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World Health Organization Regional Office for the Eastern Mediterranean Federal Ministry of Health Republic of Sudan

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(1)

Sudan

March - April 2003

IMCI Health Facility Survey

World Health Organization Regional Office for the

Eastern Mediterranean Federal Ministry of Health

Republic of Sudan

(2)
(3)

OBJECTIVES

1

(4)

! To assess the quality of outpatient care, including both clinical and counselling care, provided to sick children aged 2 months up to 5 years old at health facilities implementing the IMCI strategy;

To describe organizational and other “health systems support” elements influencing the quality of care and identify major constraints to it;

! To measure key indicators of quality care to monitor progress of the IMCI strategy at health facilities; and

! To recommend further approaches to improving the quality of outpatient child health services.

!

2

(5)

METHODOLOGY

3

(6)

SELECTION OF HEALTH FACILITIES

Systematic, random selection of 66 health facilities from a list of 136 facilities in

8 States in urban and rural areas and by type of facility:

! implementing IMCI; and

! with estimated daily caseload of at least 2 cases below 5 years old

4

(7)

DISTRIBUTION OF HEALTH FACILITIES IN THE SAMPLE BY LOCATION AND TYPE

2

32

6 3

11 12

Hospitals

No. of facilities

Health centres Dispensaries 0

5 10 15 20 25 30

35 Urban

Rural

5

(8)

SURVEY FINDINGS

6

(9)

1. Sample characteristics 2. Quality of clinical care 3. Factors influencing care

7

(10)

1. SAMPLE CHARACTERISTICS

! Case management observations:

364 children aged 2 months up to 5 years old

! Gender of cases: 46.7% female

! Age: 54.3% under 2 years old

! Caretakers interviewed: 350

! Mother caretakers: 82.6%

8

(11)

CASES MANAGED BY TYPE OF HEALTH PROVIDER (N = 364)

Nurses 3%

Medical Assistants 77%

Doctors 20%

9

(12)

2. QUALITY OF CLINICAL CARE

! ASSESSMENT

! Classification

! Treatment and advice

! ASSESSMENT

10

(13)

DISTRIBUTION OF MAIN CONDITIONS IDENTIFIED IN THE SAMPLE (N = 364)

Acute respiratory infections Fever Diarrhoeal diseases Anaemia Eye infections Ear problem Severe malnutrition and Very low weight Needing urgent referral

Percentage of all cases

0 20 40 60 80 100

63 57 30

17 11 9 7 4

11

(14)

INTEGRATED ASSESSMENT (1) : MAIN TASKS AND INDEX

5.9 out of 10 tasks

Child weight taken and checked

against growth chart Child checked for 3 main symptoms (cough, diarrhoea and fever)

Child checked for 3 general danger signs Child road-to-health card asked for Child checked for palmar pallor

WHO Index of integrated assessment

75%

60%

53%

45%

21%

9%

Child vaccination status checked

12

(15)

INTEGRATED ASSESSMENT (1): MAIN TASKS AND INDEX TRAINED vs UNTRAINED

Child vaccination status checked Child weight taken and checked against growth chart Child checked for 3 main symptoms (cough, diarrhoea and fever)

Child checked for 3 general danger signs Child road-to-health card asked for Child checked for palmar pallor

WHO Index of integrated assessment

79%

71%

63%

58%

28%

10%

6.6 62%

23%

19%

0%

0%

5%

3.4

Trained Untrained

out of 10 tasks

13

(16)

PERFORMANCE OF SELECTED TASKS:

TAKING TEMPERATURE AND WEIGHT

48

14

82

53

Temperature

taken Temperature

taken correctly Weight

taken Weight taken

correctly

Percentage of cases in which task done

0 10 20 30 40 50 60 70 80 90 100

Temperature Weight

14

(17)

PERFORMANCE OF SELECTED TASKS: TAKING TEMPERATURE AND WEIGHT TRAINED vs UNTRAINED

4 0

55

46

0 10 20 30 40 50 60 70 80 90 100

Percentage of cases in whom task done

61

18

91

55

Temperature

taken Temperature

taken correctly Weight

taken Weight taken correctly Trained

Untrained

Temperature Weight

15

(18)

PERFORMANCE OF SELECTED ASSESSMENT TASKS:

ARI (N = 228) AND DIARRHOEA (N = 109)

76

57

76

57

51

69

33

0 10 20 30 40 50 60 70 80 90

100 Acute respiratory infections (ARI) Diarrhoea

Respiratory countedrate

Respiratory countedrate correctly

Duration of diarrhoea

episode asked about

Presence of blood in stool asked

about

Something to drink

offered

Abdomen pinchedskin

Abdomen pinchedskin correctly

Percentage of cases in whom task done

ARI Diarrhoea

16

(19)

SELECTED ASSESSMENT TASKS: ARI AND DIARRHOEA TRAINED vs UNTRAINED

0 10 20 30 40 50 60 70 80 90 100

Respiratory countedrate

Respiratory countedrate correctly

Duration of diarrhoea

episode asked about

Presence of blood in stool asked

about

Something to drink

offered

Abdomen pinchedskin

Abdomen pinchedskin correctly

89

77

88

69 64

82

41

15

33 33

13

4

21

Percentage of cases in whom task done TrainedUntrained

4

ARI Diarrhoea

17

(20)

ASSESSMENT OF FEEDING PRACTICES:

CHILDREN LESS THAN 2 YEARS OLD (N = 189) AND OLDER CHILDREN WITH VERY LOW WEIGHT AND/OR ANAEMIA (N = 36)

Assessed for feeding practices

Not assessed

76%

18

24%

(21)

ASSESSMENT OF FEEDING PRACTICES IN THE TARGET GROUP TRAINED vs UNTRAINED

Child 2 years old or older with very low weight and/or

anaemia assessed 35

7

30

0 0 0

Child under 2 years old

assessed

Both groups assessed for feeding practices 0

10 20 30 40 50 60 70 80 90

100 Trained

Untrained

Percentage of cases in whom task done

19

(22)

2. QUALITY OF CLINICAL CARE

! Assessment

! CLASSIFICATION

! Treatment and advice

! CLASSIFICATION

20

(23)

AGREEMENT OF PROVIDER'S CLASSIFICATIONS WITH SURVEYOR'S CLASSIFICATIONS ON MAIN CONDITIONS

72 56

50 38 37 36 33 25 21

46

Very severe febrile disease or

malaria N=65 Very severe disease/severe pneumonia or pneumonia

Dysentery N=8 Severe malnutrition or very low weight N=26 Mastoiditis or acute or chronic ear infection N=27 Diarrhoea with severe or some dehydration N=11 Severe or non-severe persistent

diarrhoea N=10 Complicated or uncomplicated measles N=4 Severe anaemia or anaemia N=61 TOTAL AGREEMENT ON ALL CLASSIFICATIONS ABOVE

Percentage of matching classifications

0 20 40 60 80 100

21

(24)

AGREEMENT ON CLASSIFICATIONS TRAINED vs UNTRAINED

Very severe febrile disease

or malaria Very severe disease/severe pneumonia or pneumonia

Dysentery Severe malnutrition or very low weight Mastoiditis or acute or chronic ear infection Diarrhoea with severe or some dehydration Severe or non-severe persistent diarrhoea Complicated or uncomplicated measles Severe anaemia or anaemia

AGREEMENT ON OVERALL CHILD CLASSIFICATIONS

Percentage of matching classifications 71 59

50 43 30

50 43

0

23

0

49

77 40

20

75 0

0

14 0

49

Danger signs

Trained Untrained No cases seen

No cases seen

0 20 40 60 80 100

22

(25)

2. QUALITY OF CLINICAL CARE

! Assessment

! Classification

! TREATMENT AND ADVICE

23

(26)

MANAGEMENT OF SEVERE CASES NEEDING URGENT REFERRAL (N = 14):

SEVERE CASES IDENTIFIED AND REFERRED

Severe cases identified and referred

43%

Severe cases missed and/or

57%

not referred

All the 6 children correctly referred out of the 14 severe

cases were identified by IMCI-trained providers

24

(27)

PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTIC TREATMENT (N = 80 CASES WITH "IMCI CONDITIONS" NEEDING ORAL ANTIBIOTICS)

73 68

33

Prescribed

oral antibiotics Prescribed recommended oral antibiotics

Prescribed antibiotics correctly 0

10 20 30 40 50 60 70 80 90 100

Percentage of cases with an IMCI condition needing antibiotics

25

(28)

PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTIC TREATMENT FOR IMCI CONDITIONS (1)

TRAINED vs UNTRAINED

71 70

38 82

55

0 0 10 20 30 40 50 60 70 80 90 100

Prescribed

oral antibiotics Prescribed recommended oral antibiotics

Prescribed antibiotics correctly

Trained Untrained

Percentage of cases with an IMCI condition needing antibiotics

26

(29)

PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTICS FOR IMCI CONDITIONS (2)

TRAINED UNTRAINED vs

0 10 20 30 40 50 60 70 80 90 100

63

92

73

54

17

67

17

0

Correct dose Correct

frequency Correct

duration CORRECT

PRESCRIPTION Trained Untrained

Percentage of cases given a recommended antibiotic

27

(30)

CARETAKER CORRECT KNOWLEDGE ABOUT ORAL ANTIBIOTIC TREATMENT (IMCI CONDITIONS)

TRAINED vsUNTRAINED

49

59

45

25

0

11

22

CORRECT KNOWLEDGE 0

10 20 30 40 50 60 70 80 90 100

0

Correct dose Correct

frequency Correct

duration

Trained Untrained

Percentage of caretakers of cases given a recommended antibiotic

28

(31)

CARETAKER'S POTENTIAL COMPLIANCE WITH PROVIDER'S ADVICE ON DURATION OF ORAL ANTIBIOTIC TREATMENT

SHOULD CHILD GET BETTER BEFORE COMPLETING TREATMENT COURSE

Other / don't know 12%

Would continue but reduce dose Would stop treatment 1%

22%

Would continue as advised 65%

29

(32)

RATIONAL USE OF DRUGS:

CASES NOT NEEDING ANTIBIOTICS GIVEN NO ANTIBIOTICS (N = 254)

Cases correctly prescribed no antibiotics

63%

Cases prescribed antibiotics but not needing them

37%

30

(33)

74

26 26

74

0 20 40 60 80 100

Percentage of cases not needing antibiotics

Given no antibiotics Given antibiotics but not needing them

RATIONAL USE OF ANTIBIOTICS

TRAINED vs UNTRAINED

Trained Untrained

31

(34)

PRESCRIPTION OF RECOMMENDED ORAL ANTIMALARIAL TREATMENT (N = 62)

74 74

27

Percentage of cases with malaria

Prescribed oral

antimalarials Prescribed

recommended oral antimalarials

Prescribed antimalarials correctly 0

10 20 30 40 50 60 70 80 90 100

32

(35)

76 76

41

69 69

22

0 10 20 30 40 50 60 70 80 90

100 Trained

Untrained

PRESCRIPTION OF ORAL ANTIMALARIAL TREATMENT

TRAINED vs UNTRAINED

Prescribed oral

antimalarials Prescribed

recommended oral antimalarials

Prescribed antimalarials correctly

Percentage of cases with malaria

33

(36)

43

78 76

41 56

100

56

22

Correct dose Correct frequency Correct duration CORRECT PRESCRIPTION 0

10 20 30 40 50 60 70 80 90

100 Trained

Untrained

Percentage of cases given antimalarials

PRESCRIPTION OF ORAL ANTIMALARIALS TRAINED vs UNTRAINED

34

(37)

Correct dose Correct frequency Correct duration CORRECT KNOWLEDGE 0

10 20 30 40 50 60 70 80 90

100 Trained

Untrained

CARETAKER CORRECT KNOWLEDGE ABOUT ANTIMALARIAL TREATMENT

TRAINED vs UNTRAINED

35 38 43

24

0

22

0 0

Percentage of cases given antimalarials

35

(38)

ADVICE ON ORS TRAINED vs UNTRAINED

0 10 20 30 40 50 60 70 80 90

100 Trained

Untrained

Percentage of cases given ORS

72

44 40 40

0 0 0 0

Correct amount of water to prepare ORS

Correct advice on when to give ORS

Correct advice on how much ORS to

give each time

CORRECT ADVICE ON ORS 36

(39)

CARETAKER KNOWLEDGE ABOUT ORS PREPARATION AND ADMINISTRATION

TRAINED vs UNTRAINED

79

35

56

28 73

9

27

9

Knows correct amount of water

to prepare ORS

Knows when to give ORS

Knows how much ORS to give each time

CORRECT KNOWLEDGE

ABOUT ORS 0

10 20 30 40 50 60 70 80 90

100 Trained

Untrained

Percentage of cases given ORS

37

(40)

24 26

17

49

Cases with eye infection given tetracycline ointment (N =41)

Cases needing Vitamin A given

Vitamin A (N =46)

Cases needing vaccine given

it or told when/where 0

10 20 30 40 50 60 70 80 90 100

Percentage of eligible children

Cases with anaemia prescribed iron (N = 55)

OTHER CURATIVE AND PREVENTIVE TREATMENTS AND OPPORTUNITIES FOR IMMUNIZATION FOR NON-REFERRED CASES

38

(41)

CASES GIVEN ADVICE ON HOME CARE BY PROVIDER AND CARETAKER KNOWLEDGE

Signs to take child back immediately

ALL THREE HOME CARE

RULES Continue feeding

Give extra fluids

41 38

20

12 48

79

6 2

0 10 20 30 40 50 60 70 80 90 100

Percentage

Advised by provider Known by caretaker

39

(42)

ADVICE ON HOME CARE GIVEN BY PROVIDER TRAINED vs UNTRAINED

52 49

26

15

5 1 0 0

Advised to give

extra fluids Advised to

continue feeding Advised on signs to take child back immediately

ADVISED ON ALL THREE HOME

CARE RULES Trained

Untrained

0 10 20 30 40 50 60 70 80 90 100

Percentage of cases

40

(43)

CARETAKERS ADVISED ON SIGNS TO RETURN IMMEDIATELY AND KNOWING ABOUT THEM

32 21

25 21 19 14 5

32 5

70 18

4 2 1

SIGNS FOR ALL:

Becomes sicker Unable to drink FOR NO FEVER:

Develops a fever FOR NO PNEUMONIA:

Develops difficult breathing Develops fast breathing FOR NO DEHYDRATION:

Has blood in stools Drinks poorly

0 20 40 60 80 100

Percentage of cases

Caretaker advised Caretaker knowing

41

(44)

CARETAKERS GIVEN AGE-APPROPRIATE ADVICE ON FREQUENCY OF FEEDING

Given no or incorrect advice 76%

Given correct advice 24%

42

(45)

52

21 20

10

Has a mosquito

bednet Has a treated

mosquito bednet Child slept under bednet previous night

CHILD SLEPT UNDER TREATED BEDNET PREVIOUS

NIGHT 0

10 20 30 40 50 60 70 80 90 100

Percentage of caretakers interviewed

MOSQUITO BEDNETS AND THEIR USE (N = 350)

43

(46)

USE OF HOME CARE CARD AND COMMUNICATION TECHNIQUES

34

5

26 25 23

Home care card used (N = 347)

Home care card and communication

techniques used (N = 347)

Card held

properly Pictures

pointed at Caretaker understanding

checked 0

10 20 30 40 50 60 70 80 90 100

Percentage of cases

Details on communication techniques (N = 118 cases in whom card used)

44

(47)

USE OF HOME CARE CARD AND COMMUNICATION TECHNIQUES TRAINED vs UNTRAINED

Home care

card used Home care card and communication

techniques used

Card held

properly Pictures

pointed at Caretaker understanding

checked 0

10 20 30 40 50 60 70 80 90 100

Percentage of cases

Details on communication techniques (cases in whom home care card used)

44

7

26 25 23

0 0 0 0

0

45 Trained

Untrained

(48)

3. FACTORS INFLUENCING CARE

! Drug availability

! Availability of supply for IMCI

! Availability of supply for immunization

! Availability of supply for malaria laboratory

! Availability of other supply

! Supervision

46

(49)

6

12

4 5

8.7

2.6

Essential oral

treatments Non-injectable

drugs Pre-referral

injectable drugs 0

2 4 6 8 10 12 14

Index

Index if all key drugs available in all facilities

Mean no. of key drugs available in the facilities surveyed

INDEX (MEAN) OF DRUG AVAILABILITY (N = 66 FACILITIES)

(Availability of at least 1 treatment course)

47

(50)

94 91 89 88 79 45

15

Working baby scale

Source of clean water Working timing device Supplies to mix ORS

Thermometer Working adult scale

Working nebulizer

0 20 40 60 80 100

Percentage of the 66 facilities in which item available

AVAILABILITY OF SUPPLY AND EQUIPMENT FOR IMCI

48

(51)

92

77

32

17

36

1. Needles

and syringes Safety box to dispose of used needles and

syringes

2a. Functioning refrigerator with correct temperature

2b. Cold box and all ice packs frozen

AVAILABILITY OF SUPPLY AND EQUIPMENT FOR

IMMUNIZATION (1 AND 2) 0

10 20 30 40 50 60 70 80 90 100

Percentage of the 53 facilities in which item available

AVAILABILITY OF SUPPLY AND EQUIPMENT FOR IMMUNIZATION AT 53 FACILITIES PROVIDING IMMUNIZATION SERVICES

49

(52)

AVAILABILITY OF KEY SUPPLY AND EQUIPMENT FOR MALARIA LABORATORY

77 77 70 68 62

Giemsa

Slides

Functioning microscope

Lancets to prick finger

ALL 4 ITEMS FOR MALARIA LABORATORY

0 20 40 60 80 100

Percentage of the 66 facilities with the items available 50

(53)

AVAILABILITY OF IMCI RECORDS, COUNSELLING CARDS, CHART BOOKLET AND OTHER RECORDS

88 77

77 70 65 65 41

IMCI chart booklet Mother home care counselling card for provider use IMCI recording forms Road-to-health cards IMCI daily register Vaccination register Drug stock cards

0 20 40 60 80 100

Percentage of the 66 facilities in which item available

51

(54)

SUPERVISION IN THE 66 FACILITIES VISITED

50

11

26

15

2

Received at

least 1 supervisory visit in the past

6 months

managementCase observed in past 6 months

supervisoryHas book

Last visit's recommendations

recorded on the book

Clinical supervision

done and findings recorded 0

10 20 30 40 50 60 70 80 90 100

Percentage of all 66 facilities

52

(55)

CONCLUSIONS

53 55 55

CONCLUSIONS

(56)

54

1. Better clinical performance of staff trained in IMCI than those untrained

IMCI training can improve quality of outpatient child care

2. Very low clinical performance of staff not trained in IMCI

Issue of pre-service training standards

(57)

3. Weak health systems support elements

Major constraint to delivery of quality child care services and

IMCI implementation

55

(58)

RECOMMENDATIONS

TO FURTHER IMPROVE OUTPATIENT CHILD

HEALTH SERVICES

56

(59)

POLICY : EQUITABLE ACCESS TO DRUGS AND SERVICES

Consideration should be given to protecting children below 2 years old, especially in poor

families, by issuing a policy and establishing mechanisms to provide affordable drugs to them

States should commit to making key drugs regularly available to the health facilities where IMCI-trained staff work, to make the most of the

substantial investment placed in IMCI training

57

(60)

TRAINING: BASIC SKILLS AND SKILL REINFORCEMENT

Consideration should be given to strengthening pre-service training curriculum of medical assistants and introducing the IMCI outpatient

care approach as a way to develop basic skills

The Federal level and States concerned should jointly plan to develop and commit adequate human resources to follow up visits after IMCI training, to conduct them on a timely basis and

according to standard methodology

58

(61)

SUPERVISION: MALARIA LABORATORY AND ROUTINE SUPERVISION

Close supervision by Federal and State levels with quality control of malaria microscopic diagnosis

should be carried out regularly to improve the quality of malaria laboratory diagnosis

A training package on supervision of child health services should be developed. Supervisors responsible for routine supervision should be

trained in child health supervisory skills and involved in IMCI follow-up visits

59

(62)
(63)
(64)

The Italian Cooperation

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