! To assess the quality of outpatient care provided to sick children age two months up to 5 years old by health providers trained in IMCI;

Egypt

10 March - 10 April 2002

IMCI Health Facility Survey

World Health Organization Regional Office for the Eastern Mediterranean

Ministry of Health and Population Arab Republic of Egypt

OBJECTIVES

! To assess the quality of outpatient care provided to sick children age two months up to 5 years old by health providers trained in IMCI;

! To describe organisational and managerial factors (“health systems support”)

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 care

METHODOLOGY

SELECTION OF HEALTH FACILITIES:

Random selection of 50 health facilities from the list of 294 facilities in 10 Governorates in Upper and Lower Egypt:

! Implementing IMCI;

! With at least a doctor trained in IMCI; and

! Having an estimated daily caseload

of at least 4 cases below 5 years old

TYPE OF HEALTH FACILITIES SELECTED

Urban health centres Rural health facilities Hospital OPDs

0 5 10 15 20 25 30 35 40

No. of health facilities

6 6

38

ENROLMENT CRITERIA:

! AGE: 2 months “up to” 5 years old

! REASON FOR CONSULTATION: any

symptom or condition covered by IMCI

! INITIAL VISIT

Sequence at health facility

Supervisor

Waiting room Enrolment

Weight,Temperature

Doctor’s room Observation

Form 1

Surveyor 1 Surveyor 2

Supply and equipment Form 4

Surveyor’s room Exit interview

Form 2 and

Re-examination

Form 3

SURVEY FINDINGS

I. Sample characteristics

II. Quality of clinical care

III. Factors influencing care

I. SAMPLE CHARACTERISTICS:

! Case management observations: 296

! Gender of cases: 42.6% female

! Age: 66.2% under 2 years old

! Caretakers interviewed: 292

! Mother caretakers: 85.9%

II. QUALITY OF CLINICAL CARE

! ASSESSMENT

! Classification

! Treatment and advice

! ASSESSMENT

DISTRIBUTION OF THE IMCI CONDITIONS IDENTIFIED IN THE SAMPLE

78 63

60 34

27 24 18 6

2 Acute respiratory

infections

Percentage

0 20 40 60 80 100

INTEGRATED ASSESSMENT (1) : MAIN TASKS AND INDEX

100%

100%

99%

95%

88%

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 checked for palmar and mucous membrane pallor

WHO Index of integrated assessment

9.4 out of 10

INTEGRATED ASSESSMENT (2): OTHER TASKS

Child temperature taken by

thermometer 100

Child checked for ear problem 96

Child checked for throat

problem (throat and lymph nodes) 84

Child checked for the

presence of oedema of both feet 77

Child checked for visible wasting 74

Child checked for other problems 69

Percentage

0 20 40 60 80 100

100 99 100 98

Temperature

taken Temperature

taken correctly Weight

taken

Weight taken correctly

PERFORMANCE OF SELECTED TASKS: TAKING TEMPERATURE AND WEIGHT

Percentage

0 10 20 30 40 50 60 70 80 90 100

PERFORMANCE OF SELECTED ASSESSMENT TASKS: ARI AND DIARRHOEA

97

63

94 89

Respiratory countedrate

in cases with ARI

Respiratory countrate reliable

Abdomen pinched inskin diarrhoea

cases

Abdomen pinchedskin correctly 0

10 20 30 40 50 60 70 80 90 100

Percentage

PERFORMANCE OF SELECTED ASSESSMENT TASKS: THROAT AND EAR PROBLEMS

97

84 84

73

60 60

Throat

checked Lymph- nodes checked

tasksBoth done

Both ears checked in cases with ear problem

Looked for tender swelling behind

ear

tasksBoth done 0

10 20 30 40 50 60 70 80 90 100

Percentage

PERFORMANCE OF SELECTED ASSESSMENT TASKS: ANAEMIA AND MEASLES

99

89 89

74

Looked palmarfor pallor

Looked mucousfor membrane

pallor

signsBoth looked for

Measles history checked in

cases with fever 0

10 20 30 40 50 60 70 80 90 100

Percentage

ASSESSMENT OF FEEDING PRACTICES IN NON-REFERRED CHILDREN WITH LOW WEIGHT AND/OR ANAEMIA AND THOSE LESS THAN 2 YEARS OLD

Assessed for feeding practices

Not assessed

83.0%

17.0%

! Assessment

! CLASSIFICATION

! Treatment and advice

! CLASSIFICATION

No agreement

73%

27%

Agreement AGREEMENT OF PROVIDER CLASSIFICATIONS WITH SURVEYOR

CLASSIFICATIONS ON CONDITIONS PRESENT

"Very febrile disease, possible bacterial infection" (N=51)

100 100 86

82 80 64

62 0

"Persistent diarrhoea, dysentery" (N=8)

"Mastoiditis, acute or chronic ear infection" (N=9

"Severe malnutrition, low weight-for-age" (N=17)

"Very severe disease, pneumonia" (N=40)

"Throat problem" (N=72)

"Severe anaemia or anaemia" (N=79)

"Severe or some dehydration" (N=1)

0 20 40 60 80 100

Percentage

PROVIDER'S AGREEMENT WITH SURVEYOR'S CLASSIFICATIONS BY ILLNESS GROUP

! Assessment

! Classification

! TREATMENT AND ADVICE

! TREATMENT AND ADVICE

ORAL ANTIBIOTIC TREATMENT:

CORRECT PRESCRIPTION FOR NON-REFERRED CASES WITH AN IMCI CONDITION

86

74

95 100

88

Prescribed antibioticsoral

Prescribed antibiotics correctly (a+b+c)

Of those prescribed antibiotics for

an IMCI condition (N=42):

a. Prescribed

correct dose b. Prescribed correct frequency

c. Prescribed correct duration 0

10 20 30 40 50 60 70 80 90 100

Percentage

Prescribed no antibiotics Prescribed antibiotics unnecessarily

95%

5%

RATIONAL USE OF DRUGS FOR CHILDREN NOT NEEDING ANTIBIOTICS

OTHER TREATMENTS FOR NON-REFERRED CASES

86

76

93

67

Cases with anaemia prescribed

iron

Cases 6-30 months old

without anaemia prescribed iron

Cases needing vaccine given

it or told when/where

to get it

Cases needing Vitamin A

given Vitamin A 0

10 20 30 40 50 60 70 80 90 100

Percentage

CARETAKERS ADVISED BY PROVIDER ON ANTIBIOTICS AND ORS

78 99

93 95 95

90 95 95

Given advice on dose, frequency

& duration

Given

demonstration Asked checking questions 0

10 20 30 40 50 60 70 80 90 100

At least 2 of the 3

Percentage

CARETAKER'S CORRECT RECALL OF PROVIDER'S ADVICE ON ANTIBIOTICS AND ORS

60 67 88

72

a. Knows how much

to give each time

95 81

b. Knows when/how many times

per day to give 0

10 20 30 40 50 60 70 80 90 100

ORS Antibiotics

Percentage

66

c. Knows for how many days to give

antibiotic

97

c. Knows how much water

to mix with 1 ORS packet

Know all three (A+B+C)

CARETAKER'S POTENTIAL COMPLIANCE WITH PROVIDER'S ADVICE ON ANTIBIOTIC TREATMENT SHOULD CHILD GET BETTER BEFORE COMPLETING

TREATMENT COURSE

Other / don't know

Would stop treatment Would continue but reduce dose

Would continue as advised

9%

38%

9%

45%

CARETAKERS ADVISED ON FLUIDS AND FEEDING AND CORRECTLY KNOWING ABOUT THEM

96 93 91

73

93

56

About giving

extra fluids About continuing feeding 0

10 20 30 40 50 60 70 80 90 100

Percentage

Caretakers advised Caretakers knowing About both

CARETAKERS ADVISED ON SIGNS TO RETURN IMMEDIATELY AND KNOWING ABOUT THEM

92 30

23

35 15

24 0

87 87 85

85 82

81 7

SIGNS FOR ALL Develops a fever Becomes sicker Is unable to drink SIGNS FOR NO PNEUMONIA CASES Develops difficult breathing

Develops fast breathing SIGNS FOR CASES WITH DIARRHOEA/NO DEHYDRATION Has blood in stools Drinks poorly

0 20 40 60 80 100

Percentage

Caretakers advised Caretakers knowing

CARETAKERS GIVEN AGE-APPROPRIATE ADVICE ON FREQUENCY OF FEEDING

79

57

71

81

71

For children

< 6 mo. For children

6 - 11 mo. For children

12 to 23 mo. For children 2 yrs old or older with low weight and/or anaemia 0

10 20 30 40 50 60 70 80 90 100

For children

< 2 yrs old and for those with

low weight/

anaemia

Percentage

III. FACTORS INFLUENCING CARE

! Caretaker satisfaction

! Distribution of tasks

! Drug availability

! Availability of other supplies

! Supervision

! Use of services by age and sex

CARETAKERS SATISFIED WITH CHILD CARE SERVICES AT THE FACILITY

Very satisfied or satisfied

Unsatisfied 95%

5%

REASONS FOR CARETAKERS' SATISFACTION WITH SERVICES

Examination of child

Treatment given

What learnt

Immunisation services

Time spent by provider

Opportunity to ask questions

Provider's good attitude

Provide follow-up

visits 0

20 40 60 80 90

70

50

30

10 100

Percentage

86

58

17 15

7 6 5 4

PERFORMANCE OF SELECTED TASKS BY TYPE OF PROVIDER

Weight taken

Temperature taken

Questions on feeding asked for

children less than 2 years old

Advice on frequency of feeding

Advice on signs to return

ORS advice Advice on oral antibiotic 0

20 40 60 80 100

10 30 50 70 90

Nurse Doctor Both None

99 1

98 2

4 96

26 28

13 46

15 25

6 75 12 6

11 88 1

Percentage

47

INDEX (ARITHMETIC MEAN) OF DRUG AVAILABILITY

6 5.8

12 11.2

3 3

Essential oral treatments

Non-injectable drugs

Pre-referral injectable drugs 0

2 4 6 8 10 12 14

Max index if all drugs available in all facilities

Actual drug availability index in the facilities surveyed

Index

AVAILABILITY OF ORS AND ANTIBIOTICS RECOMMENDED FOR IMCI

100 100 100 100 100 100 98 60

ORS Cotrimoxazole Chloramphenicol inj.

Benzylpenicillin Gentamicin Benzathine penicillin

Amoxycillin Nalidixic acid

0 20 40 60 80 100

Percentage of the 50 facilities visited in which drug available

AVAILABILITY OF SUPPLY AND EQUIPMENT FOR IMCI

100

100

98

98

96

for immunisation (excluding hospitals)

Working nebuliser

Working baby scale

Thermometer

Supplies to mix ORS

0 20 40 60 80 100

Percentage of the facilities in which item available

AVAILABILITY OF IMCI RECORDS, COUNSELLING CARDS AND CHART BOOKLET

100

100

98

96

IMCI recording forms

IMCI chart booklet

Mother home care counselling card for provider use

0 20 40 60 80 100

Percentage of the facilities in which item available

SUPERVISION IN THE 50 FACILITIES VISITED

100

36

64

44

20

Received at least 1 supervisory

visit in the past 3 months

managementCase observed in

last visit past 3 months

Has supervisory

book

Last visit's recommendations

recorded

Clinical supervision done + findings

recorded 0

10 20 30 40 50 60 70 80 90 100

Percentage

8

49 49

OPD visits by children < 2 mo. old

OPD visits by girls

Well baby visits by girls 0

10 20 30 40 50 60 70 80 90 100

CONSULTATIONS BY AGE GROUP AND SEX IN CHILDREN UNDER-FIVE

Percentage

CONCLUSIONS

> Strong support provided by the Ministry of Health and

Population at all levels

> Critical role of follow-up visits – with feedback

meetings - after IMCI training

! Systematic examination of the child

! Rational use of drugs

! Availability of essential drugs and supplies

Promotion of quality services Promotion of quality services

Caretaker satisfaction

RECOMMENDATIONS

TO SUSTAIN AND FURTHER IMPROVE QUALITY CARE

FOR SICK CHILDREN

! Strong political support should continue to be provided to IMCI implementation by MOHP at all levels

! A revised approach should be developed in planning for training to address the issue of staff turnover

! Medical graduates’ clinical and

communication skills should be assessed to

develop a curriculum for refresher courses

! Consideration should be given to measuring public health impact of the iron

supplementation policy to address the issue of anaemia in children

! The use of the child health card should be promoted at any opportunity and IMCI home care messages could be incorporated in it

! Consideration should be given to estimating drug costs based on prescription practices of

“IMCI” and “non-IMCI” providers

! Priority should be given to testing and closely monitoring the approach to strengthen supervision on childcare at health facilities that is under

development by MOHP