Health Systems Strengthening for IMCI

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Health Systems Strengthening for IMCI

• Paula Tavrow
• January 16, 2001

Acknowledgement The Quality Assurance Project
is supported by the United States Agency for
International Development (USAID) under contract
number HRN-C-00-96-90013.
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Overview of Presentation

• Health systems
• Definitions and components
• IMCI
• Benefits and challenges
• QAP-tested interventions
• Teams
• Supervision
• Job aids

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Systems view of health services

• ? PROCESSES
• ? Financing, maintenance
• ? Logistics, financing
• ? Acquisition, maintenance
• ? Leadership, monitoring
• ? Diagnosing, treating, counseling, referring
• ? Administration, sanitation
• ? Record-keeping, planning
• ? Introduction, compliance

• INPUTS
• Facilties and utilities
• Drugs and supplies
• Equipment, vehicles, furnishings
• Managers, supervisors
• Trained providers
• Non-clinical staff
• Information, data
• Policies, standards

OUTCOMES Improved health and client satisfaction
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What is a Standard?
In its broadest sense, a standard is a
statement of the quality expected. This
includes practice guidelines, clinical
protocols, standard operating procedures,
product specifications, and performance
standards.
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What is a standard?

• In its broadest sense, a standard is a
  statement of the quality expected
• Examples practice guidelines, standard operating
  procedures, and performance standards
• Standards should be valid, reliable, clear,
  measurable, and realistic

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How do strong healthsystems introduce
standards?
Define Quality
Review / modify stds
Develop / adapt standards
Evaluate compliance
Educate / communicate stds
Obtain clients input
Remind about standards
Implement incentives
Monitor, give feedback
Identify andminimize barriers
Monitor Quality
Improve Quality
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Who typically has primary responsibility?
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Multiple involvement Stronger
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Quality interventions to strengthen health
systems
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Integrated Management of Childhood Illness
Benefits
Challenges
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Potential benefits of IMCI

• More accurate diagnosis, treatment referral
• Better patient monitoring and follow-up
• More rational use of drugs cost savings
• Reduction in missed opportunities for
  immunizations and Vitamin A distribution
• More effective counseling on nutrition
  and breastfeeding
• More effective provider-caretaker
  communication.

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Challenges of IMCI(from provider discussions in
Uganda, Kenya and Zambia)

• Providers dont regularly perform IMCI
• Within 3 months of IMCI training, about half of
  providers rarely perform IMCI
• Main reported reasons
• Lack necessary drugs or equipment
• Too time-consuming
• No support from other staff
• Mothers want injections and dont accept
  referrals
• Nurses not allowed to diagnose patients
• Why strain myself?

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Challenges of IMCI (contd.)(from observations
in Uganda, Kenya and Zambia)

• Trained providers make many errors
• About 1/3 of severe classifications missed
• About 20 to 40 of children get wrong treatment
• Main observed causes
• Providers do not use chartbook
• Providers assume they know algorithm
• Providers take shortcuts or rush to clear queue
• Providers revert to previous experience /
  training

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Challenges of IMCI (contd.)(from observations
in Uganda, Kenya and Zambia)

• IMCI training is costly and requires follow-up
• 450-750 per trainee for initial course
• Need to train all providers who see sick children
• Need to train or orient facility in-charges
  to be supportive
• Without follow-up observation and feedback,
  performance declines an additional 10 to 20

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Interventions to strengthenhealth systems for
IMCI

• What can we do?

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What should health systems do?

• Enable providers to achieve basic IMCI competence
• Motivate providers to comply with IMCI guidelines
• Decrease barriers to implementation of IMCI
• Ensure consistent drug supply and IMCI equipment
• Maintain quality of IMCI
• Monitor performance of IMCI

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Interventions QAP tested to strengthen health
systems for IMCI

• To identify and reduce barriers
• Facility-based problem-solving teams (Kenya)
• To monitor and give feedback
• Regular supervision and feedback (Niger)
• To remind about standards
• Improved job aids for providers (Zambia)

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Intervention 1 Teams

• Teams are key component of quality management
• Facility teams problem-solve using simple quality
  tools
• Supervisors train and coach teams
• Directed teams are given the problem but select
  their own solutions to implement

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Results of Kenya teams intervention
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Types of solutions implemented by Kenya teams
Number of teams
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Improvement of providers in IMCI case
management, 1998-2000

Based on composite index of 4 management
aspects assessment, classification, treatment,
counseling n Number of facilities in two
Kenyan districts
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Intervention 2 Supervision/Feedback

• Quality and regularity of supervision are
  important for performance improvement
• Supervisors need incentives and peer pressure
  to monitor regularly
• Simple assessment and feedback tools focused on
  provider performance

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The Quality Supervision System in Tahoua
Department, Niger
Semi-annual Department Meetings
Quarterly District Workshops
Supervisors
Resources, standards
Healthcare Providers
Data, local knowledge
Quality of care
Clients
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Assessment Tool ERPA

• Based on Health Facility Assessment (BASICS)
• Four parts of tool
• Direct observation of provider
• Client exit interview
• Provider interview
• Facility record review and inventory
• Feedback during district workshops

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Results of Supervision/Feedback
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Intervention 3 Job aid

• Providers who use job aids are more likely to
  perform IMCI correctly
• Current job aid (chartbook) not very
  user-friendly and avoided by many providers
• Patient forms that accompany chartbook not
  supplied to providers
• New job aid created

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Quality Design of Job Aid in Zambia

• Consultant worked with providers to develop job
  aid meeting their needs
• Job aid is embedded in patient record book, to
  avoid embarrassment to provider
• Job aid assists providers to draw causal
  connections from assessment to classifications
• Job aid evaluated in December 2000 and results
  expected in February 2001

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Conclusions

• Key challenges of IMCI
• Providers stop performing IMCI
• Providers make many errors
• IMCI is costly and requires supervision
• Need participation of multiple levels of health
  system for compliance with IMCI
• Much remains to be done to strengthen health
  systems to support IMCI
• More pilot testing of approaches needed