Orientation Guidelines: Integrated Management of Childhood Illness

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Integrated Management of Childhood Illness - Orientaon and Planning Guidelines for

Provinces and Districts


Provinces and Districts78 i

TABLE OF CONTENTS

ABBREVIATIONS AND ACRONYMS : : : : : iiiLIST OF TABLES : : : : : : : : ivFOREWORD : : : : : : : : : v

ACKNOWLEDGEMENTS : : : : : : : vi

1.0 INTRODUCTION : : 1

2.0 OVERVIEW OF IMCI IMPLEMENTATION IN ZAMBIA : : 22.1 Improvement of Health Workers skills : : : : 22.2 Improvement of Health System : 32.3 Improvement of Household and Community Practices : 32.4 Monitor ing and Evaluation of IMCI Implementation : 3

3.0 IMCI ORIENTATION FOR PROVINCIAL HEALTH OFFICE : 63.1 Objectives 63.2 Participants: 63.3 Methods 6

3.4 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 t raining Si tes : 17

5.0 PLANNING FOR IMCI IMPLEMENTATION AT DISTRICT LEVEL: : 195.1 Planning for Improvement of Health Workers Ski lls: : 205.2 Planning for Improvement of Health System: : 255.3 Planning for Improvement of Household and Community Practices: 29

6.0 ANNEXES: : : 35Annex 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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Provinces and Districtsii 77

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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Provinces and Districtsiv 75

LIST OF TABLES

Table 1: IMCI Performance Indicators for three Health FacilitySurveys...11Table 2: Inpatient sick children case load assessment..19Table 3: Inpatient sick child treatment standards20Table 4: Outpatient sick children case load assessment...21

Table 5: Outpatient sick child treatment standards.22


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Provinces and Districts74 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 by

addressing 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 ofnutrition, 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 Secretary

MINISTRY OF HEALTH

ANNEX 1: TABLE 2 PROBLEMS WITH FACILITY SUPPORTS (FOUND

DURING FIRST FOLLOW-UP VISIT AFTER TRAINING)

District Total

District name

Visiting supervisor or Team

Problems with facility supports Space and Eq uipment:

1. No functioning scale__ of __ __ of __ __ of __ __ of __

2. No timing device __ of __ __ of __ __ of __ __ of __

3. No IMCI chart booklet __ of __ __ of __ __ of __ __ of __

4. No mothers card __ of __ __ of __ __ of __ __ of __

5. No patient record cards __ of __ __ of __ __ of __ __ of __

Diarrhoea treatment corner (DTC):

6. No functioning DTC

__ of __ __ of __ __ of __ __ of __

7. No source of drinking water __ of __ __ of __ __ of __ __ of __

8. Not enough supplies (cups , ORS) __ of __ __ of __ __ of __ __ of __

9. No DTC register available __ of __ __ of __ __ of __ __ of __

Immunization:

10. No functioning refrigerator

__ of __ __ of __ __ of __ __ of __

11. No safety box __ of __ __ of __ __ of __ __ of __

12. No MCH-1 cards __ of __ __ of __ __ of __ __ of __

13. Poor vaccine conditions __ of __ __ of __ __ of __ __ of __

14. Not all vaccines available __ of __ __ of __ __ of __ __ of __

Clinic and referral services:

15. Clinic not opened as scheduled

__ of __ __ of __ __ of __ __ of __

1 6. Im mun iz at io n s es si on s n ot of fer ed d ai ly _ _ o f _ _ _ _ o f _ _ _ _ of _ _ _ _ o f _ _

17. N o ref erra l f aci lity re as on ab le tim e __ of __ __ of __ __ of __ __ of __

Quality of records:

18. No individual patient records or registers kept

__ of __ __ of __ __ of __ __ of __

19. Records not complete __ of __ __ of __ __ of __ __ of __

Management of drugs:

20. Health facilities that have all the essential IMCI drugs in

stock (Amoxicillin, Cotrimoxazloe, Coartem,

Gentamycine Vitamin A, ORS and IM chloramphenicol)

__ of __ __ of __ __ of __ __ of __

2 1. A ll a va il ab le e xc ep t IM c hl or am ph en ic ol _ _ o f _ _ _ _ o f _ _ _ _ of _ _ _ _ o f _ _

Training:

22. Health facilities with at least 60% of workers managing

children trained

__ of __ __ of __ __ of __ __ of __


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Provinces and Districtsvi 73

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)

ANNEX: TABLE 1 QUALITY OF CASE MANAGEMENT (IN CASES

OBSERVED DURING FIRST FOLLOW-UP VISIT AFTER TRAINING)

(contd)

District Total

District name


20. Caretakers of children given an antibiotic or antimalarial

drug who know: how much to give, times per day and

number of days

__ of __ __ of __ __ of __ __ of __

21. Caretakers of children with diarrhoea given ORS who

know: to give ORS, mix ORS and amount of ORS to

give

__ of __ __ of __ __ of __ __ of __

22. Caretakers of children who are given an antibiotic or

antimalarial and or ORS know how to give treatment

__ of __ __ of __ __ of __ __ of __

23. caretakers who know all 3 rules of home care ( Fluid,

Food, when to return immediately)

__ of __ __ of __ __ of __ __ of __


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Provinces and Districts72 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 Infant

Mortality 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 developing

countries is caused by five conditions: acute respiratory infections, diarrhoea,measles, malaria and malnutrition. HIV/AIDs has also become an importantcause 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 onecondition. 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.

ANNEX 1: TABLE 1 QUALITY OF CASE MANAGEMENT (IN CASES

OBSERVED DURING FIRST FOLLOW-UP VISIT AFTER TRAINING)

District Total

District name


1 . C ases a ssesse d f or a ll f ou r g en er al d an ge r s ig ns _ _ o f _ _ _ _ o f _ _ _ _ o f _ _ _ _ o f _ _

2. Cases assessed for the presence of all main symptoms

( cough, diarrhoea, fever and ear problem)

__ of __ __ of __ __ of __ __ of __

3. Cases assessed for the presence of cough, diarrhoea

and fever

__ of __ __ of __ __ of __ __ of __

4 . C as es w ho w ei gh t w as c he ck ed c orr ec tl y _ _ o f _ _ _ _ o f _ _ _ _ of _ _ _ _ o f _ _

5. Cases whose immunization status was correctly

checked

__ of __ __ of __ __ of __ __ of __

6 . S ev er e c as es n ee di ng r ef er ra l r ef er re d _ _ o f _ _ _ _ o f _ _ _ _ of _ _ _ _ o f _ _

7. Severe cases who received first dose of antibiotic before

referral.

__ of __ __ of __ __ of __ __ of __

8. Severe cases of malaria who received IM quinine before

referral

__ of __ __ of __ __ of __ __ of __

9. Cases needing an oral antibiotic or antimalarial are

prescribed correctly

__ of __ __ of __ __ of __ __ of __

10. Cases of pneumonia who received a full course of

antibiotic at the health facility

__ of __ __ of __ __ of __ __ of __

11. Cases of acute ear infection who receive a full course

of antibiotics at the health facility.

__ of __ __ of __ __ of __ __ of __

12. Cases of dysentery who received a full course of

antibiotics at the health facility

__ of __ __ of __ __ of __ __ of __

13. Cases of malaria who received a full course of

antimalarial at the health facility

__ of __ __ of __ __ of __ __ of __

14. Cases of diarrhoea with some dehydration who

received ORS solution the facility

__ of __ __ of __ __ of __ __ of __

15. Caretakers of children, not referred, advised on giving

extra fluid an continue feeding

__ of __ __ of __ __ of __ __ of __

16. Caretakers of children, not referred, advised on giving

extra fluid and continue feeding and at least 2 signs for

when to seek care

__ of __ __ of __ __ of __ __ of __

17. Cases who should have received an immunization,

according to the schedule, and received it the day of

the visit

__ of __ __ of __ __ of __ __ of __

18. Caretakers of children


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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 an

integrated 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 ofdisease 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 hasbeen 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 are

obtained 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 inte grated 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 key 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 were

performing 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

Technical Skills on fever, ITNs, breastfeeding, vitamin A, other key family practices

Participatory Needs Assessment & PlanningCounselling of CaretakersOther communications activitiesOther community support activities e.g. drug distribution, availing bed nets etc.Monitoring implementation.

.

Document lessons learntReview Strategies & Re-planningPlan for Scale Up.

Review & Evaluation


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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 in

urban 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 generaldanger signs

44.2 40.9 51.5

Child checked for the presence ofcough, diarrhoea and fever

81.9 77.2 92.5

C hild check ing for o ther p roble ms 74.6 6 1.3 92 .7Child checked against a growthcharts

32.2 31.9 34.3

Child checked for symptomaticHIV/AIDS

- 5.8 41.4

Chi ld 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 correctlyclassified

59.9 54.6 75

Child with anaemia is correctlyclassified

12.5 - -

Child is correctly classified for

general danger signs, and 3 majorsymptoms

47.0 - -

Child with very low weight iscorrectly classified

25 - -

Symptomatic HIV infection Unlikely 1.8 - -TREATMENT

Child with pneumonia correctly 76.4 79.6 72.7

Annex IX

IMPLEMENTATION STEPS FOR COMMUNITY IMCI

Pre-visit District.Orientation of District Core TeamSensitization of District Local Council (Civic & Political Leadership).Identify & Orient Other Stake Holders.

District Baseline SurveyDissemination of Baseline FindingsDistrict Level Planning and Budgeting for HH/C IMCI Activities (communication etc).

Health Centre level planning and budgeting for HH/C IMCIDevelop monitoring indicators and systems.

Pre-visit NeighbourhoodSensitization of Civic and Political leadersOrientation NHCs and CBAs on HH/C IMCI

Communication Skills including CounselingCommunity Based Management Information SystemMonitoring & Supervision

District entry / Introductory Phase

Training / orientating district resource team on

Preparation for Implementation

Preparation for implementation at Health Centre Level

Neighbourhood Level entry /

Training NHCs and CBAs


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3.0 IMCI ORIENTATION FOR PROVINCIAL HEALTH 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 Specialist

Financial SpecialistDistrict Medical officer for host townHeads 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 the

province and current interventions to address them. Prepare a presentationdescribing the situation in the p rovince.

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).

Take children to complete a full course of immunization before their firstbirthday;

Follow the health providers advice on treatment, follow-up and referral; Ensure that every pregnant woman has adequate antenatal care, and seeks

care at the time of delivery and afterwards.


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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 health

worker (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 toimprove 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.

Annex VIII

KEY FAMILY & COMMUNITY PRACTICES ADOPTED INZAMBIA

The promotion of growth and development of the child

Breastfeed babies exclusively for six months From six months, give children good quality complementary foods while

continuing to breastfeed for two years or longer;

Ensure that children receive enough micronutrients - such as Vitamin A, ironand zinc- in their diet or through supplements;

Promote mental and social development by responding to childs need forcare and by playing, talking and providing a stimulating environment.

Disease prevention

Dispose of all faeces safely, wash hands after defecation, before preparingmeals and before feeding children;

Protect children in malaria endemic areas, by ensuring that they sleep underinsecticide-treated bednets;

Provide appropriate care for HIV/ AIDS affected people, especially orphans,and take action to prevent further HIV infections.

Appropriate care at home

Continue to feed and offer more fluids, including breast milk to children whenthey are sick;

Give sick children appropriate home treatments for infections;

Protect children from injury and accident and provide treatment whennecessary;

Prevent child abuse and neglect, and take action when it does occur;

Involve fathers in the care of their children and in the reproductive health of

the family.

Care-seeking outside the home

Recognize when sick children need treatment outside the home and seekcare from appropriate providers;


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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 develop

detailed agenda, which matches the specific requirements in a province.

Introduction:

The IMCI strategy: overview and rationale (15 minutes)IMCI status in Zambia (15minutes)

Discussion

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

Discussion

Improving the Health systems (15 minutes)

Availability of drugs Organization of work in health facilities

Supervision IMCI & Health Information System

Discussion

Improving family & community practices (15 minutes)

What do the IMCI guidelines already of fer 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

Discussion

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:

It is important to inform the province in good time to prepare the topic onchild survival activities in the province.

Refer to the standard power point slides for the first 5 presentations(Annex I)

4.0 CONCLUSIONState the general impressions of the whole exercise and what was found inthe facilities/district.

5.0 Annex of District results Tables 1 &v2


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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 their

districts 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 T eam 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 p ractices 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 the

health centres and transport availability.

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

Annex VIIGUIDELINES ON REPORT WRITING FOR IMCI INITIAL FOLLOW-UP /SUBSEQUENT HEALTH WORKER CLINICAL PERFORMANCE FOLLOW-UP

1.0 Introduction

Process ( including DHMT members met, areas visited and monitoring toolsused etc.)

Number of health workers visited/ supervised / followed up What number of supervision this particular one is ( is it first or second visit

etc)? Duration of the follow-up.

2.0 Findings2.1 Reception - How were the caretakers handled generally, are the health

workers courteous?2.2 Assessment of General Danger Signs (DGS) - how many assessed able to

drink or breastfeed, vomiting everything, convulsions now or history2.3 Cough/difficulty breathing- how many counted breathes in one minute.

Checked chest in drawing, listened for wheeze /stridor.2.4 Diarrhoea - how many checked childs drinking, did a skin pinch.2.5 Fever how many did RDT, how many checked stiff neck, undressed and

checked generalized rash of measles, asked for history of measles.2.6 Ear problem - how many checked for tender swelling behind the ear2.7 Malnutrition - how many undressed and checked for visible severe wasting,

oedema of both feet and weight for age.2.8 Anaemia - how many checked for palmer pallor,2.9 HIV and AIDS- how many checked for HIV and AIDS status2.10 Immunization, Deworming and Vitamin A - how many checked immunization

status, Deworming and vitamin A supplementation status2.11 Feeding assessment - how many assessed and identified feeding problems

and gave appropriate advice.

3.0 Counseling of caretakers - how many gave follow- up dates, advised onwhen to return immediately and asked checking questions.

3.1 OBSTACLES IN IMCI IMPLEMENTATION what were the main obstaclessited by health workers in implementing IMCI i n the facilities?

3.2 Facility Review- Did the screening room have all the necessary things toadequately see a sick child? Did the ORT corner have all the necessary

things/ personnel? Did the childrens OPD cards / books have IMCI language(follow-up dates, positive findings, treatments, classifications)?How many of the books / cards were reviewed in this visit at your facilities/per facilities?


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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 ofcommunication 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/ or

communication, 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 Child

Health and Nutrition

5. Human/ financialresource

A sufficient number of District Health Management Team (DHMT)members should be trained in IMCI, including the clinical supervisors. It isproposed that at least 60% DHMT members be trained in facility andcommunity IMCI.

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

facilitators Proportion of health workers managing sick children who are trained in

IMCI. 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 supervisory

skills


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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

Part 3. CARETAKER INTERVIEW ANNEX-IV Health Facility_____________Reviewer:___________ If thechild willnot be referred,ask the mother orother caretakerthe following questions,depending

District:_____________ what youfound during yourexamination.. Tick orwrite response below.

For caretaker or the Ask: Tick or write response:child whoshould[tick all that Yes Noapply]

1. [ ] RECEIVE AN Ask the caretaker to show you the ANTIBIOTIC or 1. 1.

ANTIBIOTIC prescript ion. Then, ask:

(or a prescription a. How much will you give? a. _______ dose a. [ ] a. [ ]for one) b. How many times aday will you give it? b. _ ______ times/day b. [ ] b. [ ]

c. For how many days? c. _______ days c. [ ] c. [ ]

All3[*] All 3[*]d. When should you return for follow up? d. in _____ days d. [ ] d. [ ]

2. [] RECEIVE AN Ask the caretaker to show you the ANTIMALARIAL or 2. 2.ANTIMALARIAL prescription. Thenask:(for a prescription a. How much will give? a. _______ dose a. [ ] a. [ ]for one) b. How many times aday will give it? b. _______ times/day b. [ ] b. [ ]

c. For how many days? c. _______ days c. [ ] c. [ ]d. When should you return for follow up? All 3[*] All 3[*]

d. in _____ days d. [ ] [ ]3. 3.

3. [ ] Had a. What will you give your child at home? a. [*] ORS a. [ ] a. [ ]DIARRHOEA [ ] Other ____________ WITH SOME [ ] Does not know.DEHYDRATIONwhen child b. I fORS, how much water will you mix with the ORS? b. [* ] 1 litre b. [ ] [ ]arrived at facility. [ ] Other: ____________

[ ]Doesnotknow.[ ]Willnot giveORS

c. How muchORSsolutionwillyou give?F or P lan A a t h om e(a ft er rehy dr at io n in f ac il it y), c . [ *] Cor rect amo unt f or age c . [ ] c . [ ]after each stool: [ ] Other: ____________ Up to 2 yrs 50 - 100 ml [ ]Does not know.2 y rs t .5yrs 100 - 200 ml

4. [ ] Should a. Did your child receive an immunization today? If 4. 4.receive an YES, check card or other source to see that the a. [*] Yes and a. [*] a. [ ]IMMUNIZATION correct immunization was given. correct

5. ALL CHILDREN a. When your child is sick, should you give much less, a. [ ] less fluid 5a. 5a.about the same, or more FLUID than usual? [ ] About the same [ ] [ ]

[*] more fluidb. When your child is sick, should you give muchless, b. [ ]less food 5b. 5b.

about the same, or more FOOD or BREASTMILK [ ] About the same [ ] [ ]than usual? [*] more food

c. What signs would indicate that you should bring c. ALL CHILDREN 5c. 5c.your chi ld immediately totheheal thfaci l ity? [ ]Not able to drink

[ ] Becomessicker[ ]DevelopsfeverCHILD WITH At leastCOUGH OR COLD: two

[ ] Fast breathing signs [ ] [ ][ ] DifficultbreathingCHILDWITHDIARRHOEA:[ ] Blood instool[ ] Drinkingpoorlyother:_______________

Correct?


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

Minimal Standard of Care in the Inpatient Ward

Inpatient care should be delivered competently. Although participants in the courseare not learning inpatient management, they are learning to refer children with

severe 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 be

maintained.

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 facil ity

The suitability of the facility depends on the type and quality of services provided to

sick 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.

59 Did the health worker give the date for the next immunization? 1= yes 2= no 3= N/A

60 Did the health worker give the date for the next vitamin A supplementation? 1= yes 2= no 3= N/A

61 Did the health worker ask any CHECKING QUESTIONS to the caretaker? 1= yes 2= no

62 NOW recordthe time consultationends: ___ ___:___ ___ 63 Durationof consultation: ______

Aftertheobservation,ask thehealthworker whatproblemsdoes he/sheusually encounterin implementing IMCIat his/her healthfacility

{ probethe healthworker to get asmany obstaclesand challenges as possible}

1 . 4 .

. .

. .

2 5

. .

. .

3 . 6 .

. .

. .


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Number of children admitted

All hospitalized children may not have serious or severe illnesses. The first thing toreview 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 f ind 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

MeningitisPneumoniaSome dehydrationPersistentdiarrhoea

MalariaMeaslesMalnutritionAnaemiaHIV and AIDSBacterial 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 let

participants 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:

46 Did the HWcheck forHIV statusof the child? 1=yes 46.a HW: 1= exposed;2=positive; 3= negative; 4 unknown; 5=N/A

47 Did the HWcheck forHIV statusof the mother? 1=yes 47.a HW:1=positive; 2=negative; 3=unknown; 4=N/A

2=no

3=N/A

Part 10: FEEDING ASSESSMENT forchildrenwith malnutrition, anaemia or growthfalteringor less than 2 yearsold.

48 Did the HWask whether thechild is on breastmilk? 48.a 1= BF; 2= no BF

49 If childis breastfed, did theHW ask how many timesin 24 hours? 49.a ___ ___ times

50 Did the HWask whether thechild takes otherfood or fluids? 50.a 1= food/fluids; 2= no other food/fluids

51 If childtakes other food,did the HW askhow many times per day? 51.a ___ ___ times

52 Did the HWlist existing feedingproblems? 52.a HW: 1 2 3 4 5 6 7 8 9

{ codes forfeedingproblems: Circle appropriate codes in 44.a & b}

1= noExlus.BF; 2=BF< 8 timesin 24hrs;

3= nocompl. Foods; 4=gets < meals; 52.b Reviewer'sclassification:

5= bottlefeeding; 6=no active feed;

7= shares wth others; 8= eats less when sick; 1 2 3 4 5 6 7 8 9

9= others.

Part 11: Referal

53 Did the HWdecideto refer thechild? 53.a Ifyes, didthe healthworkergiveany 1=yes; 2= no

pre-referal treatments?

Part 12: Treatment & Other Advice - kindly ask the health worker's prescription and fill in the following matrix

54 List of drugs & other advice given Copy dosages given by the health worker

example; 1 (120mg) tablet in clinic, 1 on

after8 hrs and 1tablet BD x 2 days)

a Anti mal ar ia l: . . 1=Yes 2=No a.1

a.1 RDT Positive 1=Yes 2=No 3=Not done

b Antibiotic*: . 1=Yes 2=No b.1

c Diarrhoea treatmentPLAN c.1

Zinc tablets 1=Yes 2=No

d Vitamin A 1=Yes 2=No d.1

e Iron 1=Yes 2=No e.1

f Immunizations 1=Yes 2=No

g Feeding advice 1=Yes 2=No

* Stateif Cotrimoxazole is indicatedfor HIV exposedchildren.

Part 13: Health worker/caretaker Interaction

5 5 Di d t he he al th w or ke r o r so me on e el se i n t he c li ni c ex pl ai n ho w t o gi ve o ra l me di ci ne s a t h om e? 1 = ye s 2= n o 3= N /A

5 6 Di d t he he al th w or ke r e xp la in to th e c ar et ake r wh en to br in g t he chi ld ba ck for F OLLOW -UP ? 1 = ye s 2= n o 3= N /A

57 Did the health worker advice the caretaker when to return IMMEDIATELY? 1= yes 2= no 3= N/A

58 Did the healthworker mention any of the signsb any of the following signs? 1= Fever persists

2= Child becomes drowsy or difficult to arouse

3=Child is unable to eat

4=Child is unable to drink5=Blood instool

6=Diarrhoea persists

7=Child hasfast breathing ordifficult breathing

8=Child fails to get better

9= Other: ____________________________

2=no

1=yes

2=no

3=N/A

1=yes

2=no

1=yes

2=no

1=yes

1=yes

2=no

1=yes

2=no

Circle1= Yes( if drug prescribed) or 2=No( ifno drug is prescribed)

exceptfor 164where youcircle appropriate plan.

Aor B or C

2=no


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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 antibiot icsConvulsions Rectal diazepam (or appropriate

anticonvulsant)Severe malaria, meningitis orsevere malnutrition.

Apart from specific treatmentPrevent hypoglycaemia

Complicated malaria Injectable QuinineNO coartem or sulphadoxine-pyrimethamine (SP)

Very severe disease Injectable antibiotic, preventhypoglycaemia, Keep warm

All eligible admitted children 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 bediscussed 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 the

training 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 will focus on making the

Part 6: Ear problem Signs & symptoms found

24. Did theHWaskwhether thechildhas an 1=yes 24.a 1=yes,2= no Possible Ear Problem classifications:

ear problem? 2=no 1= acute ear infection

25. If there isan ear problem,did theHW 1=yes 25.a 1= yes; 2= no 2= chronic ear infection

askwhether there is an earpain? 2=no 3= no ear infection

4=mastoiditis

2 4. Di d t he H W as k wh et he r t he re is ea r 1 =ye s 26.a 1= yes, 2 = no 30 He alt h wor ke r' s cla ss ific ati on: ( ci rlc le )

26. discharge? 2=no 1 2 3 4

27. If there isdischarge, did the HW ask for how 1=yes 27.a ____ ____days Reviewer'sclassification:

long? 2=no 1 2 3 4

28. Did theHWcheckwhether t here i s ear 1=yes 28.a HW:1=yes;2=no

discharge? 2=no2 9 Di d th e HW lo ok f or te nd er s we ll ing 1= ye s 29.a HW:1=yes;2=no

behindear? 2=no

Part 7 a): Malnutrition signs & symptoms found

3 1 Di d th e HW u nd re ss ch il d t o lo ok f or 1= ye s 31.a HW: 1=wasted Possible Malnutrition classifications:

severe wasting? 2=no 2= normal 1= severe malnutrion 2 Very low wt or GF

32 Did theHWcheck the feet forOdema? 1=yes 32.a HW: 1= Odema 3= not ver ylow wt or growth faltering

2=no 2= normal

33 Did theHWdetermineweigh t-fo r-age 1=yes 33.a HW: 1= very lowwt 35 Healthworker' s c lass if icat ion(ci rc le)

status? 2=no 2= not very low wt 1 2 3

3 = n or ma l we ig ht R ev ie we r' s c la ss if ic at ion

1 2 3

Part 7 b): Anaemia

34 Did theHWchecked thepalmsforpallor? 1=yes 34.a HW: 1= se vere pallor ; 35b Possible Aneamia calssification

2=no 2= some pallor 1 = Severe anaemia 2 = Anaemia

3= n o pa lme r p al lor 3 = No a nae mi a

Healthworker's classification(circle)

1 2 3

Reviewer's classification

1 2 3

Part 8: HIV/AIDS Signs & symptoms found

36 1=yes 36.a Possible classification:

2=no 1=confirmed symptomatic HIV infection

3=N/A

37 1=yes 37.a 2=confirmedHIV infection

2=no 3=suspected symptomatic HIV infection

3=N/A4=PossibleHIV/HIVexposed

38 1=yes 39.a 5=SymptomaticHIV infection unlikely

2=no 6=HIV infection unlikely

3=N/A

39 1=yes 41 Health worker's classification: (cirlcle)

2=no

3=N/A

1 2 3 4 5 6

40 1=yes Reviewer'sclassification:

2=no

3=N/A

1 2 3 4 5 6

Part 9: IMMUNIZATIO N, VITAMIN A SUPPLEMENTATION AND PMTCT/Peds ART (UNDER-FIVE CARD)

42 Did theHWaskfor the child'sunder-five card? 42.a 1= card is available; 2= no card available

43 If there is


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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

Condition# Seen in the last 14days

# Seen in the lastquarter (s)

Total children seen

PneumoniaDiarrhoea

MalariaMeaslesEar 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 antibioticsDehydration ORS (pre-referral i f severe)Convulsions Rectal diazepam (appropriate

Anticonvulsant).Severe malaria, or severemalnutrition or severeanaemia

Apart from specific treatmentsprevent hypoglycaemia Pre-referral

Initial Follow up After IMCI Training

Case Management Observation (2 months up to 5 years)

Health Worker: ___________________;Facil ity:__________________; District : __________________ Reviewer:________________Date:___/___/___

Instructions:

Introduceyourself to the health worker andexplain the purpose of the visit. Assure thehealth worker that this activity is notintended to evaluate

him/her, but itis part of the IMCI training that he/she had few weeks ago.REMEMBER: do not shout at or intimidate the health worker. Just sitback

and observehow he/she ismanaging the sick child. Try notto interruptthe health worker-caretaker interaction. Ask questions about classification

and treatment at the end ofthe observation. If the health worker misses a procedure or does it wrongly,wait tillhe/she finishes with the child. Then

do or ask the partsmissed byyourself and write the information on appropriate columnsor rows.

Part 1: General Infor(circle the response code) Record time consultation begin: ___ ___: ___

1. Did HW ask the age of the Child? 1=yes; 2=no 1.1 What is the age of the child? ____________ months

2. Someone weighed the child? 1=yes; 2=no 2.1 What is the weight of thechild? ________:___ kg

3. Someone measured body temperature? 1=yes; 2=no 3.1 What is the body temperature? ________:___ 0C

4 . D id t he H W a sk w ha t a re t he c hi ld 's p ro bl em s? 1 =y es ; 2= no 4.1 What reasons did the caretaker give for

{codes for the complaints} bringing the child to the clinic today?

1= cough/DB; 2 = diarrhoea; 3= fever/m ala ria 1= cough/DB; 2= diarrhoea; 3 = fever/malaria

4= ear problem; 5= measles; 6= others 4= ear problem; 5 = measles; 6= others

Part 2: General Danger Signs Signs & Symptoms found

5. Did theHWask whether the childis not able to drink or breast- 5.1 1=yes ; 2=no General Dange rSignpre se nt ?

feed?

6. Did theHWask whether the child vomits everything? 6.1 1=yes ; 2=no 8He a lt hW orke r' s dec is ion:

1= YES 2= NO

7. Did theHWask whether the child has had convulsionsat home? 7.1 1 =y es ; 2= no R ev ie we r' s de ci si on

1=YES 2=NO

P ar t 3 : C ou gh o r Di ff ic ul t br ea th in g s ig ns & s ym pt om s f ou nd

9 . D id t he H W a sk w he th er t he c hi ld h as 1 =y es 9.a 1=yes; 2=no Possible cough or difficult breathing

cough or difficult breathing? 2=no classifications:

10. 1=yes 10.a 1 = c ou gh or co ld 2 = p ne um on ia

2=no 3= severe pnemonia

11. Did t he HW c oun t t he b re at hs i n 1m inut e? 1= ye s 11.a 12 Health worker's classification: (cirlcle2=no code) 1 2 3

12. Did t he HW c hec k whe ther t he c hi ld has 1= ye s 12.a Reviewer'sdecision:chest indrawing (CI)? {by lifting up shirt/dress} 2=no 1 2 3

Part 4: Diarrhoea Signs & symptoms found

1 3. D id th e HW a sk wh et he r t he ch il d h as 1 =y es 13.a 1=yes; 2= no Possible diarrhea classifications:

diarrhoea? 2=no 1= no dehydration; 2= some dehydration

14. if the childhas diarrhoea , did theHW ask for 1=yes 14.a __ __days 3= severe dehydration; 4= persistent

how long? 2=no 5= severe persistent; 6= dysentry

15. if the childhas diarrhoea , did theHW ask if there1=yes 15.a 1= y es; 2 = n o 1 8 H ea lt h w or ker 's cla ss if ica ti on: ( ci rlc le

is blood in stool? 2=no 1 2 3 4 5 6

1 6. D id th e HW c he ck wh et he r th e c hi ld is 1 =y es 16.a HW: 1= thirst/DP Reviewer's decision:

thirsty or drinking poorly(DP) by offering some 2=no 2= normal. 1 2 3 4 5 6

fluids?

17. Did theHWpinchthe skin of the abdomen? 1=yes 17.a HW: 1= normal;

2=no 2=slowly; 3=very slowly

Part 5: Fever Signs & symptoms found

1 8. D id th e HW a sk wh et he r t he ch il d h as 1 =y es 18.a 1=yes, 2=no Possible fever & measles classifications:

fever? 2=no 1= malaria; 2= Very severe febrile diasease

19. I f t he ch il d had fe ve r, di d t he HW ask for 1=yes 19.a ___ ___ days 3=m easles; 4= eye/mouth complications

how long the child has had the fever? 2=no 5= severe complicated measles

19.1 If the child had fever, didthe HW 1=yes 19.1a 1=yes,2=no

do RDT? 2=no

20. If the child has fever, didthe HW askwhether 1=yes 20.a 1= y es , 2 = no 2 3 H ea lt h w or ker 's cla ss if ica ti on: (ci rlc le

the child has had measles in the past three 2=no 1 2 3 4 5

months?

21. Did the HW look for stiff neck? 1=yes 21.a HW : 1 = y es ; 2 = n o R ev ie we r' s c la ss if ica tio n:

2=no 1 2 3 4 5

22. Did the HW undre ss the c hi ld to look fo r 1= ye s 22.a HW: 1= yes; 2= no

generalized rash of measles? 2=no

2=no

If the child has cough or difficult breathing did

the HW ask the duration.

HW: 1= fast; 2= normal

________ days

HW: 1= CI, 2= noCI

1=yes

1=yes

2=no

1=yes

2=no


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

Severe bacterialinfectionsAll eligible children Routine scheduled Immunizations and

Vit 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 Assessment of IMCI training Sites

ANNEX IV B CONTD

Assessconditionsandtic if theansweris"YES"or cross Afterthe assessingallconditions, give

outthe box x ifthe answeris"NO" wheretheboxis notgiven, suggestionson howtosolvethe identifiedbyw ri te t he ans wer inthe s pace provided. t ick ing a ll appl icable so lut ions :

. n c ta an ra n ng

- What isthetotal number ofHWswhomanage sick children?______ List belowthe names ofstaffwho need IMCI

- Howmany o f theseare t ra ined i n I MC I? _________________ tr ai ni ng .Area ll s ickch il dr en at tendedbyanIM CI -t ra inedHW? S ta ff whoare no t t ra ined i n I MC I shou ld manage

D id t he IMCI-trai ned H W bri ef oth er H Ws i n th e facil it y? ad ults or oth ers.

Doesthe IMCI-trained HWshare/involve othersin someIMCItasks? IMCItrainedstaffshould briefand update other

healthworkers

Suggesttaskswhichcould be doneby others

(e.g.weight& Totaking)

7. Availability of Drugs and Other Supplies.

. Pnemonia Amoxycillin E ry th ro myc in Rev iew r ati on ale u se o f dru gs w it h pe rso ns.Malaria Coartem/Fansidar(SP) Quinine responsible for prescribing..Dysentry Nalidixic Acid.Cholera Erythromycin If transportation is the problem, discuss and.Pre-referal Quinine IM Gentamycin IM identifysome alternatives (e.g. combined use of

Benzylpenicillin Diazepam Injection transportationwithnext visits ofsupervsor)

Paracetamol TEO.Others Iron G en tian V io let Rep ort t he s to ck s ho rta ges to t he D HMT .Vitamin A Mebendazole

ORS (Low osmorality) IV solutions

50% dextrose Zinc tablets

Waterfor Injections ae iatric Vs

SeptrinSterilesyringes. Supplies Cotton swabs Sterile needlesIV Sets (pediatric) skin disinfectant

DBS Supplies NG tubes(pediatric)

Are all drugs in "bold" availablein stocktoday?

NAME QUALIFICATIONS NAME QUALIFICATIONS

Arethefollowingitemsin stockon thedayofthe follow-up? Drugsinthe

ist of Health workers (HWs) Managing Sick Children who are not Trained in IMCI


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4.5.1 Follow-up to Decision 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 with

several 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).

4.5.2Follow-up to Decision 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.

FacilityName_________________ District: ________________ Reviewer: ______________________ Date: ___/___/___

Introduce yourself to the in-charge of thefacility. Tell her/him that the purpose of the visit is to give support to the healthcentre staff in reorganizing the facility in the light of the recent training of one of her/his staff in IMCI. For this reason, you

would like to ask some general questions about the clinic. Please assure that this is not inspection, but it is a support visit to

strenghen the quality of services provided in the clinic for sick children.Tell her that after the observations, you willsit withthem to discuss ways of overcoming the identified problemss.

Assessconditions and tick box if the answer is "YES" or cross After the assessing all conditions, give suggestions on

out the box x if the answer is "NO" how to solve the identified problem by tickinglisted solutions.

1. Examination AreaA re al l c ar e t ak er s a bl e t o b e s ea te d w hi le w ai ti ng ? R eo rg an iz e s pa ce an d he lp in -c ha rg e t o s et up pr op er Is ther e e noug h spa ce to see an d ex am ine patie nts? e xamina tio n area .

HW and caretakersitting on thesame side of the table?s t er e unc tio ning we ig ing sc a e or sic c i d re n denti y minimu n req uired ur niture t at c ou d e move d

s t e re a watc w it second a nd or timer to t e examination area.

Is there a functioning thermometer?

s t e re a n c a rt o o e t o r i n e xa mi ni ng r oo m e po rt t e n ee d o r m is si ng i te ms ( e. g. s ca e , t im er ,

A re t he re l am in at ed r ec or di ng f or ms a nd m ot he r' s c ar ds ? r ec or di ng f or m) t o t he D HM T.

re t ere supp ies or assessing(e.g. water,cup, spoon)

2. ORTAreao c i d re n w it s om e d e y d ra ti on g et s o ut io n a t ac i it y e org an iz e s pa ce a nd e p s et u p a n a re a.

I s t he re ad eq ua te s p ac e t o g iv e O RT ( O RT co rn er )? D is cu ss & s ug ge st wa ys to ge t a ny m i ss in g f ur ni tu re

Is there a table for mixing ORS solution or for demonstrations? and designateclean floor space for sitting.

re t ere c airs or cean space or t e careta ers to sit

Is there a source of clean water? Identify an in-charge for ORT corner Are the re ORT corne r supplies (cups, spoons, j ars,bucke ts )? De te rmine how to ge t c le an wa te r

I s t he re a h ea lt h w or ke r a ss ig ne d t o t he OR T c or ne r? R ep or t t o D HM T o f a ny mi ss in g s up pl ie s.

3. Immunization Area

I s sp ac e a de qu at e fo r Im mu ni zi ng c hil dr en ? R eo rg an iz e s pa ce a nd h el p t he i n- ch arg e i n s et ti ng

Is there a table for vaccination supplies? up proper immunization area.

Is there a functioning refridgerator/ice packfreez er?I s t he re a fu nc ti on in g r ef ri dg er at or th er mo me te r? R ep or t e qu ip me nt a nd s u pp ly n ee ds t o t he D HM T.Is there enough supply of Under 5 Cards?

Is correct vaccine condition maintained (2 -8 degree s)?

Are all vaccines available(BCG,O PV, Penta, Measles and TT)?

4. Clinic and Referal ServicesA re im mu ni za ti on s er vi ce s a va il ab le ev er yd ay ? D is cu ss w ay s o f s tr en gt he ni ng r ou ti ne im mu ni za ti on

services for sick children.

If not how oftenare immuniation servicesavailable?.........per

A re al l s ic k c hi ld re n we ig he d b ef or e a ss es se d? D is cu ss wa ys of me as ur in g th e w ei gh t a nd te mp er at ur e

Is t empe rature measured for al l s ickchi ldren beforea ssessed? of a ll s i ck children be fore being a sse ssed.

Is there an updated and well kept register for referals?Howfar away is the nea re st refe ra l fa c il ity?_________kms. Report unsolved problems to DHMT.

What is the average time taken to get to the nearest referral facility?

Is there a radio communication withthe DHMT/Hospital?

Are sharp boxes available and adequate?

5. Quality of record keepingAre the re individua l pat ient re cords or regis te rs ma inta ined? Ident ify fea s ible way to make pa tient records .

If yes, select 10 sick childre n records and assess whether: Discuss & provide examples of simple charting methods

The assessment results (positivesigns& symptoms) are recorded? (e.g. recording postiveassessment findings, abbreviated

Any IMCI classifications are recorded? classifications)

the treatments given are recorded? Have the HW practice above method on one case andthe follow-up date is recorded? give feedback.

Facility Review

Initial Follow-up After IMCITraining

Does the health worker know whre to referchildrenfor ART

services?


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5.0 PLANNING FOR IMCI IMPLEMENTA TION AT DISTRICT LEVEL

Implementation of IMCI activities requires a well established environment wherethere is availability of the sk illed 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 st rengthen and support implementation of IMCI

strategy.

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 actionplans

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 and

supplies (e.g. thermometers, weighing scales (uni-scales), timing devices(timers), paediatric formulation drugs, Ready T o Use Therapeutic Feeds

[RUTF], ORT utensils, RDT kits, DBS kits, e.t.c) Plan and budget to support community child health interventions and the

number of key family p ractices 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 in

IMCI.

* Low Osmolarity ORS packet* Zinc tablets* Clean drinking water* Common spoons for mixing ORS* Litre measure or other measuring container* Several containers used commonly in local area

* Glass or cup for tasting ORS solution

Near the classrooms, all groups need access to the following equipment andsupplies, to be shared by the groups:

* Photocopy machine* Video player and monitor, preferably on a rolling chart.


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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, g iven the support which districts must provide,key staff at district level should be trained in IMCI. Properly oriented districts are inthe 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 ofindividual 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 activities

in 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;

Annex VList of Other Supplies needed in the Classroom during IMCI trainingWorkshop.

Supplies needed for each facilitator during facilitator training and each participantduring the course:* Name tag and holder * 2 pencils

* Paper * Eraser * Ba ll point pen * Folder or large envelope to col lect* Felt tip pen * Clipboard to hold recording forms and to

write on during clinical practice* Highl ighter

Supplies needed for each small group:* Paper clips * 2 rolls transparent tape* Pencil sharpener * Rubber bands* Stapler and staples * 1 rol l masking tape of adequate quali ty

fasten large charts and flipcharts to wall* Staple remover* Scissors * Flipchart pad and markers or blackboard* Extra pencils* Bolstic * Pink, yellow and green highlighters to

colour chart booklets if necessary

* Extra erasers

Supplies for demonstrations, role plays and group activities for each smallgroup:* A baby doll (or a rolled up towel to represent a baby)* Cotromoxazole tables* Coartem tables* Iron syrup and tablets* Paracetamol tables (500mg) - bottles should contain at least 10 tablets* Vitamin A capsules* Mebendazole tables* Knife or other tool for dividing tablets* Common spoon for measuring and giving syrup* Drug envelops and small bottles with labels

(for mothers to take drugs home* Vials of chloramphenicol, one of each of these items for participants

plus several for demonstration* Sterile water or diluent* Ampoules of quinine* Tuberculin syringes with needle* 5 cc syringes with needle* Amoxyicillin tablets / syrup* Sharps container (or other safe container for disposal of needles)


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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 clinical

experience 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 takeplace? 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 join

with 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 tha

Orientation Guidelines: Integrated Management of Childhood Illness

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