR of 79 per 1,000 live births in 2005.5 Despite Tajikistan’s significant improvements in MCH outcomes, to achieve its Millennium Development Goal (MDG) goal of a two-thirds reduction in child mortality by 2015, Tajikistan’s task is to attain an IMR of 29.6 and an U5MR of 39.3 by 2015.6

Chapter 1. Introduction

1.3 Other countries with GDP levels similar to Tajikistan are making better progress towards reaching their MDG targets. In the Lao People’s Democratic Republic, for example, the IMR is 46 per 1,000 and in the Kyrgyz Republic and neigh-boring Uzbekistan; the IMR is 32 per 1,000 live births. For under-five mortality rates, Lao and the Kyrgyz Republic are respectively at 59 and 37 per 1,000 live births (UNICEF, 2011). Understanding the factors that promote or hinder progress towards achieving the MDGs critical and some of these are discussed below.

TAjIKISTAN DEMOgRAPHIC SITUATION1.4 Poverty rates in Tajikistan have declined significantly from 72.1 percent in 2003 to 53.1 in 2007 and even further to 47.2 percent in 2009. Even so, it remains the poorest country in Central Asia. Poverty is mainly a rural phenomenon, with the rural poor accounting for 75 percent of all poor and 72 percent of the extreme poor (World Bank, 2010). Out of an estimated population of 7 million people, approximately 3 million (42%) are aged 18 and under, with the median age of the population at just 20.7. Life expectancy at birth is 67.3 years. Although fertility has fallen in recent years, the total fertility rate is still greater than 3 and the annual average population growth rate is approximately 1.9 percent per year (UNICEF, 2011, UNDP, 2010). To advance overall

Figure 1: Trends in Tajikistan’s Infant Mortality Rate 1990-2006

Source: Multisectoral Determinants of Child Health in Tajikistan (2009).

3 Black et al (2008). Maternal & Child Undernutrition: Global & Regional Exposures and Health Consequences. The Lancet, 371 (9068), 243-260.

4 UNICEF State of the World’s Children Report 2011.

5 Goskomstat. (2007). Tajikistan Multiple Indicator Cluster Survey 2005 Final Report.

6 UNDP (2005). Investing in Sustainable Development: Tajikistan MDG Needs Assessment.

MOH Estimates HFA WHO WHOSIS

WHO WHOSIS: IMR = 75

WHO WHOSIS: 91

WHO WHOSIS: 38

MICS 2000-2005

MICS 2000: IMR = 89

MICS 2005: 65

LSMS 1999/2003/2007

LSMS 1999: 79

100

90

80

70

60

50

40

30

20

10

01990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006


Figure 2: Leading Causes of Post-Neonatal Mortality in Tajikistan7

7 Data are from official medical statistics and reflect only reported child deaths.

population health, policies focused on improving child health outcomes are critical.

CAUSES Of CHILD MORBIDITy & MORTALITy1.5 Preventable illnesses contribute to a considerable propor-tion of all child deaths in Tajikistan. A significant proportion of neonatal deaths are due to prematurity and low birth weight, while acute infections are the leading cause of deaths in the post-neonatal period (Table 1). Acute respiratory illness

ARI, 20%

Pneumonia,19%

Acute Diarrhea, 18%Congenital Malformations, 7%

Other, 36%

ARI, 18%

Pneumonia,21%

Acute Diarrhea, 19%CongenitalMalformations, 7%

Other, 35%

2009 2010

Total Cumulative Reported Deaths = 1,535 Total Cumulative Reported Deaths = 1,604

(ARI), pneumonia, and acute diarrhea still account for more than 50 percent of reported child deaths within the first year of life, a pattern that has remained persistent over the last eight years until the present (Figure 2).

1.6 Child morbidity and mortality patterns in Tajikistan also vary significantly by geographic area. The lowest U5MR and IMR are in the Gorno-Badakhshan Autonomous Oblast

Table 1: Leading Causes of Child Mortality in Tajikistan by Region (2001-2002)

Khatlon Region & Dushanbe City Sogd Region & RRP

Premature birth (32%) Prematurity/low birth weight (43%)

Pneumonia (21%) Birth asphyxia (33%)

Congenital malformations (12%) Acute diarrhea (12%)

Birth asphyxia (8.6%) Pneumonia (6%)

Post-neonatal Deaths Post-neonatal Deaths

Meningitis/encephalitis (20%) Acute diarrhoea (25%)

Acute diarrhea (17%) Severe/moderate malnutrition (24%)

Severe malnutrition (16%) Meningitis/encephalitis (16%)

Pneumonia (14%) Pneumonia (16%)

Severe anemia (12.6%) Severe anemia (15%)

Source: UNICEF Tajikistan, 2004. *Rayons of Republican Subordination (RRP).


(GBAO) region (54 and 46 per 1,000 respectively), as well as Dushanbe City, while the highest rates are in Khatlon region (102 and 81 per 1,000 respectively), according to the 2005 Multiple Indicator Cluster Survey (MICS). Several factors which vary by region, are known to increase the risk of poor child health outcomes in the country including short breast-feeding duration, late vaccinations, low use of oral rehydration therapy (ORT) for diarrheal diseases, micronutrient deficien-cies, and low antenatal care visits. For instance, contraceptive use among married women is highest in GBAO region (55%) and lowest in the Khatlon region (33%). Similarly, immuniza-tion coverage rates were lowest in the Khatlon region and the Rayons of Republican Subordination (RRP) and highest in the Sogd region.

1.7 Notably, only 41 percent of children in the RRP had been vaccinated against measles compared to 77 percent in Sogd (Figure 3). In addition, the proportion of exclusively breastfed infants aged 0 to 3 months was 23 percent in Dushanbe and 33 percent in Khatlon compared to 61 percent in GBAO (TLSS 2007). The practice of early weaning combined with the chronic food shortages faced by many households, par-ticularly the poorest, contribute to the relatively high levels of stunting observed in Tajik children and is also reflected in the high incidence of low birth weight babies.

1.8 According to the most recent National Nutrition Survey (NNS), the prevalence of stunting among children under the

Source: TLSS 2007.

Figure 3: Tuberculosis and Measles Vaccine Coverage for Children Aged 12-23 Months

8 Massoud et al (2001). A modern paradigm for improving health care quality. Quality Assurance Project.

9 Lin & Tavrow (2000). Assessing health worker performance of IMCI in Kenya. Quality Assurance Project Case Study.

100

90

80

70

60

50

40

30

20

BCGMeasles

Tota

l

Dus

hanb

e

Oth

er U

rban

Rura

l

Sogd

Khal

ton

RRP

GBAO

None

Prim

ary

Basic

Seco

ndar

y ge

nera

l

Sec

spec

ial

Hig

her

Poor

est

2 Q

uini

tile

3 Q

uint

ile

4 Q

uint

ile

Rich

est

age of five was 29 percent nationwide, and highest in the Khatlon region at 36.9 percent, 27.9 percent the in Sogd region, 22.8 percent in the RRP, 25.4 percent in GBAO, and lowest in Dushanbe at 21.8 percent (UNICEF, 2010).

1.9 Variation in these critical factors contributes to the increased risk for poorer child health outcomes within the country. Of course, these factors alone do not entirely account for all observed child morbidity and mortality, but they are exacerbated or indirectly caused by other broader environ-mental factors, such as region of residence, maternal educa-tion and household poverty levels.

1.10 While child health outcomes are affected by multiple factors, this study chose to assess a very specific health systems aspect, namely the quality of health services in the primary health care setting. Service quality is affected by several fac-tors including information, infrastructure, materials, drugs, human resources, what activities are done as well as how they are done.8 Quality assessment is a way to measure the differ-ence between expected and actual performance to identify opportunities for improvement.9


PRIMARy HEALTH CARE IN TAjIKISTAN1.11 Over the last decade, Tajikistan has been reforming its health care system, which was based on the Soviet model of health service provision. The Soviet system was centralized and focused largely on curative inpatient services provided by highly specialized doctors, with little emphasis on pri-mary health care (PHC) and preventive services. As such, the strengthening of PHC services, including improvements in financial and human resource allocation to the primary care level, has become the basis for the ongoing health system reforms in the country. Key reform directions for strengthen-ing the management and delivery of primary health care ser-vices include the introduction of per capita financing mecha-nisms, building management capacity, and the introduction of the Family Medicine (FM) model of practice.10 The Ministry of Health has introduced these reforms in selected districts of the country on a pilot basis with the support of various international donors. Family Medicine is seen as the most important pillar of the PHC reform as it is expected to lead to better health outcomes through efficiency gains and improved population health service coverage.

1.12 It is recognized that building an adequate cadre of FM practitioners in Tajikistan will take several years. Thus a two pronged approach is being pursued to meet the country needs for FM providers; (i) retraining of health personnel specialized in another area (internists, pediatricians, obstetricians and nurses) as Family doctors and family nurses; and (ii) prepara-tion of new FM specialists at the undergraduate level.

1.13 The FM retraining is a six month long full time post graduate program that was initiated in 2001. The program includes theoretical and clinical training covering cardiology, obstetrics and pediatrics among other topics. In the last few years, the Ministry of Health and its international develop-ment partners have undertaken various small-scale assess-ments of the FM retraining process and to a lesser degree the practices. However, no overall assessment exists for the performance of Family Medicine providers in the provision of critical primary health care services, particularly those related to maternal and child health care.

1.14 The Government’s concern over the high infant and child mortality rates prompted it to introduce the Integrated

10 Family medicine is the medical specialty that provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity. American Academy of Family Physicians (2010).

Management of Childhood Diseases (IMCI) strategy, initially on a pilot basis in 2000. The strategy, developed by the WHO and UNICEF, aims to improve child health and reduce child mortality due to pneumonia, diarrhea, malaria, measles and under-nutrition.11 The strategy has three main components: (i) in-service training of PHC workers in the delivery of effec-tive and efficient preventive and curative care for the cited problems; (ii) improving family and community practices on child health; and, (iii) strengthening health systems support, including the supply of drugs and vaccines.12,13 The WHO and UNICEF recommend an eleven day in-service training program for health workers on the IMCI case management guidelines. This consists of seven modules that combine class-room work with hands on clinical experience.14

1.15 In Tajikistan training of health personnel on the IMCI guidelines has been done through continuous professional development (CPD) workshops ranging from three to nine day duration. The guidelines are also included in the six-month FM postgraduate training program, with two days (16 hours) specifically dedicated to them. This training is intended to result in improvements in the quality of care provided to sick children in PHC facilities.

1.16 The IMCI Strategy components encompass the main programmatic directions that the MOH identified in several policy and strategic documents as critical to improving the health of children aged five and under. These documents include the National Strategy on Child and Adolescent Health (2008-2015); Action Plan on Child and Maternal Nutrition (2009); and more recently, Tajikistan’s first Comprehensive National Health Strategy (2010-2020), in which maternal and child health and primary health care are central features.

1.17 The Government implemented its IMCI strategy nation-wide in 2003. Its impressive support structure included the establishment of a National IMCI Center, three regional and more than 65 district IMCI Centers to coordinate the pro-gram. Yet high morbidity and mortality rates among children under the age of five due to diarrheal diseases, malnutrition,

11 Arifeen, Bryce, Gouws et al (2005). Quality of care for under-fives in first level health facilities in one district of Bangladesh. Bulletin of the World Health Organization; 83 (4):260-267.

12 Gouws, Bryce, Pariyo et al (2005). Measuring the quality of child health care at first-level facilities. Social Science & Medicine; 61:613-625.

13 Bryce, Victora & the MCE-IMCI Technical Advisors (2005). Ten methodological lessons from the multi-country evaluation of integrated management of childhood illness. Journal of Health Policy and Planning, 20 (supplement 1): i94-i105.

14 WHO and UNICEF (1997). IMCI in service training guide. Available online: http://www.who.int/child_adolescent_health/docu-ments/9241595650/en/index.html


and pneumonia persist. With appropriate case management, correct clinical assessment, provision of appropriate treatment and counseling on continued home management, and care of the child at home the majority of these deaths can be pre-vented. The IMCI strategy provides comprehensive guidelines to treat common childhood illnesses at first level facilities. As such if these guidelines are properly followed, they should result in the provision of basic quality care for sick children.

1.18 To improve the quality of health services, and ultimately child health outcomes, policy makers, PHC managers, prac-titioners, training institutions, and organizations need to

assess how FM and other PHC practitioners use the IMCI guidelines. The WHO/Unicef IMCI Health Facility survey therefore provided a systematic and well tested approach to examine the quality of child care using the IMCI guidelines are a basis for assessing the performance of FM practitioners through the collection of primary data. To assist in this assess-ment, the team studied the nature and quality of services received by 300 sick children who visited 70 primary health care centers in three regions of Tajikistan and Dushanbe city. Details on the study methodology and descriptive statistics are provided in Annexes 1 to 3.


2.1 The main findings of the survey are presented in the subsequent sections following the main areas of focus of the IMCI guidelines, with particular attention paid to the perfor-mance of FM doctors.

QUALITy Of CLINICAL CARE2.2 This section presents the findings of case assessment, classification, treatment and counseling, which are organized according to the IMCI priority indicators (shown in Annex 4).

Assessment

Child checked for three danger signs (PI.1) – 45.7%

2.3 Assessing each child for three key danger signs: inability to drink, vomiting everything after each feeding and convulsions is critical to detect cases of very severe disease requiring urgent referral. The IMCI guidelines require that these key assess-ment tasks be performed on every sick child, irrespective of the specific complaint. Health care provider should assess all of the three danger signs in each case of a sick child visit. This assessment is the first step for early identification of patients who need urgent treatment. When assessing each danger sign independently, researchers found that providers assessed only 66.3 percent of children for inability to drink, 65.0 percent for vomiting everything after each feeding, and 52 percent for convulsions. In less than half of all cases (45.7%), providers

Chapter 2. Key Survey Results

assessed children for all three danger signs as IMCI guidelines require.

2.4 There were large variations in the distribution of the indi-cator by regions (see Figure 4). In the RRP, only 4.3 percent of children were checked for the danger signs.

2.5 Even when family doctors and pediatricians saw the chil-dren, no statistically significant difference was found. Danger signs were assessed by these specialists in respectively only 44.0 percent and 49.3 percent of cases. When analyzed by length of IMCI training, the providers trained in the longer nine-day IMCI training performed better.15

Child’s weight checked against a growth chart (PI.3) – 26.7%

2.6 Most of the children were weighed (86.7%) on the day of the assessment. However, only in a very small proportion of cases (26.7%) did health providers check the child’s weight against the growth chart or standard tables or formulas to determine the weight-for-age, which would indicate whether the child was within appropriate guidelines. Monitoring children’s weight is critical in Tajikistan because chronic underweight is a problem in nearly a third of the children aged five and under. Because malnutrition is an underlying cause of childhood diseases, early identification and proper management are imperative. The WHO growth charts are

15 p value < 0.05.

Figure 4: Assessment of Danger Signs by Regions (N=300 )

80

60

40

20

0

% o

f chi

ldre

n ob

serv

ed

Dushanbe Khatlon Sogd RRP Total

56.9 53.5

63.8

4.3

45.7


Figure 5: Assessment of Weight against Growth Chart by Regions (N=30016)

16 Sample sizes for regions are Dushanbe: N=65, Khatlon: N=86, Sogd: N=80, RRP: N=69; Total: N=300.

17 p value < 0.05.

part of the physical exam in pediatrics and a powerful tool that can sensitively detect a child’s nutritional status. In the majority of cases, providers only weighed a child but did not assess whether the child’s weight was age and height appropri-ate. Weighing a child without proper assessment has no value. A regional comparison shows that the lowest proportion of children assessed for weight-for-age was in the RRP (Figure 5).

2.7 Children seen by family doctors were twice as likely to be weighed and have their weight checked against the growth chart compared to children seen by pediatricians (30.2% vs. 14.9%17). No difference was found in this indicator for cases seen by current and former pediatricians when con-sidering the provider’s specialization before retraining into Family Medicine). When cases were analyzed according to the health workers training in IMCI, it was found that no single child was assessed weight-for-age when a health worker was not trained in IMCI (25). Among cases seen by IMCI-trained health worker (275), a third of children received weight-for-age assessment, with a higher proportion observed among children whose providers attended the nine-day IMCI course.

Child under two years of age assessed for feeding practices (PI.6) – 45.3%

2.8 The IMCI guidelines recommend that children under

two years of age be assessed for feeding practices (including breastfeeding for children under two years old, complemen-tary feeding, and feeding changes during acute episodes of ill-ness). Such assessment is very important to establish adequate feeding practices and prevent development of nutritional problems. This study shows that of the 232 children under two years of age who were not referred to a higher level of care, less than half (45.3%) were assessed for feeding practices. Children with low weight-for-age were not more likely to receive feeding assessment than those without this condition. From 40 children with low weight and not requiring referral, 45.0% were assessed for feeding problems (SI.3).

2.9 No statistically significant difference in adherence to pro-tocols was found between cases observed by family doctors and those observed by pediatricians (a finding similar to other indicators). However, providers trained in IMCI were more likely to assess children for feeding practices, and the rate was higher among cases managed by providers who attended the seven-day IMCI course.

2.10 Assessment of respiratory rate in children with cough or difficulty breathing . A child’s breathing rate is one of the most sensitive and specific indicators of pneumonia. The IMCI guidelines recommend assessing breathing rate and chest retractions in every case with a cough and diffi-culty breathing. In 147 cases, caregivers complained of their children suffering from respiratory problems. Nonetheless, providers only counted the breathing rate in half of the cases (53.1%). Failure to assess for this important indicator can easily lead to misdiagnosis, especially in infants. IMCI-

100

80

60

40

20

0

% o

f obs

erve

d ch

ildre

n


83.1

23.127.9

42.5

72.5

10.1

86.7

26.7

94.2 93.8

child weighted weighted assessed against growth chart


trained health workers were more likely assess the respiratory rate of children than those examined by non-trained staff. Assessment of respiratory rate was positively associated with the IMCI training duration, with a statistically significant difference.18

Index of integrated assessment (mean) (PI.5) – 6.9

2.11 In any sick child visit, and despite the problem and complaints for the visit, the provider should perform several key assessments, according to IMCI guidelines. A thorough and systematic assessment helps to identify conditions that are not reported by the caretaker. To measure the completeness of the assessment received by each child, an index of integrated assessment was used. The index consists of key tasks and gives equal weight to each task done (score per task done = 1). It is expressed as the mean of the number of tasks performed in each child (out of those that should have been performed). This was based on the generic index proposed by the WHO, which includes ten assessment tasks. These are child checked for three danger signs (1, 2, 3); checked for the three main symptoms (4, 5, 6); child weighed (7); and weight checked against a growth chart (8); child checked for palmar pallor (9); and, for vaccination status (10). The index of integrated assessment enables follow-up of improvements in care and progress over time. Taking into account each of the tasks of the generic index, the higher the number of tasks performed, the higher the index. It also allows comparisons with other surveys in different countries.

18 p value < 0.05.

2.12 The index of integrated assessment for Tajikistan was 6.9, indicating that on average for every child, providers performed a mean 6.9 assessment tasks of the WHO recom-mended 10 tasks.

2.13 Of the 10 main assessment tasks, health care providers most frequently perform child weighing, assessment of vac-cination status, and the check for the three main symptoms, while assessment of weight-for-age is the most neglected task, as shown in Figure 7 below.

2.14 The highest index was found in the Khatlon region (8.0) and the lowest in the RRP (4.5). No difference was found between cases observed by family doctors and those observed by pediatricians. The IMCI trainings had a positive influence on the integrated assessment. The index was higher for children observed by providers trained in a nine-day IMCI course (7.8 out of 10 tasks) than those seen by untrained providers or those trained for three to five or seven days (6.1, 6.3 and 5.8 tasks out of 10 respectively).

Classification and TreatmentChild is correctly classified (SI.5) – 49.3%

2.16 Of the 290 children not requiring referral to a higher-level facility, almost half were correctly classified according to the main symptoms of childhood illnesses. The term “correct classification” was used when the health providers’ classifica-tion agreed with that of the surveyors (“gold standard”). The following classifications were analyzed: very severe disease or severe pneumonia or pneumonia; diarrhea with severe dehy-dration or some dehydration, severe persistent diarrhea or

Figure 6: Integrated Assessment: Main Tasks and the WHO Index (N=300)

45.7

71.3

86.7

26.7

82.0

44.0

6.9 (mean)

% of children observed

0 20 40 60 80 100

Child checked for 3 general danger signs

Child checked for 3 main symptoms

Child weighted

Child’s weight checked against growth chart

Child vaccination status checked

Child checked for palmar pallor

Index of integrated assessment (mean)


persistent diarrhea and/or dysentery; very severe febrile disease or fever-possible bacterial infection; measles with or without complications.

2.17 Children seen in the RRP were classified correctly in 34.8 percent of cases (lowest rate) with the highest rate found in Khatlon (57.8%). Children seen by IMCI trained health workers were classified correctly in half of the cases and in one-third of cases if the health worker was not trained in IMCI.

2.18 In addition to the above standard indicator, the provid-ers’ classification was matched against the “gold standard” for all IMCI problems (Streptococcal or non-Streptococcal sour throat; mastoiditis; acute or chronic ear infection, pharyngeal abscess; severe malnutrition or low weight; anemia or severe anemia in addition to the above mentioned key IMCI condi-tions). The study revealed that 44.7 percent of all observed children (N=300) were correctly classified by the providers.

2.19 No statistically significant difference between provider specialties was found (family doctors versus pediatricians). However, IMCI training had a positive influence on the pro-viders’ classification skills.19

Rational Use of Antibiotics

Child needing an oral antibiotic and were cor-rectly prescribed an oral drug (PI.7) – 42.0%

2.20 Only 42.0 percent of the 69 children with an IMCI condition who did not require urgent referral and or need oral antibiotics were prescribed antibiotics correctly. Antibiotics were prescribed as recommended by the national IMCI guide-lines (first choice medications) and the national list of essen-tial medicines. For the antibiotic to be prescribed correctly, the provider had to state the dose, frequency and duration of treatment clearly in the prescription.

2.21 In the majority of cases, prescribed antibiotic dosage and the routine of administration were correct, but the treatment duration was wrong. Duration of dosage is considered a weak area in other countries as well. For example, when providers classified Streptococcal pharyngitis, they prescribed antibiot-ics for three or five days instead of the recommended duration (10 days) as advised by the IMCI guidelines.

2.22 The Sogd region showed the lowest rate of correctly administered oral antibiotics to children who needed oral antibiotic treatment (14.8%) compared to other regions.

19 9 days – 57.7%, 7 days – 34.5, 3-5 days – 32.5%, non-trained in IMCI – 24.9%; p value < 0.05.

Non-severe pneumonia was classified in 12 children, and only in 33.3 percent of cases were antibiotics prescribed correctly (SI- 6). Only five children were classified as having dysentery and were prescribed oral antibiotics, although in one case, the prescription was incorrect. A higher rate of correct oral anti-biotic prescription was found among the cases managed by family doctors (48.1%) compared to pediatricians (23.1%); however, the difference did not reach the level of statistical significance. Analyses by providers’ with IMCI training status did not show any statistically significant difference.

Child not needing antibiotics and left the facility without antibiotics (PI.8)-55.9%

2.23 In approximately half of the cases (55.9 %), health care providers did not prescribe antibiotics to patients who did not need antibiotic treatment, according to the IMCI classifica-tion. In 24.3 percent of cases (54 out of 222), providers pre-scribed antibiotics even though there was no need. Common reasons for irrational antibiotic prescription (among 54 children) were classifications not requiring antibiotic treat-ment such as “no pneumonia, cough or cold” (61.1%), non-Streptococcal pharyngitis (20.4%), or misclassification of health conditions by providers.

2.24 Regional analysis demonstrated that in Dushanbe and the RRP, the rational use of antibiotics was better than in other regions (Figure 7).

2.25 An equal proportion of cases (not needing antibiotic treatment and left without antibiotic) managed by family doc-tors and pediatricians left the facility without being prescribed antibiotics.20

Oral rehydration salt (ORS)

Child with dehydration treated correctly (SI.7) – 84.0%

2.26 Twenty-five children were classified as having diarrhea with some dehydration but not in severe condition. Of them, the majority (84%) received ORS at the facility. All children in Dushanbe and the RRP were started on oral rehydration therapy at the facility, as recommended by the IMCI guide-lines. The availability of ORS at more than 80 percent of the facilities ensured that this important action was taken.

Child with anemia treated correctly (SI.9) –21.6%

2.27 Fifty-one children were classified as having anemia but

20 57.6% vs. 56.9%; p value < 0.05.



100

80

60

40

20

0

% o

f chi

ldre

n ob

serv

ed69.2 68.8

46.253.6

14.8

38.5

62.5 64.2

42.0

55.9

needing oral antibiotic & correctly prescribed (N=69)

not needing oral antibiotic leaves facility without it (N=222)

Figure 7: Rational use of Antibiotics by Region

not in severe condition. Correct treatment was administered in about one-fifth of the children. None of children seen by non-IMCI trained health workers were prescribed iron supplements in the case of anemia, compared to children seen by IMCI-trained medical staff (27.5%).

Child received first dose of treatment at facility (SI.10) – 7.6%

2.28 In total, 66 children were identified as needing the first antibiotic dose at the facility. Out of these, only 7.6 percent received the medication at the facility. These children were managed at four of the 70 surveyed PHC facilities. One-third of the facilities of the 66 facilities where antibiotics were not administered did not have injectable antibiotics, as recommended by the IMCI guidelines.

2.29 Although health providers may know the correct treat-ment, the lack of the basic essential antibiotics prevents them from effectively managing sick children who come to their facilities. Therefore, the responsible district and local health authorities must ensure that adequate drug stocks are provided and maintained for all PHC facilities to prevent the occurrence of child deaths from easily treatable conditions.

Vaccination and Caregiver Counseling

Advise to use extra fluid and continue feeding (PI.9) – 45.5%

2.30 Counseling caretakers on home treatment of illnesses is a key step in the management of children and one of the

effective strategies in preventing complications from disease. Providers should give caretakers three basic messages on home care of children during illness. The ‘home care rules’ for caretakers of all sick children are (i) giving extra fluids, (ii) continuing feeding and (iii) knowing the danger signs of the diseases and when to urgently return to the health provider. In this survey, health care providers advised caretakers of 45.5 percent of children not needing urgent referral to give the child extra fluid and continue feeding during the illness.

2.31 Providers retrained in family medicine (49.3%) advised caretakers more frequently than non-retrained doctors (33.3%), although the difference was not statistically signifi-cant. IMCI trained health workers were more likely to advise caregivers to give extra fluid and continue feeding during the illness.21 A higher rate was found among cases managed by seven-day IMCI course attendees.

Failure to receive vaccination (PI.10) – 69.6%

2.32 Of all the observed children, 69 needed to receive a vac-cination on the consultation day, as identified by the surveyors based on the child’s vaccination card. However, 69.6 percent of the children left the facility without receiving the required vaccination during the visit. Nevertheless, more than half of the facilities visited did have at least four of the five main vac-cines (Polio, DPT, Measles and Hepatitis B) in stock during the time of the survey. The smallest proportion of children who did not receive vaccinations during their consultation were found in the Sogd region.

21 p value < 0.05.


2.33 While this finding may be due in part to some rural pri-mary health care facilities only offering vaccinations on spe-cific days, the issue requires close follow up to avoid declines in immunization coverage and completion rates.

Caretakers’ knowledge on antibiotic and ORS administration (PI.11) – 71.6%

2.34 Caretakers of children who were administered antibiotics and/or ORS by providers were interviewed before they left the facility. The caretaker was asked to describe how to give correct antibiotic treatment to the child, including amount, number of times per day and number of days. Of the 183 interviewed caregivers, 71.6 percent were able to correctly describe how to prepare and administer antibiotic / ORS to the child.

2.35 Comparison by providers’ specialization showed that caretakers’ knowledge was higher when children were man-aged by family doctors (74.8%) than those managed by pedia-tricians (57.5%), with borderline statistical significance.22

Analyses by the IMCI status also showed higher rates among IMCI-trained doctors versus non-IMCI-trained staff; how-ever, the difference was not statistically significant.

Caretaker received correct counseling for child with very low weight (SI.15) – 35.0%

2.36 Very low weight in children is a significant problem that worsens the condition of a sick child. Only 35 percent of caretakers whose children were classified as having low

weight (n=40) received correct counseling and age-appropri-ate feeding messages. This indicator is very low, indicating that providers do not pay sufficient attention to the problem of underweight, even though this is a concern for many Tajik children. The survey also showed that feeding problems are assessed more frequently than counseling on feeding practices is done. Therefore, providers are failing to follow through with the most important and main goal of the assessment: identifying the problem and correctly managing it.

2.37 Most family doctors were trained in various medical specialties prior to being retrained as FD’s (mainly pediatrics and internal medicine). To ascertain whether prior training had any bearing on patient care, a comparison of FD’s by their previous specialty was done on some selected IMCI performance indicators, which are summarized in Table 2. The findings indicate that the specialization of family doc-tors has some impact on their current daily practice. Those family doctors who previously practiced as pediatricians demonstrated slightly better assessment, classification and proper management skills compared to other family doctors. However, the only statistically significant difference was on the administration of antibiotics. Former pediatricians did not prescribe unnecessary antibiotics to sick children.

HEALTH SySTEMS ISSUES2.38 The survey included various aspects of health systems support that are needed for quality implementation of child health care services. These include training of health workers, supervision and support for health workers clinical practice, availability of essential drugs, vaccines, equipment and sup-22 p value - 0.061.

Table 2: Comparison of Selected Indicators by Family Doctors Previous Specialization

Indicator Pediatricians (%) Other (%)

PI. 1 Child checked for three danger signs 44.7 41.8

PI. 5 Index of integrated assessment (mean) 6.3 5.9

PI. 8 Child not needing antibiotic and who leaves the facility without antibiotic* 61.5 35.6

PI. 11a Caretaker of a child who is prescribed ORS, and/or an oral antibiotic, who knows how to give the treatment 76.8 69.4

SI.3 Child with very low weight is assessed for feeding problems 44.0 41.7

SI.7 Child with dehydration treated correctly 88.2 83.3

SI.9 Child with anemia correctly treated 36.0 22.2

SI.10 Child receives first dose of treatment at facility 10.8 0

* Difference statistically significant


plies necessary for full immunization. This information was collected by interviewing the PHC manager and direct obser-vation. The findings on each of these aspects are discussed in the following section.

Training and Supervision

IMCI training (PI.18)

2.39 A key factor in the successful implementation of the IMCI strategy is the training the maximum number of health care providers in the strategy. According to WHO recommen-dations, at least 60 percent of health workers must be trained in IMCI to achieve a significant impact on child health out-comes. Based on this, a coverage analysis of the proportion of health workers trained was done separately by doctors only and both nurses and doctors. Under the IMCI trainings three, five, seven and nine-day duration courses were analyzed. Among the surveyed facilities more than half (52.9%) had at least 60 percent of doctors trained in IMCI. The level of train-ing coverage was higher in Dushanbe (58.3%) and lower in Sogd (45.0%). In total, eight facilities (11.4%) had no doctor trained in IMCI.

2.40 For nurses, the findings were quite disappointing. Of the surveyed faculties, only 17.1 percent met the recommended 60 percent IMCI training coverage for both nurses and doc-tors. In the Sogd region, not a single IMCI trained nurse was

found in the 20 PHC facilities surveyed. Because nurses play a critical role in providing primary and community health care in Tajikistan, they too require the necessary basic skills and knowledge to provide appropriate care to children.

Supervision (PI.13) – 27.1%

2.41 Routine supervisory visits to the health care facilities by IMCI program supervisors are critical to assess health workers’ performance, identify shortcomings and provide on-the-job training when needed. One main task for supervisory visits is observing case management. Of the 70 surveyed facilities, only 27.1 percent of the PHC care facilities reported having received at least one supervisory visit in the past six months. Among the regions, the lowest rate of supervisory visits was in Dushanbe facilities (16.7%), and the region with the highest number of visits was Khatlon (44.4%).

Availability of Drugs2.42 The surveyed primary health care facilities were checked for the availability of basic medical supplies and medications that are required to manage cases according to the national IMCI guidelines. The presence of the following key medica-tions was assessed:

• Essential oral treatments – These are oral drugs recommended for home treatment of pneumonia, dys-

Figure 8: Vaccines Availability in Primary Health Care Facilities (N=70)

% of PHC facilities

2,94

3,24

61.4

67.1

80

85.7

30

Index of availability of four vaccines (excluding BCG) (mean)

Index of availability of �ve vaccines (excluding BCG) (mean)

HepB

Measles

DPT/Pentavalent

OPV

BCG

0 20 40 60 80 100


entery, diarrhea, anemia and fever. The list of essential oral medications include: ORS, amoxicillin, ciprofloxa-cin, iron, and paracetamol. The index score found was 3.16, indicating that a mean of three out of five drugs was available at the facility on the day of assessment (PI.14). Only six facilities (three in Dushanbe and one in each region) had all five drugs in their stock.

• According to the national IMCI guidelines, the list of injectable drugs for one-dose pre-referral treatment for children with severe classifications needing urgent referral include Chloramphenicol, Benzylpenicillin and Gentamycin. An index score of 1.17 was found, mean-ing that from three main drugs, a mean of one drug was available in the facilities (PI.15). Only two facili-ties had all required injectable antibiotics available, and 21 had no single injectable antibiotic in stock (nine in Khatlon, nine in RRP and three in Sogd).

This means that 30 percent of these facilities would have been unable to provide pre-referral treatment as recommended by the IMCI guidelines. This was con-firmed by the survey (described previously). A third of facilities that failed to administer the initial antibiotic dose to a sick child did not have the necessary drug in stock.

• RRP PHC facilities showed the lowest index for both oral and injectable drugs compared to other regions.

Figure 9: Availability of Basic Equipment and Supplies in the Facilities (N=70)

Vaccines

Availability of vaccines (PI.17a; PI.17b) – 90.0%

2.43 The PHC facilities were assessed for the availability of vaccines and supplies. The index score of the availability of five vaccines (BCG, OPV, DPT or Pentavalent vaccine, Measles, Hepatitis B) was 3.24 ranging from 2.7 in the Sogd region to 4.6 in Dushanbe. Out of four vaccines (excluding BCG), a mean of 2.9 was found in every facility. In seven facilities (10%), vaccine stocks were not available at all. This may be explained partially by the fact that in some facili-ties, immunization sessions are held on specific days of the week when facilities receive vaccines from the district level. Nevertheless, this is a worrisome finding.

2.44 The availability of vaccines was found to be lowest for the BCG, followed by Hepatitis B. The Polio vaccine was available in the majority of facilities, and that could be explained by the polio immunization campaigns, which were recently carried out. The lack of BCG vaccine in most facili-ties is possibly because BCG is in most cases provided at the maternity facilities within three days of the birth of a child.

2.45 However, the importance of ensuring that all PHC facili-ties are provided with an adequate stock of all the five basic vaccines, to ensure that all children have completed the basic immunization schedule before the first year of life, cannot be emphasized enough. This is essential to avoid vaccine prevent-able disease outbreaks.

% of PHC facilities

2,94

Child scale

Baby scale

Watch/timing device

Supplies to mix OBS

Source of clean water

Child vaccination cards

Mother’s counseling card

IMCI chart booklet

0 20 40 60 80 100


Availability of immunization equipment and supplies (PI.16)

2.46 The list of essential equipment for provision of immuni-zation includes self-destructing needles/syringes, safety boxes, functioning refrigerator with correct temperature inside, and cold box with frozen ice packs. The study found the avail-ability of immunization equipment and supplies to be at a satisfactory level. The majority of facilities (90%) had all the above equipment available. Self-destructing syringes and safety boxes were available in almost all facilities (98.6%), cold boxes were found in all facilities, and a functioning refrigera-tor with thermometer inside was respectively in 94.3 percent and 91.4 percent of facilities.

Availability of Supplies and Equipment2.47 Basic supplies and equipment needed for IMCI include scales, timing devices, supplies to mix ORS, pure water sup-ply, vaccination cards, mother’s counseling cards and IMCI chart booklet. All these equipment was available in only 38.6 percent of the 70 surveyed facilities. In the RRP, only 10 percent of facilities had all the above listed equipment in possession (SI.17).


3.1 The study findings which closely mirror those of the 2009 WHO/UNICEF IMCI survey will be of great concern to the Ministry of Health and should provide the impetus to take immediate remedial actions. Much remains to be done to improve the overall quality of primary health care services for under-five children. The quality of services varies across the regions, with Dushanbe City generally performing better in many areas of care provision than Khatlon, Sogd and RRP.

3.2 The RRP PHC facilities’ performance on many indicators of child health is of particular concern and warrants immedi-ate attention. For instance, only 4 percent of sick children in RRP were appropriately screened for the three basic danger signs: inability to drink, vomiting, and convulsions. Another worrying finding in view of the persistent problem of child-hood stunting in Tajikistan, is the low proportion of providers who checked the children’s weight against standard growth charts even though most of them did weigh the children.

3.3 On accuracy of diagnosis, the findings were equally troublesome. Providers appropriately referred ten sick chil-dren to a higher-level facility for treatment. Of the remaining 290 in the sample, only 49 percent were correctly diagnosed. While 24 percent of children not needing an antibiotic left the facility with one, or a prescription for an antibiotic. Only 8 percent of children who should have received a first dose of an antibiotic at the facility during the visit actually received it. The treatment of children with diarrhea was better. Of the children needing oral rehydration salts, 84 percent of them received a first treatment at the facility, but only 22 percent with anemia received an iron supplement at the facility.

3.4 The study also finds that supervision of PHC workers is irregular, and training does not seem to be performed system-atically to improve children’s health outcomes. For example, in the Sogd region, no IMCI-trained nurse worked in any of the 20 PHC facilities surveyed, even though they play a key role in the provision of child health services. For the majority of indicators examined, no statistically significant differences were found between providers retrained in the six-month Family Medicine program and those who were not.

3.5 While family doctors previously trained as pediatricians performed slightly better on some indicators than those trained in other specialties (ORS prescription and administra-tion of first treatment dose at the facility), these differences were not statistically significant. The current Family Medicine

Chapter 3. Conclusions

retraining program does not seem to improve the use of the IMCI guidelines for acute child health care services. These findings indicate there is an urgent need to improve the overall training of Family Medicine practitioners in the basic management of sick children following the IMCI clinical guidelines, particularly because Family Medicine practitioners are often the first point of contact between sick children and the health care system.

3.6 The findings on the duration of IMCI training offered to health personnel are unequivocal. There is a positive cor-relation between the length of primary health care provider’s IMCI training and the quality of care they give to children. Participating in a seven- to nine-day IMCI training program produces better practice results than a three- to five-day train-ing program.

3.7 Two main issues are highlighted by this study. Firstly, the quality of primary health care services provided to children is lacking in many areas, irrespective of the PHC provider’s type of training. Second, is that the family medicine and IMCI training programs and methods require further enhancement to ensure that the service quality for children improves.

3.8 Some of the findings of this survey may be due to the staff facing constraints that could be relieved with additional resources in all PHC facilities to ensure the availability of essential drugs, antibiotics and vaccines in all PHC facili-ties. However, training and incentives to provide appropriate care to sick children also need to be revisited urgently, as the existing approach is not serving children or their parents well. Training needs to be further accompanied by consistent, regular and supportive supervision, as it is well known that on its own does not necessarily lead to better performance of health personnel.

3.9 While many determinants of infant and child mortality lie outside the health care system, it is vital that when a sick child comes in contact with the medical care system that it should perform well on behalf of the child. Improving the country’s system of PHC is within the reach of the Tajikistan Ministry of Health. With careful planning and coordination, the MoH can successfully implement the recommendations outlined in the following section, which will result in much needed service improvements for sick children and their health outcomes.


4.1 In light of the study findings, several actions must be taken by the Ministry of Health and its development partners to improve the current state of affairs. Of immediate concern are the following:

(i) ensure the availability of essential antibiotics and vac-cine stocks in all first-level primary health care facilities, with a special focus on PHC facilities in the RRP;

(ii) undertake a closer assessment of factors contributing to poor performance in PHC facilities in the RRP and other poor performing rayons and implementing the appropriate solutions;

(iii) provide intensive on the job training on correct child growth monitoring and nutrition to reinforce the skills and knowledge of primary health care workers; and

(iv) improve the system of routine supervision and support of primary health care providers to identify problems and reinforce their adherence to recommended clinical practice guidelines.

Additional recommendations based on the study findings are highlighted below.

Policies 4.2 The MOH must ensure that the clinical protocols cur-rently in use for managing sick children are consistent with the IMCI guidelines to avoid conflicting messages to primary health care providers and to ensure unified a unified treatment approach.

4.3 The MOH should commit to undertaking periodic assessments of PHC services for children, using this study as a baseline reference point to evaluate the impact of the correc-tive actions to be taken.

4.4 Develop an incentive provision program for PHC provid-ers when certain targets for preventive and curative service provision to children have been met, to encourage better qual-ity of child health care and improve outcomes.

4.5 Conduct a thorough review of the current family medi-cine training programs (undergraduate and post-graduate) to identify areas for improvement in general and in pediatric care specifically.

4.6 Ensure consistency of IMCI training, follow-up and sup-portive supervision activities across the country.

Chapter 4. Recommendations

4.7 Expand coverage of IMCI training activities for PHC health workers (especially nurses), to ensure that all children under five receive equally high quality services, starting with the identified facilities in the Sogd region.

4.8 Conduct standardized IMCI training course (11 day dura-tion), as recommended by the WHO guidelines. Standardized courses enable providers to focus more on practical sessions essential for skill development. As shown by the survey short courses (3-5 day) had limited effect on practices of health workers. Recent evidence suggests that short duration com-puter-based IMCI courses can be as effective as standard training, yet considerably less expensive.

4.9 Strengthen the training on basic pediatric following the IMCI guidelines in the Family Medicine retraining courses, as the study revealed no difference between family doctors and non-Family Medicine trained heath workers on the majority of IMCI practices.

4.10 Although this study did not focus on the quality of ser-vices provided by newly graduated FM practitioners, it is very important to ensure that the IMCI guidelines are included in the undergraduate medical and nursing curriculums. This will ensure consistency in the approach to management of sick children.

Training and Supervision4.11 The IMCI trainers/supervisors should conduct small scale qualitative assessments in each of the study districts with the providers to find out the factors that diminish their ability to provide care as recommended in the IMCI guidelines.

4.12 Greater efforts should be made to ensure that PHC nurses (and other mid-level providers, e.g., feldshers23) are systematically targeted to receive training not only on IMCI but also basic management of the sick child within the com-munity setting, since most nurses maintain close contact with caregivers through home visits, etc.

4.13 IMCI training courses should focus more on main weak-nesses identified by the survey, such as assessment of danger signs in every case, weight-for-age assessment, assessment and classification of anemia and feeding practices, rational antibiotic therapy.

23 Feldshers are auxiliary medical personnel, introduced during the Soviet era to provide medical assistance to the population, particularly in rural areas.


4.14 During the training courses / supervision special atten-tion should be paid to increasing PHC providers’ practical skills in counseling caregivers on home-based care of sick children.

4.15 Regular evaluations of the quality of the IMCI training courses should be undertaken following a standardized meth-odology to ensure quality as well current clinical information is included in the course.

4.16 More emphasis should be placed on hands on training, strengthening and ensuring continuous supervisory sup-port for PHC providers (particularly new graduates), with a particular focus on first ensuring that health managers know how to conduct supportive supervisory visits. Supervisory visits should focus on the observation of case management for children under five years, identifying weaknesses, provid-ing feedback, on-the-job support, as well as development of regular peer-to-peer learning groups for providers.

4.17 Because the World Bank is one of the main develop-ment partners that has been and continues to actively support Tajikistan in improving primary health care including the FM postgraduate training programs, the findings of this study also have several implications as to how the Bank can strengthen its support to the health sector. The main areas where the Bank, within the context of its current program of support, will endeavor to work closely with the MOH in the short- to medium-term are as follows:

(i) Supporting an independent and external evaluation of the Family Medicine retraining programs by mid-2012 to ensure adequacy and relevance of content and train-ing methods, with a special focus on MCH.

(ii) Support continuous skills improvement of the trainers of Family Medicine providers at the Khatlon and Sogd Family Medicine Training Centers (2011-2012).

(iii) Intensive focus on training of PHC providers from the Khatlon and the Sogd regions in basic pediatrics, child growth monitoring and nutrition within the context of the ongoing health and nutrition projects (2011-2013).

(iv) Improving methods of paying primary health care pro-viders through further development of the current per capita system (2011-2012).

(v) Developing and piloting the use of incentive payments to Family Medicine practitioners at the primary health care level, through a results based financing scheme to improve the quantity and quality of maternal and child health care in selected districts (2011-2015).

(vi) Improve the current system of quality assurance in primary health care facilities (2011-2015).


This study aims to address the following main objectives:

a) To provide a baseline assessment of the quality of child health services provided at the primary health care level;

b) To assess the effectiveness of Family Medicine practitio-ners in delivering basic child health services;

c) To assess the facility based implementation of the Integrated Management of Childhood Illnesses (IMCI) approach.

Of specific interest is the quality of outpatient care services for sick children aged two months to five years, particularly:

• the level of care provided;

• quality of counseling provided and caretakers’ under-standing of home treatment for their sick child;

• availability of the following key health system supports: drugs and vaccines, equipment and supervision;

• recommendations for ways to improve the quality of services

Survey MethodologyThe study design was a cross-sectional survey. The specific instrument that was used for the survey was the Integrated Management of Childhood Illnesses (IMCI) Health Facility Survey. This methodology was developed by WHO/UNICEF and has been used over the last several years in multi-country evaluations of the quality of PHC child health services in countries that have implemented the IMCI Strategy.24 This health facility survey measures health worker practices in a number of areas, including correct assessment, correct classifi-cation and treatment of sick children and correct counseling of caretakers. These measures of health worker practice are called outcome measures and the clinical guidelines for first-level health facilities developed for the Integrated Management of Childhood Illness (IMCI) are used as the clinical standard against which health worker practices are compared.

Sampling. The survey evaluated services provided by doctors retrained in Family Medicine in Dushanbe City, and selected rayons of Khatlon, Sogd and RRP. The sampling frame included PHC facilities staffed by doctors and excluded those staffed only by mid-level health care providers. A total list

ANNEx 1: OBjECTIVES Of THE STUDy AND SURVEy METHODOLOgy

of 214 PHC facilities was obtained and further stratified by those staffed with doctors trained (133) and not trained (81) as Family Medicine practitioners. Data on expected caseload of children under five was needed in selecting the sample. However, as this data was not available, it was decided instead to pre-select one rayon health center (RHC) in each survey district to ensure that the target sample of 280 children would be reached.25

Nineteen districts in the Khatlon and Sogd regions, RRP (Shakhrinav, Varzob, Tursunzade) and Dushanbe City were selected. Those districts where Family Medicine has been implemented with the support of various development agen-cies (World Bank, Project SINO, USAID, ADB) were select-ed, with the exclusion of those where a similar assessment was undertaken by WHO/UNICEF in 2009.

Systematic random sampling was used. For each stratum, the first facility was identified by a generated random number, and the rest of the facilities were identified by a sampling interval. In total, 70 PHC facilities were selected, out of which 45 PHC had trained doctor(s) in Family Medicine and 25 PHC without FM doctors were selected to serve as a control group for identification of differences in practice if any.

Inclusion criteria. Children meeting all the following criteria were enrolled in the study:

• Children aged two months to five years

• Sick children brought to the facility for a particular medical condition

• First visit to the facility for the given condition

• Caretakers consent to participate in the survey

In total, 300 children were enrolled in the study.

Survey instruments. The survey employed instruments pre-viously used in the IMCI survey conducted in Tajikistan in 2009 by WHO/UNICEF. The instruments were available in Russian and had been already adapted to the local context. A few changes were suggested by the experts during the training of the surveyors. Five main forms were used as recommended by the standard IMCI methodology; EC: Enrolment form; Form 1: Observation of health facility provider’s management of a sick child; Form 2: Exit interview with the caretaker of the sick child; Form 3: Reexamination of the sick child by a

24 Evaluations done in Bangladesh, Brazil, Peru, Tanzania & Uganda, details available at http://www.who.int/imci-mce/

25 According to the survey guidelines, the sample should include at least 30 facilities and a minimum of four sick children must be observed per facility to enable valid conclusions to be drawn.


Data management: The supervisor of each survey team was responsible for the submission of completed questionnaires. Following that, the questionnaires were checked for com-pleteness and accuracy by the field coordinator. Data entry took place at the National Center of Medical Statistics and Information. Data entry was done in the EpiData software that enabled data export into other statistical programs.

Data analyses. The data analysis was done at Curatio International Foundation office using SPSS software. Standard priority and supplementary indicators were analyzed accord-ing to the calculation methods provided by the WHO manu-al. Additional analysis was done by regions, type of providers (family doctors, pediatricians and other), and IMCI training status. For comparing categorical data, Pearson chi-squared test was used and comparison of the means for more than two groups was done using the analysis of variance (ANOVA). Level of significance was set at 0.05.

Study limitations. The survey found 17 out of the 25 control PHC facilities were actually staffed with family doctors, while originally they were sampled as facilities not staffed with family doctors, based on the information provided. Thus, the final survey sample limited conducting analysis by type of provider, as the biggest proportion captured through the sur-vey is family doctors. Also, there is a possibility that findings may be biased by the Hawthorne Effect; where doctors may perform better than usual due to the presence of the research team/observers.

surveyor; Form 4: Assessment of facili-ties’ services and supplies.

Surveyors selection and training. The following requirements were set to select supervisors and survey-ors: health background (preferably in pediatrics), familiarity with the national IMCI guidelines, knowl-edge of IMCI principles and prac-tices, previous exposure to survey fieldwork.

A list of surveyors and supervisors meeting the above criteria was sug-gested by the Ministry of Health of Tajikistan, and also taken into consideration were those who participated in the 2009 IMCI survey. In total, 18 surveyors/supervisors were selected and six teams comprised of a supervisor and two surveyors were formed. A three-day training workshop took place at the Scientific Center of Pediatrics and Pediatric Surgery on September 28-30, 2010. The training was conducted by Dr. Maya Kherkheulidze with support of the national IMCI experts. The training included presentation of the survey tools, role-plays, practical work at the outpatient department of the Center of Pediatrics and Pediatric Surgery and discus-sion of logistical issues. The manual describing rules for the forms completion was developed and distributed to each surveyor along with the detailed fieldwork schedule.

Data collection. Fieldwork took place from October 2 – 16, 2010. Each team visited the facility during one working day. External quality control of the fieldwork was carried out by a local research company “Zerkalo,” specifically contracted for this task. In addition, monitoring visits were conducted by the National IMCI Program Coordinator, the Director of the Scientific Center of Pediatrics and Pediatric Surgery, and the project staff. No major violations of the survey principles were noticed. To facilitate the data collection process and ensure that doctors were in place, managers of the PHC facilities were informed in general about possible visits. However, the aim and content of the survey was not disclosed in advance. In two cases, the facilities were substituted with other facilities from the substitution list, due to the absence of the doctor during the team visit.

Table A1: Sampling Frame and Survey Sample

Region facilities with trained facilities without trained doctors in fM doctors in fM

Sampling frame Sample Sampling frame Sample

Dushanbe 1 1 13 11

Khatlon 30 12 41 6

RRP 56 19 16 1

Sogd 47 13 24 7

Total 133 45 81 25


The sample included 300 chil-dren aged two months up to five years. In total, 70 Primary Health Care (PHC) facilities were visited in Dushanbe City, the Khatlon and Sogd regions, and the RRP (Table 3). The complete list of visited facilities is provided in Annex 2.

The surveyor’s independent reexamination of each child was used as the ‘gold standard.’ Children caretakers were also interviewed (in total 294). Facilities, services and supplies were assessed and administrative staff were interviewed in all 70 PHC. In total, 130 primary health care providers were surveyed. Almost all of the children enrolled in the study were managed by doctors. The majority of the health care provid-ers were family doctors (81.5%), followed by pediatricians (17%). Two children were managed by an otolaryngologist and a feldsher. Health care workers were asked about their training experience in IMCI, specifically timing, duration and place of training.

ANNEx 2: DESCRIPTIVE STATISTICS

Table A2: PHC Facilities Visited

PHC type Dushanbe Khatlon Sogd RRP Total

Urban Health Center 12 1 4 1 18

Rayon Health Center 8 3 2 13

Rural Health Center 9 13 17 39

Total 12 18 20 20 70

The health care providers received between three to nine days of IMCI training. The majority of children (46%) were seen by doctors trained in a nine-day IMCI course. Only 8 percent of children were managed by non-IMCI-trained health care providers (see Figure A1).

Most of the health care workers underwent the nine-day course within their six-month Family Medicine retraining program.

Characteristics of Cases ObservedThe observed cases were almost equally distributed among

Figure A1: Cases Seen by Health Care Providers’ IMCI Training Status

100

90

80

70

60

50

40

30

20

10

0

% o

f cas

es o

bser

ved

by h

ealth

wor

kers

Duration of IMCI Training

Dushanbe Khalton Sogd RRS

29

77

53

13

52

29

6

4

24

19

8

87

19

52

No Training 3-5 Days 7 Days 9 Days


the regions. About half of the children (46%) enrolled in the study were under the age of one year and the majority (77.3%) were less than two years of age. The mean time spent by a provider in managing a case was 20.5 minutes. Following the providers’ examination, all children enrolled in the study were re-examined and classified by the surveyors (“gold standard”).

Table A3: Health Care Provider Type and IMCI Training Status

IMCI training family Doctors Pediatricians Other Total

3-5 days 42 1 0 43 (33.1%)

7 days 25 0 0 25 (19.2%)

9 days 39 13 2 54 (41.5%)

Not trained In IMCI 0 8 0 8 (6.2%)

Total 106 22 2 130

Table A4: Characteristics of the Sample

Characteristics Dushanbe Khatlon Sogd RRP Total

Children observed 65 (21.7%) 69 (23%) 80 (26.7) 86 (28.7) 300

Sex n=65 n=69 n=80 n=86 n=300

Girls 27(14.5%) 40(58.0%) 54(67.5%) 44(51.2%) 165(55.0%)

Boys 38(58.5%) 29(42.0%) 26(32.5%) 42(48.8%) 135(45.0%)

Age (both sexes) n=65 n=69 n=80 n=86 n=300

<1 year (2-11 months) 25(38.5%) 34(49.3%) 39(48.8%) 40(46.5%) 138(46.0%)

1 year (12-23 months) 17(26.2%) 20(29.0%) 28(35.0%) 29(33.7%) 94(31.3%) 2 years (24-35 months) 11(16.9%) 8(11.6%) 6(7.5%) 9(10.5%) 34(11.3%)

3 years (36-47 months) 9(13.8%) 5(7.2%) 7(8.8%) 5(5.8%) 26(8.7%)

4 years (48-59 months) 3(4.6%) 2(2.9%) 0(.0%) 3(3.5%) 8(2.7%)

Average time of examination Per case observed:

Range (min-max minutes) 5-80 4-65 3-77 12-79 3-80

Median (minutes) 20 20 16 16 17

Mean (minutes) 23.2 21.9 19.1 18.8 20.5


Table A5: Study PHC Facilities by Region

N Region Rayon facility type facility name

1 Dushanbe Dushanbe UHC №1

2 Dushanbe Dushanbe UHC Dushanbe











13 Khatlon A. Djami UHC A. Djami

14 Khatlon A. Djami RaHC A. Djami

15 Khatlon Dangara RaHC Dangara

16 Khatlon Dangara RuHC Chorsada

17 Khatlon Dangara RuHC Gidjovak

18 Khatlon Dangara RuHosp Sebiston

19 Khatlon Dangara RuHC Guliston

20 Khatlon Kabodien RaHC Kabodien

21 Khatlon Kabodien RuHC Kamarov

22 Khatlon Kuliab RaHC Kuliab

23 Khatlon Kumsangir RaHC Kumsangir

24 Khatlon Kumsangir RuHC №2

25 Khatlon Muminabad RaHC Muminabad

26 Khatlon Muminabad RuHC Khonatarosh

27 Khatlon Nurek RuHC Dukoni

28 Khatlon Shaartuz RaHC Shaartuz

29 Khatlon Shaartuz RuHC Binokor

30 Khatlon Shurobod RaHC Shurobod

31 RRP Shakhrinav RaHC Shakhrinav

32 RRP Shakhrinav RuHC Uzun

33 RRP Shakhrinav RuHC Chuzi

ANNEx 3: LIST Of SURVEyED PHC fACILITIES

(continued on page 25)


N Region Rayon facility type facility name

34 RRP Shakhrinav RuHC Kadi Chubor

35 RRP Shakhrinav RuHC Oiim

36 RRP Shakhrinav RuHC Khasanov

37 RRP Varzob RaHC Varzob

38 RRP Varzob RuHC Chormagzakon

39 RRP Varzob RuHC Kharangon

40 RRP Varzob RuHC Gushari

41 RRP Tursunzade RaHC Tursunzade

42 RRP Tursunzade RuHC Durbent

43 RRP Tursunzade RuHC Chkalov

44 RRP Tursunzade RuHC Leninizm

45 RRP Tursunzade RuHC Khusnabod

46 RRP Tursunzade RuHC Frunze

47 RRP Tursunzade RuHC Karatag

48 RRP Tursunzade RuHC Ifiranos

49 RRP Tursunzade RuHC Guliston

50 RRP Турсунзаде RuHC Ok Telpak

51 Sogd Khudjand UHC Khudjand

52 Sogd Khudjand UHC №6

53 Sogd Chkalovsk UHC Chkalovsk

54 Sogd Asht RaHC Asht

55 Sogd Asht RuHC Asht

56 Sogd Asht RuHC Oshoba

57 Sogd Asht RuHC Djigda

58 Sogd Isfara RaHC Isfara

59 Sogd Isfara RuHC Matpari

60 Sogd Isfara RuHC Chorkishlok

61 Sogd Isfara RuHC Oftobrui

62 Sogd Kanibadam RaHC Kanibadam

63 Sogd Kanibadam RuHC Kuchkak

64 Sogd Kanibadam RuHC Djigdalik

65 Sogd Kanibadam RuHC Firusoba

66 Sogd Kanibadam RuHC Zarbend

67 Sogd Kanibadam RuHC Lokhuti

68 Sogd Kanibadam RuHC Khamirchui

69 Sogd Spitamen RaHC №1

70 Sogd Spitamen RuHC Kurkat


ANNEx 4: IMCI PRIORITy INDICATORS

26 Includes also weight check using standard tables and formulas.

27 Oral antibiotic are needed for the following IMCI conditions: pneumonia, dysentery, acute ear infection, streptococcal sore throat, possible bacterial infection.

28 List of essential oral treatment medications includes five drugs: ORS, amoxicillin, ciprofloxacin, paracetamol and iron supplements.

29 List of injectable drugs for pre-referral treatment includes gentamycin, benzylpenicillin and chloramphenicol.

30 List of equipment and supplies for full vaccination services includes self-destructed needles/syringes, safety boxes, functioning refrigerator with correct temperature inside, cold box with ice packs frozen.

31 Recommended vaccines include BCG, Polio, DPT or Pentavalent vaccine, Measles, Hepatitis B.

32 Recommended vaccines include Polio, DPT or Pentavalent vaccine, Measles, Hepatitis B.

Priority indicators findings (N)

A Assessment of the sick child

PI.1 Child checked for three danger signs 45.7% (300)

PI.2 Child checked for the presence of cough, diarrhea, and fever 71.3% (300)

PI.3 Child’s weight checked against a growth chart26 26.7% (300)

PI.4 Child vaccination status checked 82% (300)

PI.5 Index of integrated assessment (mean) 6.85

PI.6 Child under two years of age assessed for feeding practices 45.3% (232)

B Classification and treatment of the sick child

PI.7 Child needing an oral antibiotic for an IMCI condition and prescribed a 42.0% (69) recommended antibiotic correctly27

PI.8 Child not needing antibiotic and who leaves the facility without antibiotic 55.9% (222)

C Vaccination and counseling of the sick child

PI.9 Caretaker of sick child is advised to give extra fluids and continue feeding 45.5% (290)

PI.10 Child needing vaccinations leaves the facility with all needed vaccinations 69.6% (69)

PI.11a Caretaker of a child who is prescribed ORS, and/or an oral antibiotic, 71.6% (183) who knows how to give the treatment

PI.11b Caretaker of a child who is prescribed ORS, who knows how to give the treatment 74.3% (101)

PI.12 Child needing referral who is referred to a higher level of the health system 40% (10)

D Availability of health facility supports

PI.13 Health facility received at least one supervisory visit that included observation 27.1% (70) of case management during the previous six months

PI.14 Index of availability of essential oral treatments28 (mean) 3.16

PI.15 Index of availability of injectable drugs for pre-referral treatment29 (mean) 1.17

PI.16 Health facility has the equipment and supplies to support full vaccination services30 90% (70)

PI.17a Index of availability of five vaccines31 (including BCG) (mean) 3.24

PI.17b Index of availability of four vaccines32 (excluding BCG) (mean) 2.94

PI.18a Health facilities with at least 60% of workers managing children 52.9% (70) trained in IMCI (doctors)

PI.18b Health facilities with at least 60% of workers managing children 17.1% (70) trained in IMCI (doctors & nurses)


Summary Table on Supplemental IMCI Indicators

Supplemental indicators findings % (N)

A Screening and assessment of the sick child

SI.1 Child checked for other problems 33.7% (300)

SI.3 Child with very low weight is assessed for feeding problems 45% (40)

B Classification and treatment of the sick child

SI.4 Child with very low weight is correctly classified 42.5% (40)

SI.5 Child is correctly classified 49.3% (290)

SI.6 Child with pneumonia correctly treated 33.3% (12)

SI.7 Child with dehydration treated correctly 84% (25)

SI.9 Child with anemia correctly treated 21.6% (51)

SI.10 Child receives first dose of treatment at facility 7.6% (66)

SI.11 Child checked for lethargy 100% (2)

SI.12 Child with severe illness correctly treated 20% (10)

C Counseling of the sick child

SI.13 Child prescribed oral medication whose caretaker is advised on how 40.8% (103) to administer the treatment

SI.14 Sick child whose caretaker is advised on when to return immediately 66.9% (290)

SI.15 Child with very low weight whose caretaker received correct counseling 35% (40)

SI.16 Child leaving the facility whose caretaker was given or shown a mother’s card 24.8% (290)

D Availability of health facility supports

SI.17 Health facility has essential equipment and materials 38.6 (70)

SI.18a Health facility has IMCI chart booklet and mother’s counseling cards 25.7% (70)

SI.18b Health facility has IMCI chart booklet 58.6% (70)


1 American Academy of Family Physcians (2010). Family Medicine Practice. Available online: http://www.aafp.org/online/en/home/policy/policies/f/fammeddef.html [Accessed June 20,2011]

2 Arifeen, Bryce, Gouws et al (2005). Quality of care for under-fives in first level health facilities in one district of Bangladesh. Bulletin of the World Health Organization; 83 (4):260-267.

3 Black et al (2008). Maternal & Child Undernutrition: Global & Regional Exposures and Health Consequences. The Lancet, 371 (9068), 243-260.

4 Bryce, Victora & the MCE-IMCI Technical Advisors (2005). Ten methodological lessons from the multi-country evaluation of integrated management of child-hood illness. Journal of Health Policy and Planning, 20 (supplement 1): i94-i105

5 Goskomstat. (2007). Tajikistan Multiple Indicator Cluster Survey 2005 Final Report.

References

6 Gouws, Bryce, Pariyo et al (2005). Measuring the qual-ity of child health care at first-level facilities. Social Science & Medicine; 61:613-625.

7 Lin & Tavrow (2000). Assessing health worker perfor-mance of IMCI in Kenya. Quality Assurance Project Case Study. USAID: Bethesda, Maryland.

8 Massoud et al (2001). A modern paradigm for improv-ing health care quality. Quality Assurance Project. USAID: Bethesda, Maryland.

9 UNDP (2005) Investing in Sustainable Development: Tajikistan MDG Needs Assessment.

10 WHO and UNICEF (1997). IMCI in service training guide. Available online: http://www.who.int/child_ado-lescent_health/documents/9241595650/en/index.html [Accessed June 20, 2011]

republic of tajikistan quality of child health services in...

Documents