Ministry of Public Health and Social Welfare

Integrated Supervision Strategy IMCI - EPI

Contribution to strengthening the health services in Paraguay

Dr. María Elsa Paredes Director, Integrated Child and Adolescent Health

Quito, Ecuador - 29 to 31 October 2007

• In 1997, the IMCI strategy was implemented in 10 of the 18 Regions of Paraguay, with the objective of reducing under 5 mortality (25x1000 LB) and promoting children’s growth and development through health care quality improvements.

• Paraguay’s immunization program began in 1980, to reducing morbidity and mortality from preventable diseases by vaccinating all children under 5. This is accomplished by supervising vaccination activities at health centers at all levels of care.

• The deficiencies in the health system are considered to be “the main obstacle to improving health outcomes.” The need for strengthening the health system has become a top priority in public policy.

• The integrated supervision methodology was proposed in order to optimize

the existing human and material resources for improving the quality of healthcare management and services at the regional, district, and local level.

Background

Uniform Work Concept

• IMCI-EPI supervision in regions, districts, and health centers is a joint effort between supervisors at the managerial level (national and regional) and providers at the operational level that integrates monitoring and training to focus health worker’s attention on people and their health needs in a comprehensive, integrated fashion.

COMPONENTS OF IMCI-EPI INTEGRATED SUPERVISION

• Training

• Logistics and supplies

• Information

• Monitoring

• Evaluation

Quality procedures in IMCI and EPI

GENERAL OBJECTIVES

• Provide feedback on the planning, scheduling, execution, and evaluation of EPI/ IMCI.

• Strengthen the technical skills of personnel who offer services, using a comprehensive, integrated approach to care.

• Improve management and the quality of health services at all levels of complexity.

• Framing the issue• Methodology• Implementation• Results• Lessons learned• Obstacles and challenges

DESCRIPTION OF THE IMCI-EPI INTEGRATED SUPERVISION

EXPERIENCE

Framing the issue

• Political and technical advocacy

• Mobilization of resources.

• Interprogrammatic partnerships.

Through:

Methodology

• Design the integrated supervision instrument. Each indicator contains three to six conditions that must be met for it to be considered achieved

• Training of human resources• Team Composition: A national supervisor and a

regional supervisor of IMCI/EPI• Includes the monitoring of 10 indicators

categorized as: – Service integration indicators– Existing capacity indicators

DOMAIN

In order to begin developing the IMCI-EPI integrated supervision strategy, 70 districts in six regions or departments with the greatest concentration of the country’s population (72%) were selected for their low vaccination coverage.

The 70 districts have 355 health service centers: 5 regional hospitals, 16 district hospitals, 34 health centers, and 300 health posts, which became the basic unit for analyzing the integrated supervision.

Results

• Health services integration indicators

• Indicators of improvement of existing capacities for providing health care services

Strengthening health services

Regions Districts in the Region

Priorities Total population

District Health Services

Integrated Supervision of

Health Services

Coverage

San Pedro Norte 11 8350840

64 60 94.0

San Pedro Sur 8 2 34 34 100

Caaguazu 20 12 474,261 54 54 100

Itapúa 30 20 517. 047 82 48 57.0

Alto Paraná 20 11 703.507 54 47 87.0

Central 19 16 1,860,841 59 52 88.0

Capital 1 1 519.076 9 * 1 11.0

Total 109 70 4,425572 355 281 79.0

Total country 232 6,119,642 900

Area of Implementation of the IMCI-/EPI Integrated supervision

* Has 29 , but 9 were scheduled

Geographical distribution of the Priority Districts in the Supervised Area

ParanáItapúaSan PedroPlantCaaguazúAsunción

In the regions of

Level of Complexity Existing With two rounds of supervision

Supervision coverage

Regional Hospital 5 4 80.0

District Hospital 16 16 100

Health Center 34 34 100

Health Post 300 227 76.0

Total 355 281 79.0

Supervised health services by level of complexity

Did the health center have staff trained in IMCI protocols?

N = 281

Service integration indicators

Nº= 281

Differences in application of IMCI protocols according to whether staff has received training

Service integration indicators

Nº= 281

Differences in application of IMCI protocols according to whether staff has received training (2)

Service integration indicators

Is improvement in EPI/IMCI observed in the services between the first and the second rounds of supervision?

Service integration indicators

Are there differences in the application of IMCI protocols in Alto Paraná Between the first and second rounds of supervision?

Service integration

indicators

Application of protocols

Necessary Equipment

Application of protocols

Is improvement in EPI/IMCI observed in the services in Alto Paraná between the first and second rounds of supervision ?

Service integration indicators

Nº= 69

Improvement indicators for existing capacity in the services

Is improvement in EPI/IMCI observed in the services between the first and the second rounds of supervision?

* ORS, amoxicillin, Mebendazole, Albendazole, Salbutamole, penicillin. Benzathine

Is improvement in EPI/IMCI observed in the servicesbetween the first and the second rounds of supervision?

Improvement indicators for existing capacity

Is improvement in EPI/IMCI observed in the servicesbetween the first and second rounds of supervision?

Improvement indicators for response capacity

Essential elements of PHC converge based on

the experiences of IMCI-EPI Integrated Supervision

ESSENTIAL PHC ELEMENTS OVERLAP WITH SUPERVISION PROGRAM

Comprehensive, continuous, integrated care

Coordination of preventative (vaccines) and curative (treatment) medicine during key stages in life. Coordination among all parts of the system; plan for referral and counter referral.

Appropriate care Focuses on the whole person, beginning with promotion and prevention (Community AIEPI). Treatment (Clinical IMCI) is based on the detection of problems and timely provision of vaccinations of proven effectiveness (EPI)

Pro-equity policies and programs

Availability of care and free vaccines at all levels (Immunization Act) and verification of the quality of the service through supervision. Monitoring the scope of coverage at all levels

ESSENTIAL PHC ELEMENTS OVERLAP WITH SUPERVISION PROGRAM

Emphasis on promotion and prevention

Offers education, counseling, monitored care, and its approaches are based on improvements in key family practices that benefit the health of children and their families

Adequate and sustainable resources

Monitoring of and follow-up on the availability and supply of drugs, equipment, supplies, inputs, and materials, etc.

Appropriate human resources Monitoring the training of staff with technical skills and knowledge in their area of expertise to ensure they meet technical and ethical standards.

Optimal organization and management

Legal-political and institutional framework for the organization of immunization services and integrated care to improve the health and development of children and their families.

Essential elements of PHC that overlap withthe experiences of IMCI-EPI Integrated Supervision

Weaknesses and limitations

• The availability of resources qualified to supervise training

• Lack of regional involvement in the supervisory process

• Difficulties in connecting the results of the supervision with decision-makers for better resource management

• Standardization of criteria for applying the instruments and interpreting the results

• Failure to structure services as a network

LESSONS LEARNED

• Find mechanisms to incorporate integrated supervision into the process of service management and resource allocation.

• Organize health services into a network and create stronger local management teams.

Obstacles and challenges

• Progressively turning over management of the integrated supervision program to the individual regions and service centers to ensure continuing educational supervision, optimize management supervision from within the services themselves, and improve primary healthcare.

Thank you