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Case Study

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) IMPLEMENTATION IN TANZANIA: EXPERIENCES, CHALLENGES AND LESSONS SUBTITLE Implementation research: The Tanzanian experience AUTHORS

Basu D, Govender M, Mueller DB University of the Witwatersrand, Johannesburg, South Africa COMPETENCIES To develop an understanding of the challenges of implementing a health programme and lessons learnt in the context of social determinants of health (SDH). AUDIENCE Junior and Senior Researchers in Health and Social Science Graduate students developing Master´s and PhD degrees BACKGROUND The Integrated Management of Childhood Illness (IMCI) is an integrated approach to child health that focuses on the well-being of the whole child. IMCI aims to reduce death, illness and disability, and to promote improved growth and development among children under five years of age. IMCI includes both preventive and curative elements that are implemented by families and communities as well as by health facilities. The strategy includes three main components (a) Improving case management skills of health-care staff; (b) Improving overall health systems and, (c) Improving family and community health practices. In health facilities, the IMCI strategy is expected to promote the accurate identification of childhood illnesses in outpatient settings, ensure appropriate combined treatment of all major illnesses, strengthen the counselling of caretakers, and speed up the referral of severely ill children1. OPENING PARAGRAPH Since the 1970s, the estimated annual number of deaths among children less than 5

years old has decreased by almost a third. A study conducted in 2010 which examined

1 WHO. Undated. Integrated Management of Childhood Illness. http://www.who.int/maternal_child_adolescent/topics/child/imci/en/ [accessed 10/04/2014]

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the levels and rates of decline in neonatal, post-neonatal, childhood, and under-five

mortality since 1970 in 187 countries highlighted and illustrated this trend as reflected

in figure1 below2.

Figure 1: Worldwide number of deaths in children younger than 5 years from 1970 to 2010

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This reduction, however, has been very uneven. And, in some countries rates of childhood mortality are increasing. In 1998, more than 50 countries still had childhood mortality rates of over 100 per 1000 live births. Altogether more than 10 million children die each year in developing countries before they reach their fifth birthday. Seven in ten of these deaths are due to acute respiratory infections (mostly pneumonia), diarrhoea, measles, malaria, or malnutrition—and often to a combination of these conditions3. In Tanzania, the mortality among children younger than 5 years is 147 per 1000 births,

resulting in almost 250 000 deaths each year.4 (Further information at a country level is

attached in annexure 1 at the end of the document). The Multi-Country Evaluation (MCE) of the IMCI seeks to generate information on the effectiveness, cost, and impact of IMCI that can be used to strengthen the delivery of

2 Rajaratnam JK, Marcus JR, Flaxman AD et al. 2010. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970–2010: a systematic analysis of progress towards Millennium Development Goal 4. Lancet, 375(9730):1988-2008. 3 WHO. 2005. Handbook: IMCI integrated management of childhood illness. Geneva: WHO. 4 Armstrong Schellenberg JR, Adam T, Mshinda H, et al. 2004. Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania. Lancet, 364(9445):1583-94.

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child-health interventions and the implementation of the IMCI strategy5. It includes in-depth studies in Bangladesh, Brazil, Peru, Tanzania, and Uganda 6.

Tanzania was one of the countries included in the MCE of IMCI, coordinated by WHO in 1999-2002. Special sites were selected for this particular evaluation which utilised an observational design comparing child health and survival in four neighbouring districts, two (Morogoro Rural District and Rufiji District) of which started IMCI in 1998. Another two of which started implementation in 2002 (Kilombero District and Ulanga District) served as comparison areas. The MCE study found that IMCI improved the quality of care for children under 5 years of age, reduced child mortality by 13% and was cost-effective. Based on these positive findings, the Tanzanian Ministry of Health and Social Welfare (TMOHSW) decided to scale up this intervention to the rest of the country. In addition, the Tanzania Essential Health Interventions Project (TEHIP) also supported the teams in the pioneering of 2 districts in the use of simple management tools for priority setting, monitoring, and mapping. However, a decade after the introduction of IMCI in Tanzania, several challenges have emerged and the training of health workers remains the main activity implemented7.

Available evidence suggests that reaching high and sustained implementation has been difficult. For IMCI to have an impact on child health, changes were needed at several different levels starting at the national level and moving down to the household level. IMPLEMENTATION The TMOHSW began IMCI implementation in 1996, and adapted generic IMCI case-management guidelines to reflect national child-health policies. All materials were translated into Swahili and used as the basis for preparation of national and district-level trainers. The local councils, through their local-government and health-sector reforms, have increased autonomy and control over their own health budgets and plans. They have access to a limited amount of donor-supported “basket” funding from the health-sector-wide approach. The Ministry of Health and partners pool resources in a common kitty from which funds are then directly disbursed to districts through special accounts of the council health management teams (council” refers to the local government of both rural districts and urban municipalities). The Council of Morogoro Rural and Rufiji Districts decided to adopt the IMCI and to give the highest priority to its introduction and implementation on the basis of evidence available to them from a sentinel burden-of disease information tool and a district-health-budget mapping tool developed by the Tanzanian Essential Health Interventions Project (TEHIP). These Districts reported that over 80% of health-workers managing children in first-level facilities had been trained in IMCI by mid-2000. A comparative, non-randomised study was done in 1997 to 2002 between the two districts with facility-based IMCI and two neighbouring comparison districts without IMCI. During the IMCI phase-in period, mortality rates in children under 5 years old were almost identical in IMCI and

5 Bryce H, Victora CG, Habicht JP, Vaughan P, Black RE. March 2004. The Multi-Country Evaluation of the Integrated Management of Childhood Illness Strategy: Lessons for the Evaluation of Public Health Interventions. American Journal of Public Health, 94(3):406-415. 6 Victora CG, Adam T, Bryce J, Evans DB. 2006. Integrated Management of the Sick Child. In: Jamison DT, Breman JG, Measham AR, et al., (eds) Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): The World Bank. 7 Prosper H and Borghi J. 2009. IMCI implementation in Tanzania: Experiences, challenges and lessons. http://www.crehs.lshtm.ac.uk/downloads/publications/Tanzania_IMCI_policy_brief.pdf [accessed 31/03/2014]

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comparison districts. Over the next 2 years, the mortality rate was 13% lower in IMCI than in comparison districts (95% CI: 7 to 30 or 5 to 21, depending on how adjustment is made for district-level clustering), with a rate difference of 3.8 fewer deaths per 1000 child-years. The researchers concluded that facility-based IMCI was good value for money, and supports widespread implementation in the context of health-sector reform, basket funding, good facility access, and high utilisation of health facilities3

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In this case study, the TMOH went to scale on the basis of the positive findings of the MCE study. Read the articles by Prosper & Borghi, Mayombana and Lange, and identify some key implementation challenges. These key issues should include: (a) adherence to guidelines; (b) community understanding of disease and care seeking; and (c) financial constraints of districts in the face of a costly training package.

SOCIAL DETERMINANTS OF HEALTH Health providers often formulate the problem of disease and illness in terms of lack of skills and knowledge of health care workers. We argue that while improvement of skills and knowledge of health care worker is important, it is equally important to explore local socio-cultural factors such as perceptions of disease or illness and treatment seeking behaviour. Our case study demonstrated that the TMOHSW and its partner made an enormous effort in time, energy and money for the improvement of health of the children. These efforts should be supported by addressing local socio-cultural factors for the sustainable improvement in the health care sector5. The social determinants of health (SDH) is a complex entity that seeks to link the analysis of society within the broad framework of development considering the processes of both the group order (health systems) and the individual. The WHO Commission on SDH presented three principles of action namely: (a) improve daily living conditions; (b) tackle the inequitable distribution of power, money, and resources; and (c) measure and understand the problem and assess the impact of action8. The inequity in life could be addressed through commitment to and implementation of a comprehensive approach to early life, building on existing child survival programme through IMCI. The Commission also highlighted the importance of assessment of the impact of action linked to SDH through investment in generating and sharing new evidence. CLOSING PARAGRAPH Despite abundant evidence of the efficacy of affordable, life-saving interventions, there is little understanding of how to deliver these interventions effectively in diverse settings and within the wide range of existing health systems. Implementation issues often arise as a result of contextual factors that policy-makers and health system managers may not even have considered. Implementation research is crucial for broadening and deepening our understanding of the challenges we face in confronting the real world factors and how they impact implementation. This type of research is of immense value in shining a light on the often bumpy interface between what can be achieved in theory and what actually happens in practice9.

8 WHO. 2008. Closing the gap in a generation: Health equity through action on the social determinants

of health: final report of the commission on social determinants of health. Geneva: WHO.

9 Peters DH, Tran NT, Adam T. 2013. Implementation research in Health: Practical Guide.

Geneva: WHO. http://who.int/alliance-hpsr/alliancehpsr_irpguide.pdf [accessed 31/03/2014]

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COMPLETE THE FOLLOWING EXERCISE: 1. The Tanzanian Case Study:

a. Can you identify any other SDH which can also influence the under-five mortality rate in Tanzania? (Further information at a country level is provided in Annexure 1 at the end of the document)10.

b. How does the Tanzanian Health System address these issues? c. What are the challenges of implementation of IMCI programme in

Tanzania and how they can be addressed for sustainability? 2. Your Country Experience:

a. Can you identify any other SDH which can influence the under-five mortality rate in your country?

b. How does your country Health System address these issues? 3. How can implementation research be used to influence health

policies/programmes/strategies?

10 WHO. 2010. Countdown to 2015: Maternal, Newborn and Child survival. Geneva: WHO.http://www.countdown2015mnch.org/countdown-news/50169-tanzania-case-study-findings-launched-by-president-at-country-countdown-event

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Annexure 1: WHO. 2010. Countdown to 2015: Maternal, Newborn and Child

survival. Geneva11 WHO.http://www.countdown2015mnch.org/countdown-news/50169-

tanzania-case-study-findings-launched-by-president-at-country-countdown-event

11 WHO.2010. Countdown 2015. http://www.countdown2015mnch.org/countdown-news/50169-tanzania-case-study-findings-launched-by-president-at-country-countdown-event [accessed 30/05/2014]

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Annexure 1: continued

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Teaching note

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) IMPLEMENTATION IN TANZANIA: EXPERIENCES, CHALLENGES AND LESSONS

Knowledge and learning

Previous knowledge required

Junior and Senior Researchers in Health and Social Science Graduate students developing Master´s and PhD degrees from High, Low and Middle Income Countries

Expected learning results (knowledge, skills and attitudes) and competency

To critically examine the issues related to implementation of research in the field of health and its social determinants. To better understand and to enhance the capacity to address challenges during implementing research in the field of health and its social determinants. To understand the significance of stakeholder engagement through the lifespan of research implementation-before, during and after

Contents to be learned

Integrated Management of Childhood Illness (IMCI); Implementation research; Health and its Social Determinants;

Main sources of information

Armstrong Schellenberg JR, Adam T, Mshinda H, et al. 2004. Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania. Lancet, 364(9445):1583-94. Bryce H, Victora CG, Habicht JP, Vaughan P, Black RE. March 2004. The Multi-Country Evaluation of the Integrated Management of Childhood Illness Strategy: Lessons for the Evaluation of Public Health Interventions. American Journal of Public Health, 94(3):406-415. Peters DH, Tran NT, Adam T. 2013. Implementation research in Health: Practical Guide. Geneva: WHO. http://who.int/alliance-hpsr/alliancehpsr_irpguide.pdf [accessed 31/03/2014] Prosper H and Borghi J. 2009. IMCI implementation in Tanzania: Experiences, challenges and lessons. http://www.crehs.lshtm.ac.uk/downloads/publications/Tanzania_IMCI_policy_brief.pdf [accessed 31/03/2014] Rajaratnam JK, Marcus JR, Flaxman AD et al. 2010. Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970–2010: a systematic analysis of progress towards Millennium Development Goal 4. Lancet, 375(9730):1988-2008. Victora CG, Adam T, Bryce J, Evans DB. 2006. Integrated Management of the Sick Child. In: Jamison DT, Breman JG, Measham AR, et al., (eds) Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): The World Bank. WHO. 2005. Handbook: IMCI integrated management of childhood illness. Geneva: WHO. WHO. 2010. Countdown to 2015: Maternal, Newborn and Child survival. Geneva: WHO.http://www.countdown2015mnch.org/countdown-news/50169-tanzania-case-study-findings-launched-by-president-at-country-countdown-event

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WHO. Undated. Integrated Management of Childhood Illness. http://www.who.int/maternal_child_adolescent/topics/child/imci/en/ [accessed 10/04/2014]

Key elements of the scenario

Briefly describe: a) Scenario in which case study takes place b) Stakeholders and their decision-making role for the role-playing

discussion

Group’s organization for each of the four phases: opening, analysis, discussion, and plenary

Opening=group Analysis=group Discussion=group Plenary=group Group assignment (presentations)=small groups (2-6) Teaching mode: Online and/or face-to-face

Main lines of discussion and elements

What is the implication of this case study on research projects related to health and its social determinants? What are some of the key aspects that one needs to consider when undertaking on research projects related to health and its social determinants? What are the different challenges faced during implementing research projects related to health and its social determinants? Do you have similar challenges in your country? What is the relevance of this case study to other contexts? What lessons can be drawn?

Potential distractors

Case study participants may end up discussing the case from a moral perspective, judging the behaviour of the different actors involved in the case, rather than discussing the case in terms of its content.

Evaluation Assessment methods

Small group presentation on (40%) Class participation (60%) Assignment – small group presentation The Tanzanian Case Study:

Can you identify any other SDH which can also influence the under-five mortality rate in Tanzania? (Further information at a country level is provided in Annexure 1 at the end of the document)

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How does the Tanzanian Health System address these issues?

What are the challenges of implementation of IMCI programme in Tanzania and how they can be addressed for sustainability?

Your Country Experience:

Can you identify any other SDH which can influence the under-five mortality rate in your country?

How does your country Health System address these issues? How can implementation research be used to influence health policies/programmes/strategies?

General comments

12 students per class session or less

Introduction to the case study and pre-discussion (30 min) – Self-study and preparation of presentation (2 days)- Post discussion and presentations (3 hours)

12 WHO. 2010. Countdown to 2015: Maternal, Newborn and Child survival. Geneva: WHO.http://www.countdown2015mnch.org/countdown-news/50169-tanzania-case-study-findings-launched-by-president-at-country-countdown-event

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Rubrics

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI) IMPLEMENTATION IN TANZANIA: EXPERIENCES, CHALLENGES AND LESSONS

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CRITERIA Activity Rating scale

Good Fair Deficient

Problem identification

Knowledge and

understanding of

concepts and issues

addressed in the

case

Participant shows ample

comprehension, knowledge

and ability to make use of main

concepts and ideas of case

study.

Approach to main topic of

case study is based on prior-

collected relevant evidence

(published literature) that

broadens the scope of

understanding of case study

situation. Also, it is based on

documented empirical knowledge

that serves to illustrate the main

topic of case study

Participant is able to

identify and comprehend

most of the concepts and

ideas presented in case

study Approach to main topic of case study is based on evidence (published literature) or documented empirical knowledge that serves to illustrate the main topic of case study.

Participant is unable to

comprehend or shows an

insufficient use of the

concepts and ideas

presented in case study Approach to main topic of case study is poorly based on evidence.

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Note: These rubrics should be applied to evaluate both class participation (60%) and small groups presentations (40%).

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Comprehension of of the challenges of implementing a health programme and lessons learnt in the context of social determinants of health (SDH).

Participant shows ample knowledge about the challenges of implementing a health programme and lessons learnt in the context of social determinants of health (SDH).

Participant is shows a fair degree of knowledge about the challenges of implementing a health programme and lessons learnt in the context of social determinants of health (SDH).

Participant is unable to identify the challenges of implementing a health programme and lessons learnt in the context of social determinants of health (SDH).

Debate process

Ability to work in

group and share

knowledge gained

during self-study

Ideas expressed in

participation are timely

expressed, coherently

formulated and strongly

based in scientific sources

and/or relevant authors

Opinions and participation

contributes to the

development of knowledge

and show a strong interest in

building a common

knowledge within the group

Opinions and participation

contributes to development of

knowledge in the group

Ideas expressed in

participation are mainly

drawn upon scientific

evidence and/or relevant

authors but lack further

discussion

Discussion of ideas is limited on agreement or disagreement of an original situation. Attitude towards

discussion shows

sufficient engagement but

fails to add insights for

building a common knowledge in

the group

Ideas expressed in

participation lack any kind of

evidence or support; tend to

be short and unclear

Participations do not

contribute to the

development of group

knowledge

Participant attitude is

indifferent to group

discussion

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Active participation Participations are voluntarily expressed and they contain original ideas that respond to other participants opinions

and expressions

There is a positive concern

for consensus building based on

group participation

Some participations are

voluntarily expressed and

contain original ideas and/or

respond to other participants

opinions and expression

Engages occasionally in

debate and there and

sometimes shows a

concern for consensus

building based on group

participation

There is a limited

participation in opinion and

ideas exchange between

group participants and there is no

interaction in consensus

building

Comprehensive

listening and

willingness to

reframe own

perspectives

Ideas are clearly expressed and show a strong connection with the main topic of discussion. Their

sources are acknowledged

and the participant is able to make personal

argumentation from different

sources of information

Ideas and opinions are

clearly expressed and are

frequently based on

relevant sources and/or

authors, although there is no

personal argumentation or

reflection on them.

Participation are

adequately linked to the

main topic of discussion

although sometimes they

tend to lose focus on it

Ideas and opinions lack

clarity and connection with main

topic of discussion.

Argumentation is seldom

based on relevant sources

and there is no effort to

elaborate a personal opinion on

them

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Self-expression and effective communication

Participants expresses in a fluent, respectful and timely manner. Is tolerant towards other points of view and is respectful when making statements. Answers and comments are based on valid, concrete and coherent argumentation

Participants expresses in a fluent respectful and timely manner although some ideas tend to be loosely expressed. Is tolerant towards other points of view but finds it somewhat difficult to make clear statements during discussion. Answers and comments are based on coherent augmentation

Participant expresses in a disorganized even disrespectful manner towards other points of view. Show little tolerance and comments tend to drift away from focus and show little coherence in augmentation.

Proposals on courses of action

Decision-making process

Participant is able to efficiently analyse all the elements that comprise the case the research done around it and the debate on the decision making process for possible solutions for the case study.

Participant is able to superficially analyse all the elements that comprise the case study the research done around it and the debate on the decision-making process for possible solutions the case study

Participant is unable to adequately analyse all the elements that compromise the case study and research done around it. In consequence, there is no possibility to formulate a possible solution

Consensus building Participant is able to propose solutions for case study through the engagement in discussion aimed to consensus building

Participant is particularly able to propose solutions for case study although not necessarily those proposals arise from consensus

Participant neither able to propose a solution nor to engage in consensus building discussion.