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. Knowledge, beliefs and skills of caretakers Strengthen health system supports 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

7. 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

8. 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

9. 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; 19:1-10. 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).

10. 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

11. Selected assessment tasks(assessment of the sick child) *P<0.001

12. 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 )

13. Selected assessment tasks (reducing missed opportunities while assessing the sick child) *P<0.001

14. Correct classification of the sick child(Health worker classification compared to IMCI trained “gold-standard” surveyor) *P<0.001

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 *P<0.05

16. Advice on how to administer drugs given to caregivers of sick children, and...

17. … knowledge of caregivers on how to administer those drugs at home

18. 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

19. 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