IMCI Health Facility Survey Sudan March - April 2003
World Health Organization Regional Office for the Eastern Mediterranean
Federal Ministry of Health Republic of Sudan
OBJECTIVES
1
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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.
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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 35 30 25 No. of facilities 20 15 10 5 0
32
Urban Rural
11 6 2 3 Health centres
12
Hospitals
Dispensaries
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%
Doctors 20%
Medical Assistants 77%
9
2. QUALITY OF CLINICAL CARE
! ASSESSMENT ! Classification ! Treatment and advice 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 0
63 57 30 17 11 9 7 4 20 40 60 Percentage of all cases 80 100 11
INTEGRATED ASSESSMENT (1) : MAIN TASKS AND INDEX
Child checked for 3 main symptoms (cough, diarrhoea and fever) Child vaccination status checked Child weight taken and checked against growth chart Child checked for palmar pallor Child checked for 3 general danger signs Child road-to-health card asked for
75% 60% 53% 45% 21% 9% 5.9 out of 10 tasks
WHO Index of integrated assessment 12
INTEGRATED ASSESSMENT (1): MAIN TASKS AND INDEX TRAINED vs UNTRAINED Child checked for 3 main symptoms (cough, diarrhoea and fever) Child vaccination status checked Child weight taken and checked against growth chart Child checked for palmar pallor Child checked for 3 general danger signs Child road-to-health card asked for
62% 23% 19% 0% 0% 10% 5% 28%
79% 71%
63% 58%
Trained Untrained
WHO Index of integrated assessment
3.4
6.6
out of 10 tasks
13
PERFORMANCE OF SELECTED TASKS: TAKING TEMPERATURE AND WEIGHT 100 Percentage of cases in which task done
90 80 70 60 50 40 30 20 10 0 Temperature taken Temperature taken correctly
82
53 48
14
Weight taken
Weight taken correctly
14
Temperature
Weight
PERFORMANCE OF SELECTED TASKS: TAKING TEMPERATURE AND WEIGHT TRAINED vs UNTRAINED 100 90 80 70 60 50 40 30 20 10 0 Trained Untrained
Percentage of cases in whom task done
91
61
55
55 46
18 4 Temperature taken
0 Temperature taken correctly Weight taken Weight taken correctly 15
Temperature
Weight
PERFORMANCE OF SELECTED ASSESSMENT TASKS: ARI (N = 228) AND DIARRHOEA (N = 109) 100 Acute respiratory infections (ARI) Diarrhoea
Percentage of cases in whom task done
90 80 70 60 50 40 30 20 10 0 Respiratory Respiratory rate rate counted counted correctly
76 57
76 69 57 51 33
Duration of Presence Something diarrhoea of blood in to drink offered episode stool asked about asked about
Abdomen skin pinched
Abdomen skin pinched correctly
16
ARI
Diarrhoea
SELECTED ASSESSMENT TASKS: ARI AND DIARRHOEA TRAINED vs UNTRAINED 100 90 80 70 60 50 40 30 20 10 0 Respiratory Respiratory rate rate counted counted correctly
Percentage of cases in whom task done
89 77
88 69
Trained Untrained
82
64
41 33 15 33 21 13 4 Duration of Presence Something Abdomen skin diarrhoea of blood in to drink stool asked pinched offered episode about asked about
4 Abdomen skin pinched correctly 17
ARI
Diarrhoea
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 76%
18
Not assessed 24%
ASSESSMENT OF FEEDING PRACTICES IN THE TARGET GROUP TRAINED vs UNTRAINED 100 Trained Untrained
Percentage of cases in whom task done
90 80 70 60 50 40 30 20 10 0
35
30
0 Child under 2 years old assessed
7
0
0 Both groups assessed for feeding practices 19
Child 2 years old or older with very low weight and/or anaemia assessed
2. QUALITY OF CLINICAL CARE ! ! ! Assessment CLASSIFICATION Treatment and advice
20
AGREEMENT OF PROVIDER'S CLASSIFICATIONS WITH SURVEYOR'S CLASSIFICATIONS ON MAIN CONDITIONS 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 0
72 56 50 38 37 36 33 25 21 46
Percentage of matching classifications
20
40
60
80
100 21
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 Danger signs No cases seen
71 40 43 30 50 43 59 50
77
20
75
0 0 0 0 0 0
No cases seen
14
23
Trained Untrained
AGREEMENT ON OVERALL CHILD CLASSIFICATIONS 22
Percentage of matching classifications
20
40
49 49
60
80
100
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%
24
Severe cases missed and/or not referred 57%
All the 6 children correctly referred out of the 14 severe cases were identified by IMCI-trained providers
PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTIC TREATMENT (N = 80 CASES WITH "IMCI CONDITIONS" NEEDING ORAL ANTIBIOTICS) 100 Percentage of cases with an IMCI condition needing antibiotics 90 80 70 60 50 40 30 20 10 0 Prescribed oral antibiotics Prescribed recommended oral antibiotics Prescribed antibiotics correctly
73
68
33
25
PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTIC TREATMENT FOR IMCI CONDITIONS (1) TRAINED vs UNTRAINED 100 90 80 70 60 50 40 30 20 10 0 Prescribed oral antibiotics Prescribed recommended oral antibiotics Trained Untrained
Percentage of cases with an IMCI condition needing antibiotics
82 71 70 55 38
0 Prescribed antibiotics correctly
26
PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTICS FOR IMCI CONDITIONS (2) TRAINED vs UNTRAINED Percentage of cases given a recommended antibiotic
100 90 80 70 60 50 40 30 20 10 0 Correct dose
92
Trained Untrained
63
67
73
54
17
17 0 Correct frequency Correct duration CORRECT PRESCRIPTION
27
CARETAKER CORRECT KNOWLEDGE ABOUT ORAL ANTIBIOTIC TREATMENT (IMCI CONDITIONS) TRAINED vs UNTRAINED
100 Percentage of caretakers of cases given a recommended antibiotic
90 80 70 60 50 40 30 20 10 0
Trained Untrained
59 49 45
22 11 0 Correct dose Correct frequency Correct duration
25
0 CORRECT KNOWLEDGE
28
CARETAKER'S POTENTIAL COMPLIANCE WITH PROVIDER'S ADVICE ON DURATION OF ORAL ANTIBIOTIC TREATMENT SHOULD CHILD GET BETTER BEFORE COMPLETING TREATMENT COURSE Would continue as advised 65%
Other / don't know 12%
Would stop treatment 22%
Would continue but reduce dose 1% 29
RATIONAL USE OF DRUGS: CASES NOT NEEDING ANTIBIOTICS GIVEN NO ANTIBIOTICS (N = 254) Cases correctly prescribed no antibiotics 63%
30
Cases prescribed antibiotics but not needing them 37%
RATIONAL USE OF ANTIBIOTICS TRAINED vs UNTRAINED
Percentage of cases not needing antibiotics
100
26 80
60
74
40
74
20
26 0
Given no antibiotics
Given antibiotics but not needing them
Trained
Untrained
31
PRESCRIPTION OF RECOMMENDED ORAL ANTIMALARIAL TREATMENT (N = 62) 100 90 Percentage of cases with malaria 80 70 60 50 40 30 20 10 0 Prescribed oral antimalarials Prescribed recommended oral antimalarials Prescribed antimalarials correctly
74
74
27
32
PRESCRIPTION OF ORAL ANTIMALARIAL TREATMENT TRAINED vs UNTRAINED 100 90 Percentage of cases with malaria 80 70 60 50 40 30 20 10 0 Prescribed oral antimalarials Prescribed recommended oral antimalarials Prescribed antimalarials correctly 33
Trained Untrained
76
69
76
69
41 22
PRESCRIPTION OF ORAL ANTIMALARIALS TRAINED vs UNTRAINED 100 Percentage of cases given antimalarials 90 80 70 60 50 40 30 20 10 0 34
100
Trained Untrained
78
76
56 43
56 41 22
Correct dose
Correct frequency
Correct duration
CORRECT PRESCRIPTION
CARETAKER CORRECT KNOWLEDGE ABOUT ANTIMALARIAL TREATMENT TRAINED vs UNTRAINED 100 Percentage of cases given antimalarials
Trained Untrained
90 80 70 60 50 40 30 20 10 0
35
38 22
43 24
0 Correct dose Correct frequency
0 Correct duration
0 CORRECT KNOWLEDGE 35
ADVICE ON ORS TRAINED vs UNTRAINED 100 90 Percentage of cases given ORS 80 70 60 50 40 30 20 10 0 Trained Untrained
72
44
40
40
0 Correct amount of water to prepare ORS
0 Correct advice on when to give ORS
0 Correct advice on how much ORS to give each time
0 CORRECT ADVICE ON ORS
36
CARETAKER KNOWLEDGE ABOUT ORS PREPARATION AND ADMINISTRATION TRAINED vs UNTRAINED 100 90 Percentage of cases given ORS 80 70 60 50 40 30 20 10 0 Knows correct amount of water to prepare ORS Trained Untrained
79
73 56
35 27 9 Knows when to give ORS Knows how much ORS to give each time
28 9 CORRECT KNOWLEDGE ABOUT ORS
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OTHER CURATIVE AND PREVENTIVE TREATMENTS AND OPPORTUNITIES FOR IMMUNIZATION FOR NON-REFERRED CASES 100 90
Percentage of eligible children
80 70 60 50 40 30 20 10 0
49
24
26 17
38
Cases with eye infection given tetracycline ointment (N =41)
Cases with anaemia prescribed iron (N = 55)
Cases needing Vitamin A given Vitamin A (N =46)
Cases needing vaccine given it or told when/where
CASES GIVEN ADVICE ON HOME CARE BY PROVIDER AND CARETAKER KNOWLEDGE 100 90 80 70 Percentage 60 50 40 30 20 10 0 Give extra fluids Continue feeding Signs to take child back immediately Advised by provider
79
Known by caretaker
41
48 38 20 6 12 2 ALL THREE HOME CARE RULES
39
ADVICE ON HOME CARE GIVEN BY PROVIDER TRAINED vs UNTRAINED 100 90 80 Percentage of cases Trained Untrained
70 60 50 40 30 20 10 0
52
49
26 15 5 Advised to give extra fluids
1 Advised to continue feeding
0 Advised on signs to take child back immediately
0 ADVISED ON ALL THREE HOME CARE RULES
40
CARETAKERS ADVISED ON SIGNS TO RETURN IMMEDIATELY AND KNOWING ABOUT THEM
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
32 32 5 21 25 21 18 4 2 1 5 20 40 60
Caretaker advised Caretaker knowing
70
19 14
80
100 41
Percentage of cases
CARETAKERS GIVEN AGE-APPROPRIATE ADVICE ON FREQUENCY OF FEEDING Given correct advice 24%
42
Given no or incorrect advice 76%
MOSQUITO BEDNETS AND THEIR USE (N = 350)
100 Percentage of caretakers interviewed 90 80 70 60 50 40 30 20 10 0 Has a mosquito bednet Has a treated mosquito bednet Child slept under bednet previous night
52
21
20 10 CHILD SLEPT UNDER TREATED BEDNET PREVIOUS NIGHT
43
USE OF HOME CARE CARD AND COMMUNICATION TECHNIQUES
100 90 80
Percentage of cases
70 60 50 40 30 20 10 0 Home care card used (N = 347) Details on communication techniques (N = 118 cases in whom card used)
34 26 5 Home care card and communication techniques used (N = 347) Card held properly Pictures pointed at Caretaker understanding checked
25
23
44
USE OF HOME CARE CARD AND COMMUNICATION TECHNIQUES TRAINED vs UNTRAINED 100 90 80 Percentage of cases 70 60 50 40 30 20 10 0 Details on communication techniques (cases in whom home care card used) Trained Untrained
44
26 7
25
23
0 Home care card used
0
0 Card held properly
0 Pictures pointed at
0 Caretaker understanding checked 45
Home care card and communication techniques used
3. FACTORS INFLUENCING CARE ! ! ! ! ! ! 46
Drug availability Availability of supply for IMCI Availability of supply for immunization Availability of supply for malaria laboratory Availability of other supply Supervision
INDEX (MEAN) OF DRUG AVAILABILITY (N = 66 FACILITIES) (Availability of at least 1 treatment course) 14 12 10 8 6 4 2 0 Index if all key drugs available in all facilities Mean no. of key drugs available in the facilities surveyed
12
8.7
Index
6 5 4 2.6
Essential oral treatments
Non-injectable drugs
Pre-referral injectable drugs
47
AVAILABILITY OF SUPPLY AND EQUIPMENT FOR IMCI
Working baby scale Source of clean water Working timing device Supplies to mix ORS Thermometer Working adult scale Working nebulizer 0 48
94 91 89 88 79 45 15 20 40 60 80 100
Percentage of the 66 facilities in which item available
AVAILABILITY OF SUPPLY AND EQUIPMENT FOR IMMUNIZATION AT 53 FACILITIES PROVIDING IMMUNIZATION SERVICES Percentage of the 53 facilities in which item available 100 90 80 70 60 50 40 30 20 10 0 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)
92 77
32 17
36
49
AVAILABILITY OF KEY SUPPLY AND EQUIPMENT FOR MALARIA LABORATORY
Giemsa
77 77 70 68 62 0 20 40 60 80 100
Slides
Functioning microscope
Lancets to prick finger
ALL 4 ITEMS FOR MALARIA LABORATORY
50
Percentage of the 66 facilities with the items available
AVAILABILITY OF IMCI RECORDS, COUNSELLING CARDS, CHART BOOKLET AND OTHER RECORDS
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
88 77 77 70 65 65 41 20 40 60 80 Percentage of the 66 facilities in which item available 100 51
SUPERVISION IN THE 66 FACILITIES VISITED 100 90 80 Percentage of all 66 facilities
70 60 50 40 30 20 10 0
50
26 11 15 2 Case Received at least 1 supervisory management observed in visit in the past past 6 months 6 months Has supervisory book Clinical Last visit's supervision recommendations done and recorded findings recorded on the book
52
CONCLUSIONS
55 53
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 54
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