IMCI Health Facility Survey

Transcription

1 IMCI Health Facility Survey Sudan March - April 23 World Health Organization Regional Office for the Eastern Mediterranean Federal Ministry of Health Republic of Sudan

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3 OBJECTIVES 1

4 To assess the quality of outpatient care, including both clinical and counselling care, provided to sick children aged 2 months up to 5 years old at health facilities implementing the IMCI strategy; To describe organizational and other health systems support elements influencing the quality of care and identify major constraints to it; To measure key indicators of quality care to monitor progress of the IMCI strategy at health facilities; and To recommend further approaches to improving the quality of outpatient child health services. 2

5 METHODOLOGY 3

6 SELECTION OF HEALTH FACILITIES Systematic, random selection of 66 health facilities from a list of 136 facilities in 8 States in urban and rural areas and by type of facility: implementing IMCI; and with estimated daily caseload of at least 2 cases below 5 years old 4

7 DISTRIBUTION OF HEALTH FACILITIES IN THE SAMPLE BY LOCATION AND TYPE Urban Rural 25 No. of facilities Hospitals Health centres Dispensaries 5

8 6 SURVEY FINDINGS

9 1. Sample characteristics 2. Quality of clinical care 3. Factors influencing care 7

10 1. SAMPLE CHARACTERISTICS Case management observations: 364 children aged 2 months up to 5 years old Gender of cases: 46.7% female Age: 54.3% under 2 years old Caretakers interviewed: 35 Mother caretakers: 82.6% 8

11 CASES MANAGED BY TYPE OF HEALTH PROVIDER (N = 364) Nurses 3% Doctors 2% Medical Assistants 77% 9

12 2. QUALITY OF CLINICAL CARE ASSESSMENT Classification Treatment and advice 1

13 DISTRIBUTION OF MAIN CONDITIONS IDENTIFIED IN THE SAMPLE (N = 364) Acute respiratory infections 63 Fever 57 Diarrhoeal diseases 3 Anaemia 17 Eye infections Ear problem Severe malnutrition and Very low weight Needing urgent referral Percentage of all cases 11

14 INTEGRATED ASSESSMENT (1) : MAIN TASKS AND INDEX Child checked for 3 main symptoms (cough, diarrhoea and fever) 75% Child vaccination status checked Child weight taken and checked against growth chart 53% 6% Child checked for palmar pallor 45% Child checked for 3 general danger signs 21% Child road-to-health card asked for 9% 5.9 out of 1 tasks 12 WHO Index of integrated assessment

15 INTEGRATED ASSESSMENT (1): MAIN TASKS AND INDEX TRAINED vs UNTRAINED Child checked for 3 main symptoms (cough, diarrhoea and fever) Child vaccination status checked Child weight taken and checked against growth chart Child checked for palmar pallor Child checked for 3 general danger signs Child road-to-health card asked for 23% 19% % 28% % 1% 5% 62% 58% 63% 71% 79% Trained Untrained WHO Index of integrated assessment out of 1 tasks 13

16 PERFORMANCE OF SELECTED TASKS: TAKING TEMPERATURE AND WEIGHT 1 Percentage of cases in which task done Temperature taken Temperature Temperature taken correctly Weight taken Weight Weight taken correctly

17 PERFORMANCE OF SELECTED TASKS: TAKING TEMPERATURE AND WEIGHT TRAINED vs UNTRAINED Percentage of cases in whom task done Trained Untrained 18 Temperature Temperature taken taken correctly Temperature 91 Weight taken Weight taken correctly Weight 15

18 PERFORMANCE OF SELECTED ASSESSMENT TASKS: ARI (N = 228) AND DIARRHOEA (N = 19) 16 Percentage of cases in whom task done 1 Acute respiratory infections (ARI) 9 Diarrhoea Respiratory rate counted 57 Respiratory rate counted correctly ARI 57 Duration of Presence diarrhoea of blood in episode stool asked asked about about 51 Something to drink offered Diarrhoea 69 Abdomen skin pinched 33 Abdomen skin pinched correctly

19 SELECTED ASSESSMENT TASKS: ARI AND DIARRHOEA TRAINED vs UNTRAINED Percentage of cases in whom task done Respiratory rate counted ARI 77 Respiratory rate counted correctly Duration of diarrhoea episode asked about Presence of blood in stool asked about Trained Untrained 64 4 Something to drink offered Diarrhoea Abdomen skin pinched 41 4 Abdomen skin pinched correctly 17

20 ASSESSMENT OF FEEDING PRACTICES: CHILDREN LESS THAN 2 YEARS OLD (N = 189) AND OLDER CHILDREN WITH VERY LOW WEIGHT AND/OR ANAEMIA (N = 36) Assessed for feeding practices 76% 18 Not assessed 24%

21 ASSESSMENT OF FEEDING PRACTICES IN THE TARGET GROUP TRAINED vs UNTRAINED Percentage of cases in whom task done 1 Trained 9 Untrained Child under 2 years old assessed 7 Child 2 years old or older with very low weight and/or anaemia assessed 3 Both groups assessed for feeding practices 19

22 2. QUALITY OF CLINICAL CARE Assessment CLASSIFICATION Treatment and advice 2

23 AGREEMENT OF PROVIDER'S CLASSIFICATIONS WITH SURVEYOR'S CLASSIFICATIONS ON MAIN CONDITIONS Very severe febrile disease or malaria N=65 Very severe disease/severe pneumonia or pneumonia Dysentery N=8 5 Severe malnutrition or very low weight N=26 Mastoiditis or acute or chronic ear infection N=27 Diarrhoea with severe or some dehydration N=11 Severe or non-severe persistent diarrhoea N=1 Complicated or uncomplicated measles N=4 Severe anaemia or anaemia N=61 TOTAL AGREEMENT ON ALL CLASSIFICATIONS ABOVE Percentage of matching classifications 21

24 22 Very severe febrile disease or malaria Very severe disease/severe pneumonia or pneumonia Dysentery Severe malnutrition or very low weight Mastoiditis or acute or chronic ear infection Diarrhoea with severe or some dehydration Severe or non-severe persistent diarrhoea Complicated or uncomplicated measles Severe anaemia or anaemia Danger signs AGREEMENT ON OVERALL CHILD CLASSIFICATIONS AGREEMENT ON CLASSIFICATIONS TRAINED vs UNTRAINED No cases seen No cases seen Trained 23 Untrained Percentage of matching classifications 5 59

25 2. QUALITY OF CLINICAL CARE Assessment Classification TREATMENT AND ADVICE 23

26 MANAGEMENT OF SEVERE CASES NEEDING URGENT REFERRAL (N = 14): SEVERE CASES IDENTIFIED AND REFERRED Severe cases identified and referred 43% 24 Severe cases missed and/or not referred 57% All the 6 children correctly referred out of the 14 severe cases were identified by IMCI-trained providers

27 PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTIC TREATMENT (N = 8 CASES WITH "IMCI CONDITIONS" NEEDING ORAL ANTIBIOTICS) 1 Percentage of cases with an IMCI condition needing antibiotics Prescribed oral antibiotics Prescribed recommended oral antibiotics Prescribed antibiotics correctly 25

28 PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTIC TREATMENT FOR IMCI CONDITIONS (1) TRAINED vs UNTRAINED 26 Percentage of cases with an IMCI condition needing antibiotics Prescribed oral antibiotics 55 Prescribed recommended oral antibiotics 38 Trained Untrained Prescribed antibiotics correctly

29 PRESCRIPTION OF RECOMMENDED ORAL ANTIBIOTICS FOR IMCI CONDITIONS (2) TRAINED vs UNTRAINED Percentage of cases given a recommended antibiotic Trained Untrained 54 Correct dose Correct frequency Correct duration CORRECT PRESCRIPTION 27

30 CARETAKER CORRECT KNOWLEDGE ABOUT ORAL ANTIBIOTIC TREATMENT (IMCI CONDITIONS) TRAINED vs UNTRAINED 1 Percentage of caretakers of cases given a recommended antibiotic Trained Untrained 28 Correct dose Correct frequency Correct duration CORRECT KNOWLEDGE

31 CARETAKER'S POTENTIAL COMPLIANCE WITH PROVIDER'S ADVICE ON DURATION OF ORAL ANTIBIOTIC TREATMENT SHOULD CHILD GET BETTER BEFORE COMPLETING TREATMENT COURSE Would continue as advised 65% Other / don't know 12% Would stop treatment 22% Would continue but reduce dose 1% 29

32 RATIONAL USE OF DRUGS: CASES NOT NEEDING ANTIBIOTICS GIVEN NO ANTIBIOTICS (N = 254) Cases correctly prescribed no antibiotics 63% 3 Cases prescribed antibiotics but not needing them 37%

33 RATIONAL USE OF ANTIBIOTICS TRAINED vs UNTRAINED Percentage of cases not needing antibiotics Given no antibiotics Trained Given antibiotics but not needing them Untrained 31

34 PRESCRIPTION OF RECOMMENDED ORAL ANTIMALARIAL TREATMENT (N = 62) 1 9 Percentage of cases with malaria Prescribed oral antimalarials Prescribed recommended oral antimalarials Prescribed antimalarials correctly

35 PRESCRIPTION OF ORAL ANTIMALARIAL TREATMENT TRAINED vs UNTRAINED 1 Trained 9 Untrained Percentage of cases with malaria Prescribed oral antimalarials Prescribed recommended oral antimalarials Prescribed antimalarials correctly 33

36 PRESCRIPTION OF ORAL ANTIMALARIALS TRAINED vs UNTRAINED 1 1 Trained 9 Untrained Percentage of cases given antimalarials Correct dose Correct frequency Correct duration CORRECT PRESCRIPTION

37 CARETAKER CORRECT KNOWLEDGE ABOUT ANTIMALARIAL TREATMENT TRAINED vs UNTRAINED 1 Trained 9 Untrained Percentage of cases given antimalarials Correct dose Correct frequency Correct duration CORRECT KNOWLEDGE 35

38 ADVICE ON ORS TRAINED vs UNTRAINED 1 Trained 9 Untrained Percentage of cases given ORS Correct amount of water to prepare ORS Correct advice on when to give ORS Correct advice on how much ORS to give each time CORRECT ADVICE ON ORS

39 CARETAKER KNOWLEDGE ABOUT ORS PREPARATION AND ADMINISTRATION TRAINED vs UNTRAINED 1 Trained Percentage of cases given ORS Untrained 9 Knows correct amount of water to prepare ORS Knows when to give ORS Knows how much ORS to give each time CORRECT KNOWLEDGE ABOUT ORS 37

40 OTHER CURATIVE AND PREVENTIVE TREATMENTS AND OPPORTUNITIES FOR IMMUNIZATION FOR NON-REFERRED CASES 1 9 Percentage of eligible children Cases with eye infection given tetracycline ointment (N =41) Cases with anaemia prescribed iron (N = 55) Cases needing Vitamin A given Vitamin A (N =46) Cases needing vaccine given it or told when/where

41 CASES GIVEN ADVICE ON HOME CARE BY PROVIDER AND CARETAKER KNOWLEDGE Advised by provider Known by caretaker Percentage Give extra fluids Continue feeding 2 6 Signs to take child back immediately 12 2 ALL THREE HOME CARE RULES 39

42 ADVICE ON HOME CARE GIVEN BY PROVIDER TRAINED vs UNTRAINED 1 9 Trained Untrained 8 Percentage of cases Advised to give extra fluids Advised to continue feeding 1 Advised on signs to take child back immediately ADVISED ON ALL THREE HOME CARE RULES

43 CARETAKERS ADVISED ON SIGNS TO RETURN IMMEDIATELY AND KNOWING ABOUT THEM SIGNS FOR ALL: Becomes sicker Unable to drink FOR NO FEVER: Develops a fever FOR NO PNEUMONIA: Develops difficult breathing Develops fast breathing FOR NO DEHYDRATION: Has blood in stools Caretaker advised Caretaker knowing 7 Drinks poorly Percentage of cases 41

44 CARETAKERS GIVEN AGE-APPROPRIATE ADVICE ON FREQUENCY OF FEEDING Given correct advice 24% 42 Given no or incorrect advice 76%

45 MOSQUITO BEDNETS AND THEIR USE (N = 35) 1 9 Percentage of caretakers interviewed Has a mosquito bednet Has a treated mosquito bednet Child slept under bednet previous night CHILD SLEPT UNDER TREATED BEDNET PREVIOUS NIGHT 43

46 USE OF HOME CARE CARD AND COMMUNICATION TECHNIQUES Percentage of cases Details on communication techniques (N = 118 cases in whom card used) Home care card used (N = 347) Home care card and communication techniques used (N = 347) Card held properly Pictures pointed at Caretaker understanding checked

47 USE OF HOME CARE CARD AND COMMUNICATION TECHNIQUES TRAINED vs UNTRAINED 1 9 Trained Untrained 8 Percentage of cases Details on communication techniques (cases in whom home care card used) Home care card used 7 Home care card and communication techniques used Card held properly Pictures pointed at Caretaker understanding checked 45

48 3. FACTORS INFLUENCING CARE Drug availability Availability of supply for IMCI Availability of supply for immunization Availability of supply for malaria laboratory Availability of other supply Supervision 46

49 INDEX (MEAN) OF DRUG AVAILABILITY (N = 66 FACILITIES) (Availability of at least 1 treatment course) Index if all key drugs available in all facilities Mean no. of key drugs available in the facilities surveyed Index Essential oral treatments Non-injectable drugs Pre-referral injectable drugs 47

50 AVAILABILITY OF SUPPLY AND EQUIPMENT FOR IMCI Working baby scale 94 Source of clean water 91 Working timing device 89 Supplies to mix ORS 88 Thermometer 79 Working adult scale 45 Working nebulizer Percentage of the 66 facilities in which item available

51 AVAILABILITY OF SUPPLY AND EQUIPMENT FOR IMMUNIZATION AT 53 FACILITIES PROVIDING IMMUNIZATION SERVICES Percentage of the 53 facilities in which item available Needles and syringes 77 Safety box to dispose of used needles and syringes 32 2a. Functioning refrigerator with correct temperature 17 2b. Cold box and all ice packs frozen 36 AVAILABILITY OF SUPPLY AND EQUIPMENT FOR IMMUNIZATION (1 AND 2) 49

52 AVAILABILITY OF KEY SUPPLY AND EQUIPMENT FOR MALARIA LABORATORY Giemsa 77 Slides 77 Functioning microscope 7 Lancets to prick finger 68 ALL 4 ITEMS FOR MALARIA LABORATORY Percentage of the 66 facilities with the items available

53 AVAILABILITY OF IMCI RECORDS, COUNSELLING CARDS, CHART BOOKLET AND OTHER RECORDS IMCI chart booklet 88 Mother home care counselling card for provider use IMCI recording forms Road-to-health cards 7 IMCI daily register Vaccination register Drug stock cards Percentage of the 66 facilities in which item available 51

54 SUPERVISION IN THE 66 FACILITIES VISITED Percentage of all 66 facilities Received at least 1 supervisory visit in the past 6 months 11 Case management observed in past 6 months 26 Has supervisory book 15 Last visit's recommendations recorded on the book 2 Clinical supervision done and findings recorded

55 CONCLUSIONS 53 55

56 1. Better clinical performance of staff trained in IMCI than those untrained IMCI training can improve quality of outpatient child care 2. Very low clinical performance of staff not trained in IMCI Issue of pre-service training standards 54

57 3. Weak health systems support elements Major constraint to delivery of quality child care services and IMCI implementation 55

58 RECOMMENDATIONS TO FURTHER IMPROVE OUTPATIENT CHILD HEALTH SERVICES 56

59 POLICY: EQUITABLE ACCESS TO DRUGS AND SERVICES Consideration should be given to protecting children below 2 years old, especially in poor families, by issuing a policy and establishing mechanisms to provide affordable drugs to them States should commit to making key drugs regularly available to the health facilities where IMCI-trained staff work, to make the most of the substantial investment placed in IMCI training 57

60 TRAINING: BASIC SKILLS AND SKILL REINFORCEMENT Consideration should be given to strengthening pre-service training curriculum of medical assistants and introducing the IMCI outpatient care approach as a way to develop basic skills The Federal level and States concerned should jointly plan to develop and commit adequate human resources to follow up visits after IMCI training, to conduct them on a timely basis and according to standard methodology 58

61 SUPERVISION: MALARIA LABORATORY AND ROUTINE SUPERVISION Close supervision by Federal and State levels with quality control of malaria microscopic diagnosis should be carried out regularly to improve the quality of malaria laboratory diagnosis A training package on supervision of child health services should be developed. Supervisors responsible for routine supervision should be trained in child health supervisory skills and involved in IMCI follow-up visits 59

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64 The Italian Cooperation