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Base de datos de evaluación

Evaluation report

PAK 2000/027: Process Evaluation of Early Implementation Phase of IMCI in Two Pilot Districts of Pakistan



Author: Abdur Rahman Associates

Executive summary

Background

Integrated management of childhood illness (IMCI) is a broad strategy to reduce child mortality and morbidity in developing countries. It encompasses interventions to prevent illness and reduce deaths from the most common child health problems, and to promote child health and development. The IMCI interventions are delivered through three components namely: improving health worker case management skills; improving the health systems to deliver IMCI; and improving family and community practices.

Purpose / Objective

The assessment is a process evaluation to assess the benefits of implementing a new WHO/UNICEF strategy Integrated Management of Childhood Illness (IMCI) at the first-level health facilities to replace the past fragmented services provided through ARI, CDD, breast feeding, etc. The assessment is not focusing on outcomes or impact as the country entered in early implementation phase in the last quarter of calendar year 2000 and it takes more than five years to document impact. The evaluation mainly focused on:
- Case management skills of the first-level health facility workers
- Monitoring and supervisory practices of the district supervisory staff
- Improvements in the district health systems with reference to availability of essential drugs and related logistics
- Family and community practices as assessed by the health seeking behavior of the parents/family, treatment compliance, care of the sick child at home, and knowledge and practice of essential preventive services like immunization, breast feeding practices, etc.
- Quality of services as measured by patients' satisfaction
- Commitment of the health services managers and decision/policy makers as assessed by their perceptions towards the IMCI strategy

Methodology

A sample of 10 first-level health facilities was randomly taken from 22 facilities in two districts. Two health facilities not implementing IMCI and two facilities from the Aga Khan Health Services (AKHSP) implementing IMCI were also studied. A pre-tested questionnaire was used to study the following parameters: case management skills of health workers; supervisory practices of the district supervisory staff; improvements in the district health systems covering essential drugs and related logistics; family and community practices covering treatment compliance, care of the sick child at home, and knowledge and practice of essential preventive services; quality of services as measured by patients' satisfaction; and commitment of the health managers. The information on the above parameters was collected by review of facility statistics, exit poll of up to three caretakers of child patients at each first-level health facility, interview of facility staff, and interview of project managers, pediatricians of referral hospitals, decision/policy makers and some of the UN technical agencies.

Key Findings and Conclusions

The conclusions drawn can be classified into success stories and challenges, and feasible options need to be explored to address the challenges. The good news is as follows:

First line drug - The knowledge of health workers in correctly identifying the first line drug for various diseases was highly satisfactory.

Management of convulsions - Health workers have acquired new knowledge and skills to manage a life-threatening symptom among severely ill children.

Instructions for re-visit of the patient - The health workers were rigorous in giving advice to the caretakers for follow-up visit of sick children. For pneumonia and dysentery, the health workers were more closely following instructions contained in the IMCI management protocols than for measles, malaria and wheeze.

Usefulness of essential equipment, logistics and recording forms - The health facility staff expressed their satisfaction on the usefulness of essential drugs and equipment.

Immunization coverage - The immunization coverage of child population using IMCI services was highly impressive.

Self-assessment - 70 percent of health workers, while doing their own assessment, posed confidence in the use of IMCI protocols. The other evidence shows that health workers were over confident in self-assessment.

Danger signs - Using danger signs as a proxy indicator for application of newly acquired skills, the MOs seemed to be examining every child to check for the danger signs.

Four new skills that health workers have learnt - There was a wide range of responses from the trained health workers, covering almost the entire spectrum of IMCI protocols.

Instructions for home care - Health workers in Multan district were more vigilant in giving instructions to the caretakers and explained more clearly than those from the Abbottabad district.

Challenges:
The initial implementation phase of IMCI faces the following challenges, which relate to two areas, namely: improved drug availability, supervision, other health system improvements; and training of health workers/follow-up visits.

Turnover rate of trained staff - At least seven health facilities were either well staffed or reasonably staffed, with 70 percent trained staff in position. Around two out of every five trained workers had been transferred and replaced by untrained workers in the last 12-15 months. The replacement of trained with untrained staff was found to be one of the impediments in the effective implementation of IMCI.

Supply of prescribed drugs to patients - The IMCI-related drugs and equipment were in short supply at the first-level health facilities. In the joint WHO/UNICEF regional consultation of November 2000, a WHO participant also observed a constraint in the lack of all needed IMCI drugs in sufficient quantities.

Changes in the functioning of First-level Health Facilities after introduction of IMCI - Three areas were found to be neglected i.e. recording and follow-up of supervisory notes, and supply of IMC drugs and related equipment.

Referral of severe cases to the hospital - The referral system is non-responsive.

Supervisory visits - The supervision was irregular and less educative. The root cause of most of the repeat observations on the performance of health workers mostly related to the transfer of trained staff, insufficient supply of drugs and related logistics or equipment, and insufficient supply of patient cards and related stationary items from the DHO office.

The desire for acquisition of skills - The health workers identified the following areas for more skills training: nebulization, IV line management, passing NG tube, ARI, nutritional deficiencies, physical examination of child and research techniques.

Review of patient cards to assess dosage of prescribed drugs. There appears to be a lack of interest in consulting IMCI protocols for determining the correct dosage as per weight of the sick child. This deficiency could be due to less emphasis during initial training, inappropriate supervision or both.

Observation of interviewers while health workers were examining sick children - Nearly half of the trained workers, especially the paramedics, were not comprehensively examining the sick children as recommended in the IMCI protocols.

Instructions to mothers on child spacing - The health workers lack focus on educating mothers on child spacing.

Qualitative assessment of health workers' knowledge - The IMCI knowledge of 3 out of 13 health workers could be rated as satisfactory (two doctors and one LHV).

Child patients waiting in queue - Long wait time was observed at a busy RHC and a poorly functioning BHU.

Attendance of child patients at first-level health facilities - In two BHUs of Abbottabad district, the overall attendance of child patients fell after the introduction of services based on the IMCI strategy. For example, in BHU Managal, the number of child patients fell from 163 in quarter July-September 2000 to 43 in the same quarter of 2001, and from 143 in October-December 2000 quarter to 64 in the same quarter of 2001. Although some of the trained health workers have been transferred out, none of them was without an IMCI trained health worker. The out-of-stock position of drugs and supplies was not very different from other sampled health facilities. The reasons need to be explored.

Recommendations

The essential areas that require immediate focus are: training of untrained health workers; short refresher course for the already trained health workers to reinforce their knowledge and sharpen their skills; and continuing educative supervision on the pattern of AKHSP.

The review indicates that the initial implementation phase of IMCI remained hostage to shortage of resources and started without strengthening district health systems. Therefore, scale-up must be backed by a rational strategic plan.

MoH should integrate country-wide implementation of IMCI with its PHC and Family Planning Program (LHW program). This decision would also create enabling environment for the implementation of community component of IMCI through the LHW program. There would also be better prospects of streamlining staff training, and supervision through LHW supervisors. As a second option, every provincial Department of Health (DoH) should prepare its own comprehensive PC 1 for the next five years for the expansion of IMCI strategy to the first-level health facilities.

The essential areas that should be addressed in the provincial strategic plans and, consequently, under the financing plan should include:
- The literature review suggests that the regular supply of essential drugs and equipment, and related logistics could bring about overall cost savings at country level
- Turnover of trained staff - A system needs to be institutionalized to ensure regular training of untrained health workers who are induced at first-level health facilities
- Behavior change communication (BCC) - There is a lack of awareness of the IMCI strategy among policy makers, health providers, and civil society especially the mothers. A BCC strategy needs to be developed for influencing: behavior of health workers and managers; resource mobilization; and demand creation for the services.
- Referral of serious cases to the hospitals - There is a need to formalize two-way referral to improve the quality of management of sick child and, thereby, improve the image of first-level health facility. Such a system is functioning in AKHSP.



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Report information

Date:
2002

Region:
ROSA

Country:
Pakistan

Type:
Evaluation

Theme:
ECD - Health

Partners:
Ministry of Health

PIDB:

Follow Up:

Language:
English

Sequence Number:
2000/027

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