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-- Global Challenges with Scale-up of the IMCI Strategy

Sunday, 10th of February 2013

 

•     GLOBAL CHALLENGES WITH SCALE-UP OF THE INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS STRATEGY: RESULTS OF A MULTI-COUNTRY SURVEY

 

Abstract below; full text is at http://www.biomedcentral.com/1471-2458/11/503

Ameena E Goga1* and Lulu M Muhe 2

* Corresponding author: Ameena E Goga Ameena.Goga@mrc.ac.za

Author Affiliations

1 Health Systems Research Unit, Medical Research Council, 1 Soutpansberg Road, Pretoria, 0001 Pretoria, South Africa

2 Department of Child and Adolescent Health and Development (CAH), World Health Organisation, Avenue Appia 20, 1211 Geneva 27, Switzerland

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BMC Public Health 2011, 11:503 doi:10.1186/1471-2458-11-503

 

Abstract

Background

The Integrated Management of Childhood Illness Strategy (IMCI), developed by WHO/UNICEF, aims to contribute to reducing childhood morbidity and mortality (MDG4) in resource-limited settings. Since 1996 more than 100 countries have adopted IMCI. IMCI case management training (ICMT) is one of three IMCI components and training is usually residential over 11 consecutive days. Follow-up after ICMT is an essential part of training. We describe the barriers to rapid acceleration of ICMT and review country perspectives on how to address these barriers.

Methods

A multi-country exploratory cross-sectional questionnaire survey of in-service ICMT approaches, using quantitative and qualitative methods, was conducted in 2006-7: 27 countries were purposively selected from all six WHO regions. Data for this paper are from three questionnaires (QA, QB and QC), distributed to selected national focal IMCI persons/programme officers, course directors/facilitators and IMCI trainees respectively. QC only gathered data on experiences with IMCI follow-up.

 

Results

33 QA, 163 QB and 272 QC were received. The commonest challenges to ICMT scale-up relate to funding (high cost and long duration of the residential ICMT), poor literacy of health workers, differing opinions about the role of IMCI in improving child health, lack of political support, frequent changes in staff or rules at Ministries of Health and lack of skilled facilitators. Countries addressed these challenges in several ways including increased advocacy, developing strategic linkages with other priorities, intensifying pre-service training, re-distribution of funds and shortening course duration. The commonest challenges to follow-up after ICMT were lack of funding (93.1% of respondents), inadequate funds for travelling or planning (75.9% and 44.8% respectively), lack of gas for travelling (41.4%), inadequately trained or few supervisors (41.4%) and inadequate job aids for follow-up (27.6%). Countries addressed these by piggy backing IMCI follow-up with routine supervisory visits.

 

Conclusions

Financial challenges to ICMT scale-up and follow-up after training are common. As IMCI is accepted globally as one of the key strategies to meet MDG4 several steps need to be taken to facilitate rapid acceleration of ICMT, including reviewing core competencies followed by competency-driven shortened training duration or 'on the job' training, 'distance learning' or training using mobile phones. Linkages with other 'better-funded' programmes e.g. HIV or malaria need to be improved. Routine Primary Health Care (PHC) supervision needs to include follow-up after ICMT.

 

Background

The Integrated Management of Childhood Illness Strategy (IMCI), developed by WHO and UNICEF, has been identified as a key strategy to meeting the fourth millennium development goal (MDG4). IMCI has three components, viz. case management training (ICMT), strengthening the health system and intensifying household and community behaviours to improve child health [1]. ICMT is presented as an 11-day course (usually residential) and teaches health care providers to manage sick children up to the age of 5 years, presenting to primary health care facilities with illnesses that account for major childhood morbidity and mortality. The course comprises six key modules and clinical practice. WHO recommends that 44.2% of course time is spent on clinical practice 1.2% on Introduction, 20.9% on Assess and Classify, 4.9% on Identify Treatment, 11.6% on Treat the Child, 6.9% on Counsel the Mother, 6.9% on Sick Young Infant and 3.5% on Follow-up. The IMCI management algorithms or charts are colour coded and each trained health care provider is provided with a chart booklet to use during consultations. Each ICMT course is facilitated by trained facilitators and a 1:<4 facilitator: participant ratio is recommended.

Follow-up after training is an essential component of ICMT, as laid down in the IMCI information package [1]. The package describes follow-up after ICMT as an opportunity to reinforce skills acquired during training and solve problems encountered during IMCI implementation. The approach to follow-up developed by the WHO Department of Child and Adolescent Health and Development (CAH), also serves as a bridge to ongoing district-level supervision.

ICMT has been shown to reduce under-five mortality [2] and to improve antimicrobial use in first level facilities [3].

Despite data on the effectiveness of IMCI in decreasing antimicrobial prescription by health workers, improving quality of care, child health indicators, quality of counselling provided to caregivers, and bed net use [3-10], current global coverage by IMCI-case management-trained health workers is low [11]. Furthermore recent data from South Africa showed that although health workers in South Africa were implementing IMCI, clinical assessments using IMCI were frequently incomplete - only 18% checked for all main symptoms [12]. Focus group discussions amongst health workers in South Africa also showed that although they found the training interesting, informative and empowering the training time was short and follow-up visits, though helpful, were often delayed resulting in no ongoing clinical supervision [13].

In view of the potential contribution that IMCI scale-up could have on childhood morbidity and mortality, and the dearth of documented information on how IMCI was actually being implemented globally we conducted a survey in 2006 to review the training approaches and methods used for IMCI case management, document challenges to rapid scale-up of ICMT, document how countries are addressing these barriers and explore country experiences with follow-up after ICMT. It was intended that this information be used to guide future approaches to ICMT.

The first two questions (reviewing training approaches and methods) have been addressed in a separate paper [14]. This paper reports the challenges to rapid ICMT scale-up, how countries have tried to address these, and country experiences with follow-up of IMCI trainees after ICMT.