imci orientation and planning guidelines for provinces and disricts

7/27/2019 IMCI Orientation and Planning Guidelines for Provinces and Disricts

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MINISTRY OF HEALTH

INTEGRATED MANAGEMENTOF CHILDHOOD ILLNESS

Orientation and PlanningGuidelines for Provinces

And Districts

DIRECTORATE OF PUBLIC HEALTH ANDRESEARCH CHILD HEALTH UNIT

October 2009

Second Edition


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Integrated Management of Childhood Illness Orientation and PlanningGuidelines for Provinces and Districts i

TABLE OF CONTENTS

ABBREVIATIONS AND ACRONYMS : : : : : iiiLIST OF TABLES : : : : : : : : ivFOREWORD: : : : : : : : : vACKNOWLEDGEMENTS : : : : : : : vi

1.0 INTRODUCTION : : 1

2.0 OVERVIEW OF IMCI IMPLEMENTATION IN ZAMBIA : : 2

2.1 Improvement of Health Workers skills : : : : 22.2 Improvement of Health System : 32.3 Improvement of Household and Community Practices : 32.4 Monitoring and Evaluation of IMCI Implementation : 3

3.0 IMCI ORIENTATION FOR PROVINCIAL HEALTH OFFICE : 63.1 Objectives 63.2 Participants: 63.3 Methods 63.4 Notes to guide the meeting : : 73.5 Agenda : : 8

4.0 GUIDELINES ON PRELIMINARY VISITS TO DISTRICTS NOTYET IMPLEMENTING IMCI : : 10

4.1 General Objectives : : 104.2 Specific Objectives : : 104.3 Detailed guidelines for District Assessment during Preliminary visits:

154.4 Selection of Facilities for Conducting IMCI Training : 114.5 Outcome of Assessment of IMCI training Sites : 17

5.0 PLANNING FOR IMCI IMPLEMENTATION AT DISTRICT LEVEL: : 19

5.1 Planning for Improvement of Health Workers Skills: : 205.2 Planning for Improvement of Health System: : 255.3 Planning for Improvement of Household and Community Practices: 29

6.0 ANNEXES: : : 35

Annex I Presentations for Orientation in IMCI : 36Annex II:List of IMCI Recommended Drugs & Other Supplies : 44Annex III: Checklist for IMCI training materials : 47Annex IV: Guidance for budgeting for IMCI training course : 49Annex V: List of other Supplies needed in the Classroom during IMCI


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Integrated Management of Childhood Illness Orientation and PlanningGuidelines for Provinces and Districts ii

Training workshop: : 52Annex VI: IMCI Supervisory Tools : 54Annex VII: Guidelines on Report Writing for IMCI Follow-up Visits : 62Annex VIII: Key Family & Community Practices 65Annex IX: Implementation Steps for Community IMCI 69Annex X List of Contributors 76


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Integrated Management of Childhood Illness Orientation and PlanningGuidelines for Provinces and Districts iii

ABBREVIATIONS AND ACRONYMS

AFRO Regional Office for Africa

AIDS Acquired Immuno-Deficiency Syndrome

ARI Acute Respiratory Infections

CARE Cooperative for Assistance and Relief Everywhere

CHIF Community Health Innovation Funds

CHW Community health Worker

C-IMCI Community Integrated Management of Childhood Illness

DHMT District Health Management Team

HIV Human Immuno-deficiency Virus

HMIS Health Management Information Systems

HSSP Health Services and Systems Program

ICT Integrated Competence Training

IMCI Integrated Management of Childhood Illness

JICA Japanese International Cooperation Agency

MoH Ministry of Health

OPD Out-patient Department

ORT Oral Rehydration Therapy

PHO Provincial Health Office

SP Sulphadoxine-Pyrimenthamine

UNICEF United Nations International Childrens Emergency Fund

USAID United States Agency for International Development

WHO World Health Organization

ZDHS Zambia Health Demographic SurveyZIHP Zambia Integrated Health Program


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Integrated Management of Childhood Illness Orientation and PlanningGuidelines for Provinces and Districts iv

LIST OF TABLES

Table 1: IMCI Performance Indicators for three Health Facility

Surveys...11Table 2: Inpatient sick children case load assessment..19Table 3: Inpatient sick child treatment standards20Table 4: Outpatient sick children case load assessment...21Table 5: Outpatient sick child treatment standards.22


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Integrated Management of Childhood Illness Orientation and PlanningGuidelines for Provinces and Districts v

FOREWORD

The Integrated Management of Childhood Illness (IMCI) strategy providesintegrated training and support for frontline health workers on management ofconditions such as pneumonia, diarrhoea, malaria, anaemia, malnutrition,measles and HIV/AIDS infection. The strategy also targets the community byaddressing child-related aspects of pneumonia. Diarrhoea, malaria control andtreatment, nutrition, HIV/AIDS, immunization and essential drug programme atcommunity level. The prevalence of these conditions demand that specialattention be given to this important strategy. IMCI is an effective part of the basichealth care package of public health interventions at primary health care level.

Although the major stimulus for IMCI came from the needs of curative care, thestrategy combines improved management of childhood illness with aspects of

nutrition, immunization, and other important disease prevention and healthpromotion elements. This package if addressed adequately will effectivelycontribute to the reduction of child morbidity and mortality and hence to theachievement of the Millennium Development Goal (MDG) of child mortalityreduction by the year 2015.

This document is designed to provide standard guidelines for IMCI which aretechnically sound and also feasible in the current environment of health careservices in Zambia. The guidelines address all the three components of IMCI andare applicable at all levels of health care system.

The challenges Zambia faces in child health include the high burden of childhooddiseases, a relatively weak health system and high attrition of health workers.Despite these challenges, the Ministry of Health is committed to improving thequality of care provided to both sick and well children as a cornerstone of qualityhealth services.

We rely on each other to ensure that these guidelines are implemented.

Dr. Peter MwabaPermanent SecretaryMINISTRY OF HEALTH


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Integrated Management of Childhood Illness Orientation and PlanningGuidelines for Provinces and Districts vi

Acknowledgements

The Ministry of Health is grateful to the World Health Organization for thepublication from which this guide was developed. Other partners who supportedthe development of these guidelines include:

Cooperative for Assistance and Relief Everywhere (CARE) InternationalJapanese International Cooperation Agency (JICA)United Nations International Childrens Emergency Fund (UNICEF)United States Agency for International Development (USAID)World Health Organization (WHO)


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Integrated Management of Childhood Illness Orientation and PlanningGuidelines for Provinces and Districts 1

1.0 INTRODUCTION

Child Health is one of the six health thrusts of the Zambian Health Reforms.Current child health indicators in Zambia are showing stead improvement. TheZambia Demographic Health Survey (ZDHS) of 2007 indicates that the InfantMortality Rate (IMR) and Under-five Mortality rate (U5MR) are 70 and 119 perthousand live births, respectively. These rates are still significantly high despitereduction from the IMR and U5MR of the ZDHS of 2001/2 (95/1000 and168/1000) figures.

The Ministry of Health adopted the Integrated Management of Childhood Illness

(IMCI) strategy in 1995 in order to reduce the child mortality rates in the country.Implementation of IMCI started in 1996. The IMCI strategy contributes to thereduction of child morbidity and mortality through the key components which are:

1. Improvement of health worker skills in management of the sick child2. Support for health systems3. Improvement of Household and Community Practices

A large proportion of childhood morbidity and mortality in the developingcountries is caused by five conditions: acute respiratory infections, diarrhoea,measles, malaria and malnutrition. HIV/AIDs has also become an important

cause of child morbidity and mortality. The IMCI strategy encompasses a rangeof interventions to prevent and manage these major illnesses, both in healthfacilities and at home. The strategy incorporates many elements of diarrhoealand acute respiratory infection control programmes, as well as child- relatedaspects of malaria control and treatment, nutrition, immunisation, and essentialdrug programmes.

An integrated strategy is needed to address the overall health of children for thefollowing reasons:

1. Most sick children present with signs and symptoms of more than one

condition. Thus, more than one diagnoses maybe necessary. Healthworkers need to be prepared to assess for signs and symptoms of all themost common conditions, not simply those of a single illness.

2. When a child has several conditions, therapies for those may need to becombined. Health workers need to be prepared to treat conditions whenthey occur in combination.

3. Care needs to focus on the child in a holistic approach and not just thediseases and conditions affecting the child.


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Other factors that affect the quality of care delivered to children such as

availability of drugs, organization of the health system, referral pathways

4. and services, and community behaviors are best addressed through anintegrated strategy.

Implementing the IMCI strategy requires and facilitates collaboration between

health programmes at all levels of the health system. The IMCI strategy does not

involve taking responsibility for existing programmes, but requires to ensure that

activities are well coordinated and implemented to contribute to IMCI. By

improving coordination and quality of existing services, the IMCI strategy will

increase the effectiveness of care and reduce costs as the country works to

achieve the following objectives:

1. To reduce morbidity and mortality associated with the major causes of

disease in children.2. To improve health systems that promote effective care of children3. To improve household and community practices

The purpose of these guidelines is to assist all levels of the health system toplan, implement and monitor IMCI activities.

2.0 OVERVIEW OF IMCI IMPLEMENTATION IN ZAMBIA

Zambia has been implementing the IMCI strategy since 1996. Progress has

been made in implementation of the three components of IMCI and indication ofimproved care provided to sick children has been documented.

2.1 Improvement of Health Worker skills

As of September 2009, 450+ health workers had been trained in IMCI casemanagement skills and 90 % had received follow up support. All the 72 districtsare implementing IMCI in Zambia. This is due to financial and human resourcecrisis. The Nation Health Strategic plan (2006 to 2010) target is to train 80% of


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health workers per health facility in IMCI by 2010 (Saturation). Currently the IMCItraining coverage in the health facilities in the country is at 64%.

2.2 Improvement of Health System

At the inception of IMCI, essential drug kits were adjusted to include most IMCIdrugs required at primary health care level. Drugs not available in kits areobtained by individual districts as supplemental drugs using the 4% from totaldistrict grant allowed for drug purchase

Health workers in districts have been trained to conduct follow-up after trainingand supervision of IMCI trained health workers. The integrated supervisorychecklist includes IMCI indicators and IMCI is part of the routine supportivesupervision in districts which are implementing IMCI.

2.3 Household and Community Practices

The household and community component of IMCI is an integrated child Careapproach that aims at improving Key family and community practices that arelikely to have the greatest impact on child survival, growth and development. It iskey to the provision of equity of access to cost effective and quality health careas close to the family as possible.

The component focuses on the 16 ke

y family practices but the country has prioritized 6 key practices and districts areencouraged to add based on the common problems affecting mothers andchildren.

The National Community IMCI Strategic plan is in place to assist in the scaling upof Community IMCI (C-IMCI).

2.4 Monitoring and Evaluation of IMCI Implementation

IMCI training and support has been found effective in Zambia. The IMCI HealthFacility Survey conducted in 2008 which covered 94 health facilities revealed thefollowing: Almost all (96.9%) of the health workers who were trained in IMCI wereperforming clinical duties which included caring for sick children, and 43.4% ofthe health workers spent more than 50% of their work time on caring for sickchildren. On assessment, overall 44.2% of the children were checked for threegeneral danger signs. The findings revealed that 77.2 % children were assessedfor cough, diarrhoea and fever in rural areas and 92.5 % in urban areas. Forother problems (61.3 % rural verses 92.7% urban) and children 2 years of agewere assessed for feeding practices (35% verses 55.7%). Five (5.8%) of the 86


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children in rural areas, and 12 (41.4%) of the 29 children of urban areas wereassessed for HIV infection. It was found that 1 in 5 (21.8%) children had morethan one classification. The most common classification was malaria (66.7%),followed by pneumonia (18.3%). Overall 50.6% and 12.5% of children werecorrectly classified for pneumonia and anemia respectively.

Five (5.8%) of the 86 children in rural areas; and 12 (41.4%) of the 29 children inurban areas were assessed for symptomatic HIVSignificantly more children with malaria were correctly treated using IMCIrecommendations in urban (78.0%) than rural (50.0%) areasOverall, 76.4% of the children with pneumonia were correctly treated; and 88.3%of the children needing an oral antibiotic were prescribed the drug correctly

Table1 IMCI Health Facility Survey 2008Rural & Urban (%) Rural (%) Urban (%)

ASSESSEMENTS

Child Checked for three eneraldanger signs

44.2 40.9 51.5

Child checked for the presence ofcough, diarrhoea and fever

81.9 77.2 92.5

Child checking for other problem 74.6 61.3 92.7

Child checked against a growthcharts

32.2 31.9 34.3

Child checked for symptomatiHIV/AIDS

- 5.8 41.4

Child under 2 years of ageassessed for feeding practices

- 35 37

CLASSIFICATION

Child with pneumonia correctlyclassified

50.6 50.0 52.2

Child with some dehydration iscorrectly classified

76.9 - -

Child with malaria is correctlclassified

59.9 54.6 75

Child with anaemia is correctlyclassified 12.5 - -

Child is correctly classified orgeneral danger signs, and 3 majorsymptoms

47.0 - -

Child with very low weight iscorrectly classified

25 - -

Symptomatic HIV infection Unlikel 1.8 - -

TREATMENT

Child with pneumonia correctly 76.4 79.6 72.7


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treated

Child with dehydration tre tedcorrectly

30 - -

Child with malaria orrectly treatedusing IMCI recommendations

56.2 50.0 78.0

Child with anaemia correctlytreated

20.6 - -

Child needing an oral antimalarialis prescribed the drug correctly

94.2 91.5 100

Child needing antibiotic leaves thefacility without one

82.9 83.9 81.1

Child needing an oral antibiotic isprescribed the drug correctly

88.3 85.5 93.8

hild needing an oral antibioticand/or an oral antimalarial (doesnot include anaemia) is prescribedthe drug correctly

65.7 60.6 83.1

Child with severe illness correctlytreated

26.0 - -

The IMCI health facility results have revealed that despite challenges faced byhealth workers they have exhibited commitment to improving the care for sickchildren. The assessment, classification and consequently treatment of thecommon illnesses, namely malaria and pneumonia by health workers could have

been done better. Experience shows that with IMCI training and support healthworkers who previously did not have adequate clinical skills to manage sickchildren can manage childhood illnesses according to national standards. It istherefore appropriate to scale up the IMCI course in all the pre-service traininginstitutions.


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3.0 IMCI ORIENTA TION FOR PROVINCIAL HEAL TH OFFICE

3.1 Objectives

To provide information and reach a common understanding of the conceptsand practical principles of the IMCI strategy.

To discuss its advantages and implications for the health systems. To discuss the need and explore options for strengthening the coordination

for implementation of the IMCI strategy.

3.2 Participants

Provincial Medical officerProvincial/hospital pharmacistClinical Care SpecialistPNO-MCHPrincipal NutritionistChief Environmental Health officersData Management SpecialistFinancial SpecialistDistrict Medical officer for host town

Heads of health training institutions (e.g. nursing school)Medical superintendent of provincial hospitalLocal partners, as relevant

3.3 Methods

This may be a - 1 day meeting. For the formal orientation meeting, plan abalance between presentations (to introduce the different aspects of the IMCIstrategy), descriptions of the national situation, and discussions.

3.3.1 Preparations and materials needed

Gather data related to the epidemiology of major childhood illnesses in theprovince and current interventions to address them. Prepare a presentationdescribing the situation in the province.

Provide each province with a copy of the IMCI information folder, the jointWHO/UNICEF statement on IMCI, and the brochure: Improving Child Health-IMCI: the integrated approach (WHO/CHD/97.12 Rev.2) (optional, if available).


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Materials required to be displayed for the meeting include the following:

IMCI wall charts

chart booklets

The course Integrated Management of Childhood Illness for first-level healthworker (Set of modules and guides)

IMCI Guidelines for follow-up after training

The document: Improving family and community practices (WHO/CAH/98.2)

Community IMCI Strategic Plan (2006-2009)

Maternal, Newborn and Child health Communication Strategy

Other reference materials as they become available (consult Ministry ofHealth for an updated list).

3.4 Notes to guide the meeting

Describe the IMCI strategy and rationale. Focus on the three components andtheir interventions. Through the orientation, emphasize the need to planactivities in all three components in a balanced way.

Suggest identification or formation of a coordination structure for IMCI, such asprovincial Child Health working group.

When discussing implementation, stress the importance of developing clearplans for improving drug supplies, establishing mechanism for supervision,

improving referral pathways, improving family and community practices, linkingrelated programme activities such as breastfeeding counselling training with IMCItraining, documenting the IMCI activities , etc, in addition to planning for trainingof first-level health workers.

Throughout the meeting, explore mechanisms for making the IMCI strategysustainable. Encourage active partner-ships with all health-related partners fromthe onset of implementation.

Address the importance of active collaboration and involvement of all relevantprogrammes in implementation of training and finding feasible solutions to

improve the health system and developing the family and community component.Ongoing activities and existing resources should be used in a coherent way inorder to maximize the effect of IMCI beyond training of first-level health workers.

As an example, specify how breastfeeding activities complement the IMCI coursefor first-level health workers and how they relate to all three components of IMCI.

It may not be possible to keep key officials for the entire period of the meeting.Organize the agenda in such a way that some key messages about the IMCIstrategy are delivered in their presence.


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Provide ample opportunity for discussion and examine how the IMCI strategyrelates to the national situation.

3.5 Agenda

Below is an outline for a provincial orientation meeting. It lists the topics that areuseful to address and approximate time requirements. It can be used to developdetailed agenda, which matches the specific requirements in a province.

Introduction:

The IMCI strategy: overview and rationale (15 minutes)

IMCI status in Zambia (15minutes)

Discuss ion

Planning for IMCI implementation according to the three components

IMCI guidelines for first-level health workers and training course improving skillsof health workers (15 minutes)

Training and follow-up after training

Discuss ion

Improving the Health systems (15 minutes)

Availability of drugs

Organization of work in health facilities

Supervision IMCI & Health Information System

Discuss ion

Improving family & community practices (15 minutes)

What do the IMCI guidelines already offer

Conduct a situation analysis


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Ensure consistent health education and promotion messages

Strengthening and supporting ongoing community- based interventions

Designing new interventions

Discuss ion

Child survival activities in the province: overview of achievements andongoing activities

Discussion

Suggestions for Child Health coordinating structure at provincial level(15minutes)

Documentation of IMCI activities

DiscussionOpen discussion at the end of the meeting (30 minutes- 1 hour).

Note:

I t is important to inform the provinc e in goo d t ime to prepare the topic on

chi ld surv ival act iv i t ies in the pro vince.

Refer to the standard power point s l ides for the f i rst 5 presentat ion s

(Annex I)


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4.0 GUIDELINES ON PRELIMINARY VISITS TO DISTRICTS NOT YETIMPLEMENTING IMCI:

Provincial staff and others involved with implementation of IMCI will make aPreliminary visit to orient the DHMT on the IMCI strategy and to assess districtpreparedness (e.g. drug supplies, supervision, referral issues) and encouragefurther preparations. The Performance Audit format used by Provincial staff in theirdistricts visits should be further developed to enable support to districts in theirimplementation of IMCI. Written guidelines should be prepared to assist districtswith the planning of IMCI activities, including the above mentioned support activities.Below are guidelines for an IMCI preliminary visit to districts.

4.1 General Objective

To orient the District Health Management Team in IMCI planning, adequatebudgeting and implementation as well as to conduct an assessment of the suitabilityof available training sites.

4.2 Specific objectives

To provide information on district planning, adequate budgeting andimplementation of IMCI

To assess the suitability of the District Hospital and health centres as IMCItraining sites.

To assess the health systems for IMCI implementation.

To assess the current status of community child health interventions and thenumber of key family practices being promoted in the district.

4.3 Detailed guidelines for District Assessment during preliminaryvisits

4.3.1 Detailed criteria for District Support Systems:

1. Situation of drugs and other supplies in the district

Use list of IMCI essential drugs and other supplies to check drug andother supplies situation (refer to annex II)

Assess the functioning of the drug kit system, the supplemental drugpurchase system, the distribution of drug/supplies from the DHMT to thehealth centres and transport availability.

2. Present situation as regards to supervision of Health Workers andCommunity Health Workers


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Plans and budgets for supervision in District Action Plan: frequency ofsupervisory visits, team composition (inclusion of administrators, cliniciansas well as MCH coordinators), and transport availability.

Tools used by supervision team; supportive character of the visit,checklist, Facility review, case management observation and caretakerexit interview.

Reports of supervisions done.

Supervisory capabilities of supervisors: Skills in IMCI supervision,counselling, quality assurance and / or supervisory training.

3. Referral system, including communication

Communication: Availability of telephones, radios, other means of

communication and their use. Availability of transport for ferrying sick children to the next level of care

Take note of distances from health centre to the nearest referral facility,and available services at referral facility

Health facilities with problems of distance, transport and/ orcommunication, should be identified. These need additional training, andsupport for management of severe cases. The district needs to supportthese health facilities to be able to take care of as many severe cases aspossible.

4. Health information system

Information available (Health Management Information System etc).

Analysis and use of information.

Community based information, for community participation related to ChildHealth and Nutrition

5. Human/ financial resource

A sufficient number of District Health Management Team (DHMT)members should be trained in IMCI, including the clinical supervisors. It is

proposed that at least 60% DHMT members be trained in facility andcommunity IMCI.

Availability of capable staff to be trained as facility and community IMCIfacilitators

Proportion of health workers managing sick children who are trained inIMCI.

Inventory and distribution of CHWs trained in C-IMCI

Distribution of IMCI trained health workers.

Inventory and distribution of trained health workers in C-IMCI supervisoryskills


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Financial resources planned for facility and community IMCI trainingincluding other support activities. Note committed financial resources frompartners.

4.4 Selection of Facilities for Conducting IMCI Training

Ideally all districts that plan to implement IMCI training should have their own trainingfacility. However, not all districts will have suitable facilities in their area. A group ofdistricts may share a training facility which has all the necessary qualities forconducting quality training including clinical practice.

Absolute criteria for choosing training facilities are difficult to define. The team willhave to weigh the different options and choose between the good and bad aspects.

Necessary requirements for the training site are:

1. An inpatient facility with sufficient case load including severe cases;the quality of case management should be up to IMCI standards.

2. For a small group of 6-8 participants an outpatient facility, withsufficient caseload and quality of care.

3. Classrooms, one for each group of 6-8 participants and one spacewhere the whole group can come together at the start and end of theworkshop. Lodging with catering facilities, like lunches and teasshould be near the classrooms where applicable. Transport betweenthe different facilities.

4. Non residential option should be considered where applicable.

The facilities should not be very far apart, not more than 10-15 minutes drive andpreferably less, to minimize the cost of transport.

4.4.1 Selection of Facilities for Conducting IMCI Training - The InpatientFacility

One of the major objectives of IMCI training is to train front-line health workers inassessing, classifying and referring sick children with severe illnesses. It may not beeasy to find children with serious illnesses at the outpatients facilities, while on theother hand one is more likely to see children with serious conditions at the inpatientfacilities. On the standard 8-day IMCI training, about 28% of the entire course workis usually devoted for the inpatient clinical practice. Therefore, it is important to


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spend some time in selecting the most appropriate facility for the clinical inpatientpractice of the training.

Minimal Standard o f Care in th e Inp atient Ward

Inpatient care should be delivered competently. Although participants in the courseare not learning inpatient management, they are learning to refer children withsevere illness to an inpatient facility in order to reduce mortality. Many have someexperience managing inpatients.

Ideally, the paediatric ward should practice standard case management of acuterespiratory infections (ARI) and diarrhoeal diseases. The inpatient ward should offerprovider initiated testing and counseling (PITC) and refer those testing HIV positivefor further care. The ward should also follow the recommendations provided for themanagement of severe malaria and severe malnutrition and other severe illnesses.

Appropriate antibiotics and antimalarials should be used correctly; injectableantibiotics should be given routinely for severe pneumonia; antibiotics should not beused to treat coughs or colds; and good nursing procedures should be followed.Children with severe malnutrition, severe malaria, and meningitis should be treatedto prevent hypoglycaemia. Immunizations which are due should be given to allunimmunized as appropriate. Rectal diazepam and/or other appropriateanticonvulsants should be readily available for the management of convulsions.Children should be monitored on a regular basis. Basic cleanliness should bemaintained.

It should be possible for a mother to stay with a sick infant or child to breastfeed.She should be granted 24 hours access to the ward. When a child is critically ill andunable to suckle, the staff should show the mother how to maintain her milk supplyby expressing her breast milk. They should help her re-establish breast-feeding assoon as the child gets better.

It may be possible, in some setting, for the inpatient instructor and the CourseDirector to work with the responsible ward staff in advance of the course to improveward procedures.

Assessing the type and quality of services at the facilityThe suitability of the facility depends on the type and quality of services provided tosick children. The assessment can be done through discussions with the medicalofficer in charge of the paediatric ward, checking registers and records and touringaround the ward (s). Large facilities may have different wards for various conditions,like neonatal conditions, malnutrition, etc.


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Number of children admitted

All hospitalized children may not have serious or severe illnesses. The first thing to

review is whether the facility regularly admits children with severe conditions. Thiswill allow participants to observe certain less common clinical signs, particularly forpneumonia, malnutrition, measles, and signs of serious bacterial infection in younginfants.

Absolute numbers are not necessary, but some indication of whether it is one caseper month, or one per day or 5-10 per day. On the day of the visit, check the ward,register and other records to find out approximate numbers of cases admitted of thefollowing conditions and draw up a similar table.

Table 2: In patient sick children case load assessment

Conditions #Admitted inthe last 14

days

Severe/

complicated

#Admittedin the lastquarter(s)

Severe/Complicated

Meningitis

Pneumonia

Some dehydration

PersistentdiarrhoeaMalaria

Measles

Malnutrition

Anaemia

HIV and AIDS

Bacterial Infectionsin young infants ( 0up to 2 months)

Case management

Inpatient facilities should follow the standard case management protocols for AcuteRespiratory Infections (ARI) and diarrhoeal diseases. For example, in order to letparticipants see the transition from some dehydration to no dehydration, the facilityshould provide Oral Rehydration Therapy (ORT). In addition, the facility shouldprovide routine childhood vaccinations for all sick children. Level of nursing careshould be optimum and basic cleanliness should be maintained.

Discuss the few following basic general protocols expected to be operational in allpotential inpatient facilities for IMCI training and draw up a similar table:


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Table 3: In patient Sick child treatment standards

Condition Standard case Management Casemanagement atthe facility

Severe pneumonia Injectable antibiotics

Cold or coughs NO antibioticsConvulsions Rectal diazepam (or appropriate

anticonvulsant)Severe malaria, meningitis orsevere malnutrition.

Apart from specific treatmentPrevent hypoglycaemia

Complicated malaria Injectable Quinine

NO coartem or sulphadoxine-pyrimethamine (SP)

Very severe diseas Injectable antibiotic, preventhypoglycaemia, Keep warm

All eligible admitted childre Routine scheduled immunizationsVitamin A supplementation dewormingand PITC.

Other aspectsThe caseload and management are paramount in deciding which facility is the bestto be used for training. However, a number of facilitating aspects should be

discussed during the facility visit:

1. A room where small group discussion can be held for case presentations,maximum needed capacity is the size of the classroom group: 6-8 participantsand inpatient clinical instructor.

2. A person from the health facility who can assist the inpatient clinical instructorand participants during the preparation of the cases and during the training.This is especially important in a situation where an inpatient clinical instructorwill have to be brought in from outside.

3. During each clinical session, each group visits the same inpatient ward(s).This flow of participants in two or three groups in and out of the wards mayput a burden on the facility. The willingness of the staff to assist with thetraining should be a factor in the decision-making.

4.4.2 Selection of Facilities for Conducting IMCI training The OutpatientFacilities

The majority of time spent in clinical practice is in the outpatient facilities, about 56%of the entire course work. The work in the outpatient facility wil l focus on making the


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application of the IMCI algorithm a routine practice. Few severe cases will be seenin these facilities.

Number of children seenAssess the number of children seen at the health facility by drawing up the followingtable:-

Table 4: Out patient sick children case load assessment

Cond i t ion# Seen in the last 14days

# Seen in the lastquarter (s)

Total children see

Pneumonia

DiarrhoeaMalaria

MeaslesEar infections

MalnutritionAnaemia

Bacterial infection (0 up to 2months)

Case managementOutpatient facilities, which may be either the hospital Out Patient Department (OPD)

or health centres, are also expected to follow standard case management protocolsfor Acute Respiratory Infection (ARI) and diarrhoeal disease. For example, simplecoughs and colds should not be treated with antibiotics. The facility should alsoprovide routine childhood vaccinations and growth monitoring and promotion for allsick children.

Discuss the following basic general protocols expected to be operational in allpotential outpatient facilities for IMCI training and draw up a similar table:

Table 5: Outpatient Sick child treatment standards

Condition Standard case management Casemanagementat the facility

Colds of coughs NO antibiotics

Dehydration ORS (pre-referral if severe)

Convulsions Rectal diazepam (appropriateAnticonvulsant).

Severe malaria, or severemalnutrition or severeanaemia

Apart from specific treatmentsprevent hypoglycaemia Pre-referral


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Complicated malaria Injectable QuinineNo coartem or Sulphadoxine-Pyrimethamine (SP)

Severe bacterialinfections

All eligible children Routine scheduled Immunizations andVit A. supplementation and deworming

Other aspects

1. Room or corner where participants can do the clinical practice, withsufficient space for a weighing scale. The maximum needed size relatesto the classroom group of 6-8

2. A person from the health facility who can assist the facilitators andparticipants; finding materials like scales, thermometers, cups; assistingwith the selection and flow of the patients within the OPD; etc.

3. During the training the facility will see a group of participants everymorning for a large part of the morning. The willingness of the staff toassist with the training should therefore be a factor in the decision making.

4.4.3 Selection of Facilities for Conducting IMCI training: The Classrooms,lodging and other logistics

1. The cost of training is decreased if training is non-residential, but insituations where this is not possible it is important that participants areaccommodated in the same venue preferably government institutions.

2. Each small group of 6-8 participants require one classroom. The roomshould be big enough to allow for a group table in the middle and smallbreakaway tables in corners. In the rooms facilities like flip charts/blackboards, and video/ TV sets (if necessary this can be shared) need tobe available.

3. Depending on the distances, vehicles are needed to transport participants,facilitators and inpatient instructor from the place of lodging to theclassrooms, in and outpatient facilities and lunch/tea areas. Remember,that for 2 or 3 groups, transport is needed at practically the same time.You may need one vehicle per group.

4. Preparation of training materials should be done before training. Refer tochecklist on standard materials required. (annex III)

4.5 Outcome of A ssessment of IMCI training Sites


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4.5.1 Fol low -up to Decis ion A

The district has fulfilled the criteria to a satisfactory level.

After reports of the visit have been shared with DHMT, Provincial and Central (MOH)Office, the district in co-ordination with the provincial office should start organizing anorientation meeting. Preferably the orientation meetings would take place withseveral districts together. This makes co-ordination amongst districts and with theprovince more efficient and improves sharing of knowledge and experience usefulfor further activities.

During the orientation meeting a plan should be developed to implement IMCItraining and to further improve all the support functions from the districts to thehealth facility based implementation. This plan needs to be integrated with theoverall district Action Plan. The plan needs to outline all the necessary activities, atime frame, responsible persons, dedicated partners, and expected outcomes/outputs including a budget (refer to annex IV).

4.5.2 Fol low -up to Decis ion B

The district has fulfilled the criteria for IMCI implementation. The team shouldrecommend that further work should be done on the specific deficient area.

After reports of the visit have been shared with DHMT, Provincial Office should takethe lead in holding further discussions with the DHMT, to improve the planning for(IMCI) support functions. When improvements have taken place to an acceptablelevel, given the above criteria, the district will be asked to organize an OrientationMeeting. See process for decision A.


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5.0 PLANNING FOR IMCI IMPLEMENTATION AT DISTRICT LEVEL

Implementation of IMCI activities requires a well established environment wherethere is availability of the skilled human resource in IMCI, resources and supplies forstrengthening health systems (e.g. drug supplies, supervision, referral issues) andimproving key family and community practices. Provincial, district staff and otherstakeholders involved in IMCI should strengthen and support implementation of IMCIstrategy.

In order to achieve impact in reducing childhood mortality rates, districts shouldensure that planning and budgeting for IMCI caters for all three components namely:Improving health workers skills, health systems strengthening and improving keyfamily and community practices.

5.1 General Objective

To increase IMCI training coverage from 64% to 80% by 2011 to attaining saturationlevels in all districts; ie 80% of health centre staff trained in IMCI case managementand 80% of districts having one CHW per 500 population by the end of 2015.

5.2 Specific objectives

To train at least 80% qualified staff in IMCI per each health facility To ensure inclusion of at least 80% key IMCI activities in the districts action

plans

To implement 80% of the district planned IMCI activities To put in place the IMCI monitoring and evaluation mechanisms through

supportive supervision/ TSS and periodical surveys To train 80% of CHWs in c-IMCI per district (to achieve one CHW per 500

population).

Note: Below are the Key IMCI activities

Planning and budgeting for scaling up facility IMCI trainings Plan and budget for regular Performance assessment/Technical support

supervision (with emphasis on IMCI case observations)

Plan and Budget for facility and community IMCI basic equipment, drugs andsupplies (e.g. thermometers, weighing scales (uni-scales), timing devices(timers), paediatric formulation drugs, Ready To Use Therapeutic Feeds[RUTF], ORT utensils, RDT kits, DBS kits, e.t.c)

Plan and budget to support community child health interventions and thenumber of key family practices being promoted in the district.

Plan and budget for community IMCI supportive supervision Plan and budget to scale up training in community IMCI Plan for provincial/district MNCH technical committee meetings to enhance

programme linkages


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5.3 Planning for Improvement of Health Worker Skills

The integrated case management training course for first line health workers is a keyelement of IMCI strategy which aims at improvement of skills of health workers. Thecourse is designed for in-service and pre-service training.

5.3.1 In-service training

In-service training provides training to health workers who have already finished theirclinical health training and are working and treat sick children. Health workers aretaught how to effectively manage sick children aged zero up to five years in acomprehensive and systematic manner.

Training of first-level health workers includes the case management training coursefor initial skill acquisition and follow-up visits to reinforce skills and help to solveproblems. Four to six (4-6) weeks following the IMCI course, district staff shouldarrange for initial follow-up as part of the training. Supportive supervisory visits tothe work site of each participant are undertaken to strengthen case managementskills and assist with initial implementation of IMCI.

The recommended standards for an 8-day training course which have been adopted

nationally include:

8 day (minimum 64 hours) case management skills training course forfrontline health workers.

Facilitator / participant ratio of 1:4

Proportion of time in clinical sessions: 74%

Average number of patients managed per participant: At least 10 -15

Number of course participants: Not more than 24

The overall aim to have impact is having at least 60% of health workers screeningsick children in a primary health facility trained in IMCI. The national target is to trainat least 80% of health workers screening sick children in a primary health facility inIMCI.


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5.3.2 Pre-service training

To sustain expansion of IMCI efforts it is vital that IMCI is in cooperated in health

worker pre-service training. This way the students will have IMCI skills on

graduation. Pre-service training is significantly cheaper than in service training.

Provincial Medical Offices (PMOs) and districts should collaborate with training

institutions to facilitate introduction of IMCI pre-service training.

5.3.3 Spreading IMCI - training staff thinly is not cost effective

Experience shows that training only a few health workers at large health centre willnot effectively change the way sick children are managed. At least 60% of staffscreening sick children at a larger health centre and 100% of staff at smaller healthcentres should go through the IMCI course. A district should be aim to train asufficient number of staff to cover the health centres in their district within areasonable amount of time. Similarly , given the support which districts must provide,key staff at district level should be trained in IMCI. Properly oriented districts are in

the best position to assure that as IMCI training progresses, there will be enoughpersons trained in each of their health centres to make a difference.

5.3.4 Quality training is essential

Experience with training conducted by the vertical Programmes demonstrates thatwhen the quality of training is compromised, impact is limited. The standard IMCIcourse lasts 8 days (64 hours). It is recommended that participants arrive atsessions on time and participate fully. Participants should work in small groups of 6to 8 with each small group having 2 facilitators. Classroom work consists of

individual reading and exercises, and group activities. The course also includesoutpatient and inpatient clinical sessions during which participants assess 10-15patients each. Facilitators provide individual feedback and lead the group activitiesin both class and clinical sessions.

5.3.5 Additional requirements for IMCI training:

74% of the time during the course is spent on clinical practice. Thus thetraining site must include 2 or more busy outpatient Clinics and a sizeable in-patient childrens ward;


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The accommodation, classroom and clinical practice sites are usually not alllocated at the same sites, thus, transport is required to get participants fromone site to another

A team of trainers is needed consisting of i) a course director, ii) anexperienced in-patient clinical instructor and iii) one facilitator with clinicalexperience for each 3 to 4 participants.

Considerable administrative support is required to organize classroom,clinical practice sites, accommodation and meals, transport, facilitators,participants, training modules, stationery and other supplies;

District staff joined by some facilitators, will carry out an initial follow-up visitto the trained health worker at their work site 4 to 6 weeks following thecourse. This initial follow-up visit is an integral part of IMCI training.

5.3.6 Where does training take place? Who manages training?

Training can be based in the district and managed by the district. Alternatively,training can be based at a training institution and managed by the training institutionin collaboration with the district. In either case, capacity for training will have to bestrengthened to provide for adequate facilitators, clinical institutions will have to joinwith neighbouring districts and institutions (e.g. hospitals) to obtain the human andmaterial resources required to put on the course. If training is managed by thetraining institutes, the same importance should be given to preparing the relevantdistrict for IMCI implementation. Districts should always be involved in the planningof training workshops, as well as selection of appropriate participants. Trainingcosts for IMCI can be reduced if government training institutions are used foraccommodation and meals for participants. The cost of IMCI training cost for 24participants may range from K100 to K120 million. ((Subject to change according toexchange rate)

Most of this cost is for accommodation and meals. If government institutions wereused for lodging and meals, the cost could probably be reduced by more than 50%.Other costs include transportation, allowances (e.g. out of pocket) etc. The cost oftraining materials is K400, 000 per participant (K10 million for 24 participants). Thecost for training materials may be reduced if participants only keep chart bookletsand workbooks while the training modules are kept by training institutions. Anexercise workbook with exercises from all modules has been developed forparticipants to use during the training for reference after training. Provinces shouldbe encouraged to come up with provincial targets in line with national strategic plan.


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5.3.7 What are the possible mechanisms for funding of IMCI training?

1. District funds2. Pooled funds from districts3. Local partners.

5.3.8 Guidan ce w hen plann ing for an IMCI Cour se an d Ini t ial

Fol low -up after train in g

a) Case management training

1. Aim at training at least 60% of health workers who see children at a healthcentre

2. When planning to train the trainers; one trainer will handle 4 participants meaning you canplan to train 8, 12, 16, 20, 24 participants depending on the resources the district has.Hence if the district plans to train 24 health workers then you need to plan for 6 facilitators,one course director and one inpatient instructor. (see Annex IV for IMCI course budgetguide)

Target group for training will include Doctors, Nurses, Clinical Officers,Environmental Health Technicians, Clinical instructors, Tutors and ideally all staff managing

sick children. Districts should ensure that staffs from training institutions, the private sector aswell as the hospitals are targeted for these trainings.

Potential facilitators can be identified from participants who have undergone casemanagement training and have demonstrated capacity of understanding the course contentadequately. These should go through five days facilitation course to be conducted by mastertrainers from within the provinces. Various districts need to identify from the existingfacilitators persons to under go IMCI training of trainers course in order to build capacity atprovincial level.

3. The required training materials include:

For each participant: Set of 6 modules, Chart booklet, Photograph booklet andparticipants work book.

Course Director Guide, Facilitator Guides, Clinical Inpatient Guide and Outpatientguides for facilitation.

Teaching aids including a set of 6 wall charts.

The lists of equipment and supplies needed to carry out an IMCI course is shown inAnnex V

4. Facilities are required for hands on practice.


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5. The standard training is for 8 days therefore in the budget include accommodation, meals,

out of pocket allowances/ DSA where participants are not accommodated. In order to cutdown on cost, where possible, it is suggested that out of residence training is consideredand where needed, use government institutions, such as nursing schools, foraccommodation encouraged.

Ensure that training s i tes have su ff ic ient case load, access to o ut pat ient and inpat ient

departments, acceptable qual i ty of care, and DHMT staff interested and able to co nduc t

a numb er of courses.

Initial Follow up after training

Follow-up after training is viewed as an extension of the IMCI training course for first levelhealth workers, and may or may not utilize the existing supervising system. Thisshould takeplace four to six weeks after initial training to provide support to trained health workers.Districts are reminded to allocate funds for this activity. Visits are usually conducted by anIMCI trained supervisor and a facilitator in an IMCI case management course including thestaff from the Provincial Medical Office.

b) Objectives of the follow-up visit:

To reinforce IMCI skills and help health workers transfer these skills to clinical workin facilities

To identify problems faced by health workers in managing cases and to help solvethese problems

To gather information on the performance of health workers and the conditions thatinfluence performance, in order to improve the implementation of IMCI guidelines.

Core activities to be done during initial follow-up visit:

Introduce the follow-up activity

Observe case management and reinforce skills

Review facility supports

Facilitate problem solving with the staff Give feedback to the health worker

Complete a summary report of the visit

C) Other additional possible activities are :

Caretaker exit Interview (to determine knowledge of how to continue care at homeand satisfaction with care received at the facility)

Review of Patient Recording Forms (as a way to identify and discuss casemanagement problems)


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Practice Exercise (to review guidelines when children are not present during thevisit).

I t is recommended to p air rout ine supervisors w ith IMCI trainers to cond uc t fol low-up

vis i ts . Staff recommended to do fol low-up vis i ts :

Should have completed an IMCI case management training course, and should betrained in IMCI facilitation skills and in conducting follow-up visits

Should be district -based and available to conduct visits to health facilities where healthworkers have been trained.

If DHMT has a l imi ted number o f superviso rs with adequ ate clinical ski l ls to do fol low-

up vis i ts , consider u sing o ther IMCI trained staf f from o ther faci l i t ies.

5.4 Planning for Improvement of Health Systems

When planning activities to improve health worker skills, also plan activities tostrengthen the health system. Consider the current situation and improvementsneeded. Decide on priorities to be addressed during implementation. Consider thefollowing areas when planning health system improvements:

Availability of recommended IMCI essential drugs in right formulation andother supplies.

Improvement of referral pathways and services

Improvement of organization of workers at the health facilities

Improved supervision of health workers Linking IMCI classification and the health information system

5.4.1 Drugs and supplies needed for IMCIThe IMCI strategy recommends the use of second-line treatments and pre-referraltreatment for severely ill children at the first-level health facility. These treatmentshave been introduced based on the evidence that a proportion of deaths in severelyill children could be prevented if those children are given an immediate dose of anappropriate antibiotic, instead of delaying that treatment for several hours until thechild reaches a referral facility . Within the context of the IMCI strategy, thesesecond-line and pre-referral drugs become essential drugs to cope with the

treatment needs of major childhood illness. Previously they have been available atthe referral level for use under the supervision of those who are trained in their use.Using the IMCI strategy, workers at first-level health facilities are trained in their use.Implementation of IMCI is most effective if health staff have a steady supply of thedrugs. The availability and steady supply of drugs is related to:

Availability of drugs; store and stock management;

Rational prescription and dispensing of drugs;

Compliance/adherence. (For list of IMCI recommended drugs refer to Annex II)


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When second-line and pre-referral drugs are available, well-trained and supervisedhealth workers will increase their impact on childhood mortality. IMCI training andclose supervision will help to promote the rational prescription and dispensing ofthese drugs.

Districts should plan to purchase supplemental pre referral drugs through the 4%drug budget if these are not adequate through the rural drug kit system.

5.4.2 Improve referral pathways and services

During implementation the emphasis is on improving case management at the first-level facilities. The case management guidelines for this level assume that referralservices exist and are functioning sufficiently for severely ill children to receive carethere. Review current pathways and practices for referral of children from first level

facilities. Access to quality of care in the referral sites is an important determinantinfluencing whether children needing effective referral care will receive it. It isrecommended that the following be considered in improving the referral system inthe district:

Distances of health centre to the nearest referral health facility.

Availability of required services at referral facility.

A list of health centres which have problems with distance, transport and / orcommunication.

A list of hard to reach health centres which need additional support formanagement of severely ill children who cannot be referred to next level. Thedistrict needs to support these health centres to be able to take care of severecases, while at the facility.

How referrals are conducted in the district, both at community and healthcentre level.

Supply of pre-referral drugs and other medical supplies.

The outcome of this discussion should be a section of the district plan including:

1. An agreement of assessment of the situation with regard to referral pathwaysand referral practices in each of the implementation districts.

2. A description of recommended steps for improving the referral system wherethere is a problem.

5.4.3 Organization of work in health facilities


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In planning for implementation, health workers often express concerns regardingorganization of work in health facilities. Common concerns relate to the duration ofconsultation if the integrated case management process is fully applied, as well as todistribution of tasks. Districts need to arrange trained staff to continuously orient andshare tasks with other staff.

The facility organization includes:

Weighing sick children before assessment

Taking temperature before assessment

Screening room with the necessary equipment for assessing children

Administration of drug of first dose of prescribed drug at health facility (either

in the screening room or dispensary) Counselling

Follow-up arrangement

ORT-location

Functioning ORT corner

Vitamin A supplementation, immunization and deworming in OPD

Documentation of Vitamin A supplementation, immunization and deworming

5.4.4 Health worker supervision

Training alone is not enough

To sustain improved health workers performance, the practices taught in the IMCIcourse should be reinforced and supported by districts. District capacity needs to bestrengthened to support IMCI. In order to effectively support IMCI implementation,the following activities have to be undertaken:

Supervision: support, motivation and on-the-job training in management ofchildhood illness should be carried out by district staff and health centre in charges as part of their on-going, routine, integrated supportive supervision.

In addition to supervision, other district supports are also essential to thesuccess of IMCI: improved drug management, clinic organization, personnelmanagement and planning.

Supervision that includes observation of case management is an important means ofstrengthening and sustaining health workers skills. Tasks that are part of a follow-up visit are aimed specifically at improving health workers skills and are relevant forroutine supervision as well. When planning for follow-up after training it isrecommended that district supervisors be involved in follow-up visits and thus theyneed to be trained to perform these tasks.


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Initial follow-up supervision visit takes place 4-6 weeks after training as part of IMCItraining. It reinforces as well as transfers skills from class to working environmentafter training. This follow-up visit should be backed with routine supervision byPMO/ DHO. It could be integrated in the existing provincial/district provincesupervisory tool. (Refer to IMCI Supervisory tools- Annex VI)

Following current MOH Performance Assessment visit, identify health worker skillsthat require reinforcing. Staff oriented in IMCI should be part of the supervision/technical support team. In facilities where there is a supervisor who has beentrained in IMCI case management and facilitation skills, that supervisor shouldreinforce the health workers skills as they implement IMCI activities.

Distr ic ts are encou raged to ident i fy a focal person for coord inat ing IMCI

act iv i t ies wh ich includes training suppo rt ive supervis ion and repor t wr i ting.

5.4.5 Report writing

Report writing cannot be overemphasized. Districts are expected to submit reportstwice yearly after conducting supportive visits. Districts are also expected to providereports on trainings conducted. This will assist the country to keep an inventory ofthose trained and those needing to be trained. (For report writing districts, shouldrefer to Annex VII)

5.4.6 Linking IMCI classifications and the health information system

The IMCI strategy and the disease surveillance component of a health informationmanagement system (HMIS) have different purposes. The IMCI guidelines aredesigned to improve the treatment of individual ill children and use classification andnot diagnosis. HMIS is designed to detect the occurrence of specific diseases. As aresult, some IMCI classifications may have no corresponding HMIS classification (forexample, mastoiditis); and some IMCI classifications may satisfy the case definitionsfor two or more HMIS classifications (for example, very severe febrile illness maysatisfy the HMIS case definition for both malaria and meningitis). In these instances,IMCI and HMIS classifications are incompatible. Since health workers have the dual

responsibility for treating children and disease surveillance, IMCI-HMISincompatibilities may lead to confusion among health workers. Linking of IMCIclassifications and diagnoses in the HMIS need to be done. Use of data at point ofcollection is very important in terms of planning, generating activities and review ofsuccess and failures. There are a number of HMIS indicators that are derived fromIMCI e.g. the number of pneumonia, non-pneumonia, bloody diarrhoea cases etc.


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5.5 Planning for Improvement of Household and Community Practices

Improving household and community practices is one of the three components of theIMCI strategy, which is an intervention included in National Health Strategic Plan.Community IMCI (C-IMCI) is an integrated child health care approach that aims atimproving key family practices that are likely to have the greatest impact on childcare for survival, growth and development. The vision of MOH in the National Healthstrategic plan is to implement the vision of basic health care package. C-IMCI is keyto the provision of equity of access to cost effective and quality health care as closeto the family as possible. The objectives of C-IMCI include:

Improve growth and development of children by promoting exclusivebreastfeeding, appropriate complementary feeding, micro -nutrients and psycho-social stimulation.

Improve family and community level preventive activities for common childhoodillnesses, injuries and abuse.

Improve management of sick children at home.

Improve appropriate and timely care seeking behaviours especially when a sickchild needs additional assistance out side the home (home referral, this involvesearly seeing or recognition of illness, seeking for appropriate treatment andadvice).

Promote a suitable or an enabling environment at household and communitylevel for child survival, growth and development (this involves streamlininggender issues, livelihood, feeding, food security, resource allocation etc).

5.5.1 Key household and Community practices

C-IMCI seeks to address household practices that are key for child survival, growthand development. They have been categorized into four main areas:

1. Growth promotion and development

This category includes behaviours whose impact is seen mainly in helping the childto grow and develop physically and mentally, and include behaviours that targetnutrition and psycho-socio development.

2. Disease prevention

Behaviours in this category are practiced in the household before the onset of adisease to provide protection against disease.


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3. Home Management

Home management behaviours are those behaviours which take place in the hometo help a child when it is realized that the child is sick or is in any way unwell. Thisincludes behaviours performed as soon as the child begins to show signs of ill healthor injury.

4. Care seeking and compliance

Care seeking behaviour includes those behaviours that involve going out of thehome to seek health care. (See details on Key practices on AnnexVIII)

5.5.2 The role of the province / district in planning for C-IMCI.

It is proposed that provinces encourage districts to plan and implement C-IMCIfollowing recommended steps and guidelines for planning and implementation(refer to Annex IX) for standard guidelines on C-IMCI) starting with a few key familypractices from which they build on the minimum of the six family and household keyinterventions, e.g. districts can start with Growth monitoring and add on Malariaprevention, Water and sanitation, HIV/ AIDS prevention, Immunization or ExclusiveBreastfeeding. Etc. Currently the MOH planning circle has an input from thecommunity.

5.5.3 Inter-sectoral collaboration.

Inter-sectoral collaboration is encouraged for C-IMCI to be successful. This involvesadvocacy on some aspects of C-IMCI like behavioural change for example,traditional leaders could be used to change some of the beliefs and taboos, whichcould have an impact on child health. Another example could be inter-ministerialcollaboration for water and sanitation, social welfare, Agriculture and Education.

The optimization of multi-sector-based platform for C-IMCI requires:

Partnership among the health structures and communities

Accessibility and quality of care and information supply by community care

providers Promotion of key practices, which have impact on child survival, growth and

development.

5.5.4 Support systems

For C- IMCI activities to be sustained there is need to develop a system that will linkand support the Child Health Interventions. The support required may need logisticslike weighing scales, registers, stationery, community Health Worker (CHW) kits,


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bicycles etc. Supervision of community based activities is cardinal in monitoring thequality of service being offered at the community level. It is proposed that theprovince encourages districts to identify supervisors from technical staff tocoordinate and monitor community level activities.

5.5.5 Mobilization of resources for community activities

DHMTs should provide technical support for effective use of community basketfunds

Provincial Medical Offices to encourage District Health Management

Teams on provision of information on Income Generating Activities. (IGAs)

The DHMT should guide the community on effective use of user fees.

The provinces can also advice the district to seek other sources of fundingfrom local partners.

5.5.6 Motivation strategies

Income generation activities that have direct effect on the community should be

explored. The province and the districts should come up with ways of motivating theCHWs e.g. a prize for a hard working group or a group that has maintainedstandards. Motivation strategies may include provision of free medical services,inclusion of CHWs in national events that have monetary incentives, provision ofidentity cards, regular refresher courses, meetings etc.

5.5.7 Referral and communication.

The province should encourage districts to assist communities and otherstakeholders to come up with ways of quickening home referral as well as innovationon community transport and communication.

5.5.8 Monitoring and Evaluation

Innovative ways of utilizing data at community level should be encouraged at point ofservice delivery. Provinces and districts should be able to evaluate communityinterventions through peer review.


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CAUSES OF 3,8 MILLION DEATHS OF CHILDREN

UNDER 5 YRS EACH YEAR IN AFRICA. WHO 1996

Pueumonia

30%

Diarrhoea

20%Malaria

15%

Measles

13%

Other

22%

Underlying

malnutrition 50%

AIDS related 30%

NB: Excluding

perinatal deaths

I MCI Over view and r at ionale

Fever

Cough

Diarrhoea

Ear problems

Skin lesions

Abdominal pain

Eye discharge

Dental problems

Neck swelling

Generalized swelling

Anorexia

Rectal prolapse

Headaches

(Not recorded)

0 10 20 30 40 50 60

Percentage of all children

Source:WHO/CHD/HQ/Geneva

Frequency of presenting complaints of

Gondar, Ethiopia

Frequency of Presenting Symptoms of 450 Children

Gondar, Ethiopia, 1994

Coveredi

nIMCI

Separate

disease

specific

clinical

guidelines

and training

materials

National

programmes

conduct

disease

specific

training

courses

" Integration "

of clinical

guidelinesby the health

worker

ARI

Diarrhoea

Measles

Malaria

Malnutrition

Integratedclinical

guidelines

and

training

materials

NationalProgrammes

collaborate in

integrated

trainingcourses

INTEGRATED

CLINICALCASE

MANAGEMENT

HIV &AIDs

Vertical health programmes and an individualhealth worker

Separate disease specific

clinical guidelines and training

materials

National programmes

conduct disease specific

training courses

"Integration" of clinical

guidelines by the health

worker

ARI

CDD

IMCI and an individual health worker

Integrated clinical guidelinesand training materails

National programmes collaborate inintegrated training courses

Integrated clinicalcase management

fTo improve the quality of care provided to

children under five years at family,

community and first - level health facilities

OBJECTIVES OF IMCI:

f To reduce childhood mortality


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Age groups and IntegratedAge groups and IntegratedAge gr oups and IntegratedManagement of Childhood Il lnessManagement of Chil dhood Il l nessManagement of Childhood Il l ness

0 2 months 5 years

Young infant Child

Important elements of improving childhealth

improving management of sick children

improving nutrition

immunization

other disease prevention

prevention of injuries

improving psychosocial support and

stimulation

COMPONENTS OF IMCI

f Improving case managementskills of health workers

f Improving the health system to deliverIMCI

f Improving family andcommunity practices

IMCI-2

IMCI-1

IMCI-3

Interventions for integrated managementof childhood illness

Response

to sickness

IMCIPrevention of disease

Promotion of Growth

Community home / basedinterventions to improve

nutrition

Insecticide-impregnated

Bed nets

Early casemanagement

Appropriate care

seeking

Compliance with

treatment

Vaccination

Complementary

feeding

Breastfeeding counselling Micronutrient supplementation

Case management of

ARI, diarrhoea, measles,malaria, malnutrition and

other seriousinfections

FAMILYand COMMUNITY

HEALTHSERVICES

IMCI components and intervention areas

Improving family

and community

practices

Improving healthworkers skills

Improving Health System

Case management guidelinesand standards

Training of facility-based

public health providers

Maintenance of competenceamong trained health workers

IMCI roles for private providers

Care seeking, Nutrition

Home case management

Adherence to

recommended treatment

Community involvement inhealth planning and

monitoring

District planning and

management

Availability of IMCIdrugs

Organization of work

at health facilities

Quality improvement

and supervision at

health facilitiesReferral pathways

and services

HIS

IMCI and health

sector reforms

Advantages of IMC Focuses on care of the child as a whole and not

on the reason for the visit.

Ensures the early identification of all seriously illchildren

Ensures integrated management of all prevalentillnesses that the child may present.

Includes the application of preventive measuresalong with treatment for detected illnesses andhealth problems

Includes actions to improve parental practices incaring for the child at home

Can be adapted to the local epidemiologicalsituation


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1

Status of IMCI in Zambia

n

IMCI Strategy adopted in 1995nAdaptation of generic materials & training

1996

n 1999, all districts had adopted IMCI as keystrategy to reduce child morbidity &mortality

nAll 72 districts currently are currentlyimplementing IMCI

3

In-service IMCI Case ManagementTraining

n First training course held in May 1996

n By September 2009, 4 800 health

workers had been trained

n 85% of trained health workers havehad initial follow-up visits by IMCI

trainers & supervisors

4

Pre-Service IMCI Training

n Discussions started 1999

n IMCI Pre-service working group formedin 1999

n Orientation meeting in 2000

n Lecturers/Tutors trained 103(Cumulative) from various healthtraining schools (2009)

5

Pre-Service IMCI Trainingn IMCI incorporated in RN & EN school curriculum

n 15 Pre-service institutions are conducting IMCItraining -Chainama College, Post-basic Nursing(PBN), Lusaka (UTH), Ndola, Kitwe, Solwezi,Mukinge, L/stone, St.fransis, Chipata, Chilonga,Kasama, Mansa and St. Pauls

n Chainama College of Health Sciences Training ofMedical Licentiates started in December 2002 (11-day training)

n PBN having IMCI concepts taught during regularteaching per iods

n New RN curriculum is already in use

6

Health System Strengthening

n At inception of IMCI, essential drug kits adjusted to

include most IMCI drugs required at primary healthcare level

n Drugs not available in kits obtained by individualdistricts using :n Supplemental drugs

n 4% allowed for drug purchase in grant

n Supervision, referral & health system issuesstrengthened in IMCI implementing districts

n IMCI monitoring tools incorporated in routinesupervisory checklist


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7

1997 1999 2002 2004 2006 2008

Districts 6 19 34 38

Facilitators 32 66 110

TrainingSites

2 8 9 9

Initial F-up 54% 70% 80% 80%

HW Trained 156 735 1,711 2064

Achievements in IMCI - I

8

Achievements in IMCI II

1997 1999 2002 2004 2006

CHWs trained ? 300+ 2,000+ ?

GMP ? 60 1,000+ ?

Tutors/

lecturers Trained

21 103 112

9

Experience Gained in Scaling up

IMCI in Zambia

n Nationwide expansion of IMCI strategy required tomaximise impact on child morbidity

n Current status shows inadequate coverage of existinginterventions

n With limited resources, targeting areas of most needis vital during expansion

n Partnerships have increased financial resources at

country leveln Human resource constraints adversely affects scaling

up of IMCI implementation

10

Challenges & Constraints of Scalingup IMCI

n Major challengesnAccelerating nationwide expansion of IMCI

n Implementation of all components of IMCI,particularly improvement of health systems & C-IMCI

n Key Constraintsn

Weak health systemn Inadequate financial investment in IMCI and

other child health strategies

n Inadequate health workers to effectivelyimplement strategy

Guidance for planning IMCI caseManagement Training

Aim at training at least 60% of health workers who

see children at a health centre One facilitator will handle 4 participants meaning

you can plan to train 8,12, 16, 20, 24 participantsdepending on the resources the district has

To train 24 health workers you need to plan for 6

facilitators, one course director and one inpatientinstructor

Include accommodation, meals and out of pocketallowances

Consider non-residential training to reduce thecosts

1

Guidance for planning the course contd

Duration of the standard training course is now 8

days (minimum 64 hours)

Proportion of time in clinical sessions: 30%

Average number of patients managed per

participant: at least 10 15

Each participant receives his/her own copy of the

chart booklet

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Target group

Target group for training includes

- Doctors

- Nurses

- Clinical officers

- Environmental Health Technicians

- Clinical instructors

- Tutors and ideally all staff managing sick

children.

3

Required training materials For each participant

- Set of 6 modules

- Chart booklets- Photograph booklet

For facilitation of the training

- Course Directors Guide, facilitator guide for

modules, Outpatient guide and inpatient

clinical guide

- One set of 6 modules per participant

- Wall charts and other facilitator aids

Site of training

Ensure that training sites have sufficient case load

for clinical practice

Training sites for classes must have easy access

to out patient and inpatient departments for

clinical practice

Health facilities used for clinical practice must

have acceptable quality of care

5

Follow up after training

Recommended to take place four (4) to six (6) weeks

after initial training in IMCI case management skills.

Undertaken by IMCI trainers in collaboration with

provincial and/or District Health officers/supervisors

Objectives:

- To reinforce IMCI skills and help health workers

transfer these skills to clinical work in facilities

- To identify problems faced by health workers in

managing cases and to help solve these problems

- To gather information on the performance of health

workers and the conditions that influence performance,

in order to improve the implementation of IMCI

guidelines

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1

Improving the health system to

deliver IMCI

n Improve availability of drugs and supplies

n Improve service quality and organizationat health facility

n Improve referral pathways and services

n Identify/develop methods for sustainablefinance and ensure equity of access

n Link IMCI and Health Information Systems

2

Improve availability of drugs andsupplies

n 8 essential oral drugs are recommended in

IMCI case management, includingantibiotics and antimalarial drugs

n Injectable drugs for pre-referral treatmentshould also be available, including X-pen,Chloramphenical, Gentamycin andQuinine

n Drugs and supplies needed for effectiveimplementation of IMCI case managementneed to be available in health facilities

3

Improve service quality and

organization at health facility

n The quality of care provided f

imci orientation and planning guidelines for provinces and disricts

Documents