Has Integrated management of childhood illness IMCI Improved Quality Of Care

1
Has Integrated management of childhood illness
(IMCI) Improved Quality Of Care?

• ICIUM Conference, Thailand
• Shamim Qazi
• Department of Child and Adolescent Health
  Development
• World Health Organization, Geneva

2
Outline

• Multi-country evaluation of IMCI
• Objectives and design
• Results from health facility surveys
• Conclusions

3
Main components of IMCI
Improve health worker performance
4
MCE objectives

• To evaluate the impact of the IMCI strategy as a
  whole on child health, including child mortality,
  child nutritional status, and family behaviours
• To evaluate the cost-effectiveness of the IMCI
  strategy
• To document the process and intermediate outcomes
  of IMCI implementation, as a basis for improved
  planning and implementation of child health
  programmes

5
Summary of MCE study designs

• Bangladesh RCT of 10 IMCI x 10 comparison
  catchment areas
• Tanzania pre-post comparison of 2 IMCI x 2
  comparison districts
• Uganda dose-response design including 10
  districts with varying levels of IMCI
  implementation
• Peru Comparison of 25 departments with different
  levels of IMCI implementation
• Brazil comparison of municipalities with and
  without IMCI in 4 states
• For full details of the design, methods and
  survey tools visit http//www.who.int/imci-mce

6
Objectives of Health Facility Surveys (HFS)

• To assess the quality of case management of sick
  children in accordance with IMCI guidelines
• To assess health system support for IMCI

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What are we evaluating?
IMCI Intro/Planning
Improved drug availability, supervision, other
health system improvements
Training of health workers/follow up visits
Family and community interventions
Improved quality of care in health facilities
Improved careseeking, increased utilization
Improved household compliance/care
Improved health/nutrition
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Methodology of HFS

• Cross-sectional surveys of health facilities in
  each country
• Facilities randomly selected from districts /
  municipalities
• Data collection
• adopted WHO generic HFS tools
• Observation checklist
• Exit interview
• Re-examination of sick child
• Facility, equipment supplies checklist
• Case scenarios

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Sources Results from MCE health facility surveys

• Tanzania IMCI Multi-Country Evaluation Health
  Facility Survey Study Group. The effect of
  Integrated Management of Childhood Illness on
  observed quality of care of under-fives in rural
  Tanzania. Health Policy and Planning 2004
  191-10.
• Amaral J, Gouws E, Bryce J, Leite AJM, Cunha ALA,
  Victora CG. Effect of Integrated Management of
  Childhood Illness (IMCI) on health worker
  performance in Northeast-Brazil. Cadernos de
  Saude Publica (In press)
• Pariyo GW, Gouws E, Bryce J, Brunham G and the
  Uganda IMCI Impact Study team. Improving health
  facility care for sick children in Uganda. Paper
  submitted.
• Gouws E, Bryce J, Habicht JP, Amaral J, Pariyo G,
  Schellenberg J, Fontaine O. Improving
  antimicrobial use among health workers in first
  level facilities results from the Multi-Country
  Evaluation of the Integrated Management of
  Illness strategy. Bulletin of WHO (in press).

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Results from MCE health facility surveys

• IMCI case management training significantly
  improved quality of care received by children
  under 5 visiting first level health facilities in
  Uganda, Northeast Brazil and Tanzania

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Selected assessment tasks(assessment of the sick
child)
Plt0.001
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Index of correct assessment over three rounds of
HF surveys in Uganda
( Completeness of assessment received by sick
children in terms of 10 assessment tasks )
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Selected assessment tasks (reducing missed
opportunities while assessing the sick child)
Plt0.001
14
Correct classification of the sick child(Health
worker classification compared to IMCI trained
gold-standard surveyor)
Plt0.001
15
Proportion of children for whom drugs were
correctly prescribed (dose, frequency,
formulation)
Percentage of children needing antibiotics and/or
anti-malarials who were prescribed the drug
correctly in IMCI and non-IMCI facilities
Plt0.05
16
Advice on how to administer drugs given to
caregivers of sick children, and...
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knowledge of caregivers on how to administer
those drugs at home
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In outpatient facilities in Brazil, Tanzania and
Uganda, the introduction of IMCI was
significantly associated with

• reductions in the misuse of antibiotics

• correct treatment of child illness with
  antibiotics

• more frequent administration of the first dose at
  the facility

• improved efforts by health workers to educate
  caregivers on home treatment

• increased knowledge among mothers about how to
  administer drugs correctly

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Conclusions

• IMCI case management training is associated with
  significant improvements in the performance of
  health workers in three of the MCE sites
• In Uganda and Brazil there is room for further
  improvement in health worker performance
• Tanzania results reflect intensive efforts at
  district level
• Training is only one aspect of health worker
  performance. Further research is needed on the
  effect of contextual factors on health worker
  performance