Training in case management: Lessons learnt working in the Lake

Zone, Tanzania, 2012 - 2014

Tibu Homa Dissemination Workshop,

13th – 14th November, 2014

Dr. Festus M. Kalokola

Presentation Outline

• Introduction

• Methodology

• Results

• Lessons learnt

IMCI Implementation

• Integrated Management of Childhood Illnesses (IMCI) was introduced in Tanzania in 1996 and scaled up in all districts in 1998.

• Referral Care Manual (RCM) adopted as a policy in 2005 to address 10-20% of under fives (UFs) referred.

• IMCI implementation improved quality of care provided by health care workers (HCWs), lowered UF mortality by 13%, and was cost effective (Bryce MCE, 2005).

• Councils were unable to sustain the 11 day training.

Factors contributing to HCWs non-adherence to IMCI guidelines

• Use of single diagnoses rather than IMCI classifications

• Shortage of medicines and supplies

• Frequent turnover among trained HCWs

• Inadequate mentorship and supportive supervision

• Inadequate supplies of IMCI guidelines and job aids

• Insufficient refresher courses

Training methods used by THP

• 5-6 HCWs of hospital pediatric quality improvement teams (PQITs) undergo 6-day training (3 days in quality improvement (QI) and 3 days RCM/ supply chain management (SCM).

• 5-6 PQIT HCWs from health centers (H/Cs) and 1-2 PQIT members from dispensaries receive 6-day training ( 3day in QI and 3 days IMCI/SCM training package training for all.

• Training for H/Cs and dispensary later changed to a 10 weeks course using dIMCI (3 one day face to face encounter with facilitators) QI and SCM is integrated at first encounter (6 days)

• Analyze gaps in case management (CM) and develop QI improvement plans.

Training methods used by THP (cont’d)

• Reorient IMCI facilitators on updated guidelines to serve as clinical mentors.

• Regional and Council Health Management Teams (R/CHMTs) and clinical mentors undergo a 6-day comprehensive supportive supervision and mentorship (CSSM) training.

• Provide monthly clinical, logistic supplies and QI mentorship, and data management support.

• Provide feedback to PQIT/health management team (HMT) and the rest of R/CHMT.

Region and district coverage to date

Region Facility level Community levelDistrict District Ward

Kagera Misenyi Misenyi Kilimilile, Kasambya

Muleba Muleba Kasharunga, Gwanseri

Karagwe, Ngara, Biharamuro, Bukoba Urban, Bukoba Rural and Kyerwa

Mwanza Sengerema Sengerema Mwalubuhi, Katwe Nyamagana Nyamagana Igoma, MkolaniMagu, Misungwi, Kwimba, Ukerewe, and Ilemela

Mara Musoma Rural Musoma Rural Butiama, Bisumwa Tarime Tarime Muriba, Susuni Rorya, Serengeti, Bunda,and Musoma Urban

Geita Geita MC Geita Kalangarare, Katoro

Geita DC, Mbogwe, Chato, Bukombe and Nyanwale

Shinyanga Shinyanga MCKishapu Kishapu Kishapu, Binambiyu

Simiyu Maswa DC Maswa Buchambi, Shishiyu

Maswa DCBariadi TC and Bariadi DC

Training accomplishments through March 2014, by facility, community, cadre

Facility/Cadre

Period

% of health facilities coveredOct 12 - Sept 13 Oct 12 - Mar 14

Hospitals 41 47 87.2%

Health Center 49 68 50%

Dispensary 107 286 25%

Total H/Facilities 197 396 29.8%

HCWs 1085 1279

Clinical Mentorship 148 176

CHW 166 166

Medicine Therapeutic committees

50 70

Tibu Homa training activities

Tibu Homa Project Health Facility (PQIT)

Between 2011 and March 2014: trained 1279 HCWs in updated case management guidelines, using an approach that combines QI methods and standardized case management; formed 396 health facility PQITs in three regions.

Redesigned case management flow maps that resulted in improving clinic efficiency

Between 2011 and March 2014: trained and mentored 267 QI coaches, logistic and 176 clinical mentors among the R/CHMTs.

Improved compliance to case management guidelines (IMCI and RCM)

Conducted monthly coaching and mentorship in collaboration with R/CHMT

Improved diagnosis of malaria and other causes of fever

Conducted 3 learning sessions Improved health facility stocks of essential medicines and supplies

Conducted 2 harvest and synthesis workshops

Improved health information system and using data for decision making

In the year 2013, prepared a change package

Lessons learnt

• Improving HCWs’ performance is achieved through classroom and on-the-job training.

• Selection of participants should be done through RMOs, DMOs and MO in-charges.

• Participants should be informed that they will be expected to train other HCWs after receiving training.

• Include on-job-training in the health facility routine activities through case reviews/presentations and death audits.

Lessons learnt (cont’d)

Compliance to standard guidelines depends on:

• Performance of health care workers

• Coverage of IMCI within the Health Management Information System (HMIS)

• Availability of IMCI guidelines and job aids

• Adequate human resources

• Availability of IMCI content in routine supervision

• Availability of medicines and supplies

Lessons learnt (cont’d)

• PQITs have been found to address these problems by applying QI methods, testing and implementing practices that have been proven to bring results.

• Functional PQIT teams are those receiving support from HFM (work plans included into the health facility (HF) and comprehensive council health plans (CCHP)

• Faster improved case management is associated with internal/external on-the-job training and regular comprehensive supportive supervision/mentorship.

Lessons learnt (cont’d)

THP has also observed that using a collaborative improvement method where health facility teams come together to present and share improvement results have been associated with shared learning and scaling up best practices and overall rapid improvement.

Improvement collaborative model

Mobilise

National

Leadership/

stakeholders

Form

Technical

Leader Group

and

Collaborative

Management

Structure

Select

Region

s and

Sites

Finalise

Technical

Content/

Change

Package

Thank you.