Sudan
March - April 2003
IMCI Health Facility Survey
World Health Organization Regional Office for the
Eastern Mediterranean Federal Ministry of Health
Republic of Sudan
OBJECTIVES
1
! To assess the quality of outpatient care, including both clinical and counselling care, provided to sick children aged 2 months up to 5 years old at health facilities implementing the IMCI strategy;
To describe organizational and other “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
METHODOLOGY
3
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
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
SURVEY FINDINGS
6
1. Sample characteristics 2. Quality of clinical care 3. Factors influencing care
7
1. SAMPLE CHARACTERISTICS
! Case management observations:
364 children aged 2 months up 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
CASES MANAGED BY TYPE OF HEALTH PROVIDER (N = 364)
Nurses 3%
Medical Assistants 77%
Doctors 20%
9
2. QUALITY OF CLINICAL CARE
! ASSESSMENT
! Classification
! Treatment and advice
! ASSESSMENT
10
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
INTEGRATED ASSESSMENT (1) : MAIN TASKS AND INDEX
5.9 out of 10 tasks
Child weight taken and checkedagainst growth chart Child checked for 3 main symptoms (cough, diarrhoea and fever)
Child checked for 3 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
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
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
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
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
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 TrainedUntrained4
ARI Diarrhoea
17
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%
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
2. QUALITY OF CLINICAL CARE
! Assessment
! CLASSIFICATION
! Treatment and advice
! CLASSIFICATION
20
AGREEMENT OF PROVIDER'S CLASSIFICATIONS WITH SURVEYOR'S CLASSIFICATIONS ON MAIN CONDITIONS
72 56
50 38 37 36 33 25 21
46
Very severe febrile disease ormalaria N=65 Very severe disease/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
AGREEMENT ON CLASSIFICATIONS TRAINED vs UNTRAINED
Very severe febrile diseaseor 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
023
049
77 40
20
75 0
0
14 0
49
Danger signs
Trained Untrained No cases seen
No cases seen
0 20 40 60 80 100
22
2. QUALITY OF CLINICAL CARE
! Assessment
! Classification
! TREATMENT AND ADVICE
23
MANAGEMENT OF SEVERE CASES NEEDING URGENT REFERRAL (N = 14):
SEVERE CASES IDENTIFIED AND REFERRED
Severe cases identified and referred
43%
Severe cases missed and/or
57%
not referredAll the 6 children correctly referred out of the 14 severe
cases were identified by IMCI-trained providers
24
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
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
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 Correctfrequency Correct
duration CORRECT
PRESCRIPTION Trained Untrained
Percentage of cases given a recommended antibiotic
27
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 Correctfrequency Correct
duration
Trained Untrained
Percentage of caretakers of cases given a recommended antibiotic
28
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
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
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
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
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
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
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
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
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
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
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
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
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
CARETAKERS GIVEN AGE-APPROPRIATE ADVICE ON FREQUENCY OF FEEDING
Given no or incorrect advice 76%
Given correct advice 24%
42
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
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
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
3. FACTORS INFLUENCING CARE
! Drug availability
! Availability of supply for IMCI
! Availability of supply for immunization
! Availability of supply for malaria laboratory
! Availability of other supply
! Supervision
46
6
12
4 5
8.7
2.6
Essential 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
94 91 89 88 79 45
15
Working baby scaleSource of clean water Working timing device Supplies to mix ORS
Thermometer Working adult scale
Working nebulizer
0 20 40 60 80 100
Percentage of the 66 facilities in which item available
AVAILABILITY OF SUPPLY AND EQUIPMENT FOR IMCI
48
92
77
32
17
36
1. 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
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
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
SUPERVISION IN THE 66 FACILITIES VISITED
50
11
26
15
2
Received atleast 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
CONCLUSIONS
53 55 55
CONCLUSIONS
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
3. Weak health systems support elements
Major constraint to delivery of quality child care services and
IMCI implementation
55
RECOMMENDATIONS
TO FURTHER IMPROVE OUTPATIENT CHILD
HEALTH SERVICES
56
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
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
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
The Italian Cooperation