Chapter 7: Conclusions and recommendations
7.2 Recommendations
7.2.1 Strengthening IMCI implementation
Advocacy is needed to increase resources allocation to IMCI, and to revitalise IMCI as a key priority for Departments of Health in South Africa and elsewhere. Advocacy for IMCI at district level should encourage decision-makers in IMCI districts (visiting doctors, district paediatric specialists for example), to provide consistent messages in support of IMCI.
There should be a clear national strategy for strengthening IMCI, in South Africa and other IMCI countries, to address these research findings, and improve overall coverage and quality of IMCI implementation. There is a need to institutionalise IMCI at national, provincial and district levels with adequate planning and budgeting, and to co-ordinate the three components of IMCI to capitalise on the synergies between these components.
IMCI functions best when combining horizontal approach for implementation at primary health care level, with a vertical management approach at district and national levels. Dedicated national and provincial IMCI focus people should be appointed to co-ordinate and oversee planning and implementation, and to provide momentum to the process of scaling-up IMCI.
Managers at clinic and sub-district level need to provide leadership in the change process, and provide the right climate for enhancing performance of health workers. Change requires careful planning and good leadership. A training course for managers at grass-roots level to support IMCI could be developed and evaluated.
7.2.1.2 IMCI implementation
Strategies need to be developed to encourage comprehensive implementation. This should include a workable approach to on-going clinical supervision for IMCI practitioners with support and feedback on performance. This would assist in maintaining IMCI skills over time. Innovative ways to improve adherence to IMCI guidelines can be developed and tested. One example is eIMCI, where a PDA (palm-top computer or personal digital assistant) is used to prompt health workers to implement IMCI guidelines.
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Supervision strategies should be complemented with mechanisms to ensure competency of IMCI practitioners. These could include regular assessments of clinical skills, IMCI accreditation and strategies for reinforcing implementation. Examples include audit and feedback on performance (similar to follow-up after training), quality improvement, and use of accreditation.
Regular IMCI updates at district or sub-district level could provide peer support and
encouragement for IMCI practitioners, as well as assist in maintaining IMCI skills over time. This would be particularly important for the HIV component, as guidelines for HIV management are complex and change frequently.
A system of accreditation of the clinic, a ‘Certificate of IMCI Excellence’, could be used as an additional incentive to improve practises. There should be a defined set of evaluation criteria, and the accreditation process could be conducted by an outside body, at defined intervals, for re- accreditation.
Consistency of prescribing practise is vital. Inconsistent prescribing practises are undermining IMCI implementation at clinics. There are clear guidelines about recommended treatments according to IMCI, and these should be provided to non-IMCI trained health workers who see sick children to ensure that they are adhered to. Where possible, treatments not recommended by IMCI, like cough syrups, should not be available at PHC clinics.
With regard to transferring of new IMCI skills into the workplace, attention should be paid to encouraging the change in practise that is required after IMCI training. For example, an ‘IMCI internship’ could be introduced, where newly trained IMCI health workers are mentored in the workplace, and assisted in implementing their new skills.
Models of task shifting should be developed for different settings, either by shifting case management in its entirety to a lower cadre of health worker, or by shifting certain tasks to auxiliary health workers working in partnership with the professional health worker. These models should be evaluated.
Shortage of staff is a real problem in PHC clinics. Dedicated IMCI trained health workers, who see all sick children, could be used to ensure that all children receive the care recommended by IMCI.
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7.2.1.3 More research is needed to...
Generate knowledge about the complex determinants of health worker performance, and to evaluate ways to change health worker behaviour, improve performance, and ‘normalise’ IMCI into routine and everyday clinic work.
With regard to long consultation times, further research could determine how the time during the consultation is spent and evaluate innovative methods of providing information/ services to mothers that could cut down consultation time.
All approaches to improving and maintaining health workers skills should be adequately field tested and evaluated, including their cost-effectiveness, to define the measures, or combinations of measures, that could most effectively maintain health workers skills and improve coverage of child survival interventions.
7.2.2 IMCI Training
Dedicated budget lines should be allocated for IMCI training, so that this is on-going, and does not get side-lined by other priority programmes.
Training for IMCI needs to be reviewed and more innovative methods of training should be developed and evaluated. For example, distance learning approaches could be used to cover the theoretical components, whereas residential training should focus more on clinical practise.
Computer based learning is being developed, and this should be strengthened and evaluated.
Outcomes for different durations of training need to be evaluated in those countries where the IMCI training has been shortened.
A refresher course for IMCI practitioners returning to the management of sick children at PHC level, after a period of working in another clinical area, could assist with updating practitioners.
7.2.2.1 More research is needed...
to evaluate the different training approaches being developed. Different training approaches should be co-ordinated at WHO level, rather than on an ad hoc basis from country to country. All training methods and content should be evaluated, and outcomes should be compared to
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determine the best training method for a given situation. In this way, countries would have multiple training resources to call on, which can be adapted to the local situation.
7.2.3 Health systems strengthening
Capacity in health systems research is required in countries. Both technical expertise and expertise in working with policy makers to develop relevant research agendas is required.
7.2.3.1 More research is needed…
To demonstrate the cost-effectiveness of the IMCI strategy, thereby increasing the attractiveness to funders of supporting IMCI implementation.
To assist in scaling up and sustaining interventions. The distinction between effective interventions and delivery strategies is essential and the knowledge base for designing, implementing and sustaining effective service delivery needs to be strengthened.
There is a need for assessments and comparisons of different delivery systems for public health interventions.
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References
1. Ahmad OB, Lopez AD, Inoue M. The decline in child mortality: a reappraisal. Bulletin of the World Health Organization. 2000;78(10):1175-91.
2. Barros FC, Victora CG, Scherpbier R, Gwatkin D. Socioeconomic inequities in the health and nutrition of children in low/middle income countries. Rev Saude Publica. 2010;44(1):1-16.
Epub 2010/02/09.
3. Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Claeson M, Habicht JP. Applying an equity lens to child health and mortality: more of the same is not enough. Lancet.
2003;362(9379):233-41.
4. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year?
Lancet. 2003;361(9376):2226-34.
5. United Nations. United Nations Millenium Declaration. In: Office of the United Nations Commissioner for Human Rights. New York: United Nations, 2000.
6. UNICEF, World Health Organization, World Bank, UN Population Division. Levels and trends in child mortality report 2010. New York: 2010.
7. You D, Jones G, Hill K, Wardlaw T, Chopra M. Levels and trends in child mortality, 1990- 2009. Lancet. 2010;376(9745):931-3. Epub 2010/09/21.
8. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. How many child deaths can we prevent this year? Lancet. 2003;362(9377):65-71.
9. Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J, et al. Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child survival. Lancet.
2010;375(9730):2032-44. Epub 2010/06/24.
10. Walker N, Schwartlander B, Bryce J. Meeting international goals in child survival and HIV/AIDS. Lancet. 2002;360(9329):284-9.
11. Nannan N, Timaeus IM, Laubscher R, Bradshaw D. Levels and differentials in childhood mortality in South Africa, 1977-1998. Journal of biosocial science. 2007;39(4):613-32. Epub 2006/11/17.
12. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet. 2010;375(9730):1969-87.
Epub 2010/05/15.
139 HORWOOD CM
13. Murray CJ, Laakso T, Shibuya K, Hill K, Lopez AD. Can we achieve Millennium Development Goal 4? New analysis of country trends and forecasts of under-5 mortality to 2015. Lancet.
2007;370(9592):1040-54. Epub 2007/09/25.
14. WHO. Achieving Health Equity: From root causes to fair outcomes. World Health Organization, 2006.
15. UNICEF. The state of the worlds children 2009: maternal and newborn health. New York:
UNICEF, 2008.
16. Bradshaw D BD, Nannan N. What are the leading causes of death among South African Children? MRC Policy Brief. 2003;No 3.
17. SA Department of Health, Medical Research Council. South African Demographic and Health Survey, 2003. . Pretoria: 2007.
18. Bryce J, Boschi-Pinto C, Shibuya K, Black RE. WHO estimates of the causes of death in children. Lancet. 2005;365(9465):1147-52.
19. UNICEF. Children and AIDS: A stocktaking report. New York: UNICEF, 2007.
20. Newell ML, Coovadia H, Cortina-Borja M, Rollins N, Gaillard P, Dabis F. Mortality of infected and uninfected infants born to HIV-infected mothers in Africa: a pooled analysis. Lancet.
2004;364(9441):1236-43.
21. Tonwe-Gold B, Ekouevi DK, Viho I, Amani-Bosse C, Toure S, Coffie PA, et al. Antiretroviral treatment and prevention of peripartum and postnatal HIV transmission in West Africa: evaluation of a two-tiered approach. PLoS medicine. 2007;4(8):e257. Epub 2007/08/24.
22. Giuliano M, Guidotti G, Andreotti M, Pirillo MF, Villani P, Liotta G, et al. Triple
antiretroviral prophylaxis administered during pregnancy and after delivery significantly reduces breast milk viral load: a study within the Drug Resource Enhancement Against AIDS and
Malnutrition Program. J Acquir Immune Defic Syndr. 2007;44(3):286-91. Epub 2006/12/06.
23. Mphatswe W, Blanckenberg N, Tudor-Williams G, Prendergast A, Thobakgale C,
Mkhwanazi N, et al. High frequency of rapid immunological progression in African infants infected in the era of perinatal HIV prophylaxis. AIDS. 2007;21(10):1253-61. Epub 2007/06/05.
24. Lallemant M, Jourdain G, Le Coeur S, Mary JY, Ngo-Giang-Huong N, Koetsawang S, et al.
Single-dose perinatal nevirapine plus standard zidovudine to prevent mother-to-child transmission of HIV-1 in Thailand. N Engl J Med. 2004;351(3):217-28. Epub 2004/07/13.
25. Jackson JB, Musoke P, Fleming T, Guay LA, Bagenda D, Allen M, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: 18-month follow-up of the HIVNET 012 randomised trial. Lancet. 2003;362(9387):859-68. Epub 2003/09/19.
140 HORWOOD CM
26. Chintu C, Bhat GJ, Walker AS, Mulenga V, Sinyinza F, Lishimpi K, et al. Co-trimoxazole as prophylaxis against opportunistic infections in HIV-infected Zambian children (CHAP): a double- blind randomised placebo-controlled trial. Lancet. 2004;364(9448):1865-71. Epub 2004/11/24.
27. UNICEF. Children and AIDS: Fifth stocktaking report, 2010. New York: UNICEF, 2010.
28. World Health Organization. Antiretroviral drugs for treating pregnant women and
preventing HIV infections in infants: recommendations for a public health approach 2010 Geneva:
World health organization, 2010.
29. Chopra M, Daviaud E, Pattinson R, Fonn S, Lawn JE. Saving the lives of South Africa's mothers, babies, and children: can the health system deliver? Lancet. 2009;374(9692):835-46.
Epub 2009/08/28.
30. Bradshaw D, Groenewald P, Laubscher R, Nannan N, Nojilana B, Norman R, et al. Initial burden of disease estimates for South Africa, 2000. South African medical journal 2003;93(9):682- 8.
31. Tomlinson M, Chopra M, Sanders D, Bradshaw D, Hendricks M, Greenfield D, et al. Setting priorities in child health research investments for South Africa. PLoS medicine. 2007;4(8):e259.
32. Bradshaw D, Dorrington R. Child mortality in South Africa--we have lost touch. South African medical journal. 2007;97(8):582-3. Epub 2007/10/24.
33. Bradshaw D, Chopra M, Kerber K, Lawn JE, Bamford L, Moodley J, et al. Every death counts: use of mortality audit data for decision making to save the lives of mothers, babies, and children in South Africa. Lancet. 2008;371(9620):1294-304. Epub 2008/04/15.
34. Chopra M, Lawn JE, Sanders D, Barron P, Karim SS, Bradshaw D, et al. Achieving the health Millennium Development Goals for South Africa: challenges and priorities. Lancet. 2009. Epub 2009/08/28.
35. Abdool Karim SS, Churchyard GJ, Abdool Karim Q, Lawn SD. HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response. Lancet.
2009;374(9693):921-33. Epub 2009/08/28.
36. Dorrington RE JL, Bradshaw D, and Daniel T. The Demographic Impact of HIV/AIDS in South Africa. National and Provincial Indicators for 2006. Capetown: Centre for Actuarial Research, 2006.
37. Department of Health. Antenatal survey 2005: National HIV and syphillis antenatal seroprevalence survey in South Africa 2005. Pretoria: National Department of Health: Republic of South Africa, 2006.
38. South Africa National Department of Health. 2009 National antenatal sentinel HIV and syphillis seroprevalence survey. Pretoria: SA National Department of Health, 2010.
39. The World Bank. World Development Report: Investing in Health. New York: The World Bank, 1993.
141 HORWOOD CM
40. Bryce J, Black RE, Walker N, Bhutta ZA, Lawn JE, Steketee RW. Can the world afford to save the lives of 6 million children each year? Lancet. 2005;365(9478):2193-200.
41. Tulloch J. Integrated approach to child health in developing countries. Lancet. 1999;354 Suppl 2:SII16-SII20.
42. UNICEF. The state of the worlds children 2008: child survival. New York: UNICEF, 2008.
43. Sazawal S, Black RE. Meta-analysis of intervention trials on case-management of pneumonia in community settings. Lancet. 1992;340(8818):528-33. Epub 1992/08/29.
44. WHO. Integrated management of the sick child. Bulletin of the World Health Organ.
1995;73(6):735-40.
45. Claeson M, Gillespie D, Mshinda H, Troedsson H, Victora CG. Knowledge into action for child survival. Lancet. 2003;362(9380):323-7.
46. Victora C, Adam T, Bryce J, Evans DB. Chapter 63: Integrated Management of the Sick Child. In: Jamison T, Brenan JG, Measham AR, editors. Disease Control Prioirties in Developing countries. New York: Oxford University Press; 2006. p. 1177-92.
47. Campbell H, Gove S. Integrated management of childhood infections and malnutrition: a global initiative. Archives of disease in childhood. 1996;75(6):468-71. Epub 1996/12/01.
48. Kinney MV, Kerber KJ, Black RE, Cohen B, Nkrumah F, Coovadia H, et al. Sub-Saharan Africa's mothers, newborns, and children: where and why do they die? PLoS medicine.
2010;7(6):e1000294. Epub 2010/06/25.
49. Gove S. Integrated management of childhood illness by outpatient health workers:
technical basis and overview. The WHO Working Group on Guidelines for Integrated Management of the Sick Child. Bulletin of the World Health Organization. 1997;75 Suppl 1:7-24.
50. Lambrechts T, Bryce J, Orinda V. Integrated management of childhood illness: a summary of first experiences. Bulletin of the World Health Organization. 1999;77(7):582-94.
51. Winch PJ, Leban K, Casazza L, Walker L, Pearcy K. An implementation framework for household and community integrated management of childhood illness. Health policy and planning. 2002;17(4):345-53. Epub 2002/11/09.
52. World health organization. Child and adolescent health and development progress report 2009. Geneva: World health organization, 2010 ISBN 92 4 159223 0.
53. Kalter HD, Burnham G, Kolstad PR, Hossain M, Schillinger JA, Khan NZ, et al. Evaluation of clinical signs to diagnose anaemia in Uganda and Bangladesh, in areas with and without malaria.
BullWorld Health Organ. 1997;75 Suppl 1:103-11.
54. Weber MW, Kellingray SD, Palmer A, Jaffar S, Mulholland EK, Greenwood BM. Pallor as a clinical sign of severe anaemia in children: an investigation in the Gambia. Bulletin of the World Health Organization. 1997;75 Suppl 1:113-8.
142 HORWOOD CM
55. Zucker JR, Perkins BA, Jafari H, Otieno J, Obonyo C, Campbell CC. Clinical signs for the recognition of children with moderate or severe anaemia in western Kenya. Bulletin of the World Health Organization. 1997;75 Suppl 1:97-102.
56. Simoes EA, Desta T, Tessema T, Gerbresellassie T, Dagnew M, Gove S. Performance of health workers after training in integrated management of childhood illness in Gondar, Ethiopia.
Bulletin of the World Health Organization. 1997;75 Suppl 1:43-53.
57. Kolstad PR, Burnham G, Kalter HD, Kenya-Mugisha N, Black RE. The integrated
management of childhood illness in western Uganda. Bulletin of the World Health Organization.
1997;75 Suppl 1:77-85.
58. World Health Organization. Integrated management of childhood illness: field test of the WHO/UNICEF training course in Arusha, United Republic of Tanzania. WHO Division of Child Health and Development & WHO Regional Office for Africa. Bulletin of the World Health Organization.
1997;75 Suppl 1:55-64.
59. Rowe AK, Rowe SY, Holloway KA, Ivanovska V, Muhe L, Lambrechts T. Does shortening the training on Integrated Management of Childhood Illness guidelines reduce its effectiveness? A systematic review. Health policy and planning. 2011. Epub 2011/04/26.
60. Bryce J, Victora CG, Habicht JP, Black RE, Scherpbier RW. Programmatic pathways to child survival: results of a multi-country evaluation of Integrated Management of Childhood Illness.
Health policy and planning. 2005;20 Suppl 1:i5-i17.
61. Bryce J, Victora CG, Habicht JP, Vaughan JP, Black RE. The multi-country evaluation of the integrated management of childhood illness strategy: lessons for the evaluation of public health interventions. American journal of public health. 2004;94(3):406-15.
62. Goga AE, Muhe LM, Forsyth K, Chopra M, Aboubaker S, Martines J, et al. Results of a multi-country exploratory survey of approaches and methods for IMCI case management training.
Health Res Policy Syst. 2009;7:18. Epub 2009/07/21.
63. World Health Organization. Multicountry Evaluation Integrated Management of Childhood Illness. 2012 [3/01/12]; Available from: http://www.who.int/imci-mce/.
64. Gouws e, Bryce J, Habicht JP, Amaral J, Pariyo G, Schellenberg JA, et al. Improving antimicrobial use among health workers in first-level facilities: results from the multi-country evaluation of the Integrated Management of Childhood Illness strategy. Bulletin of the Health Organization. 2004;82(7):509-15.
65. Pariyo GW, Gouws E, Bryce J, Burnham G. Improving facility-based care for sick children in Uganda: training is not enough. Health policy and planning. 2005;20 Suppl 1:i58-i68.
143 HORWOOD CM
66. Armstrong Schellenberg JR, Adam T, Mshinda H, Masanja H, Kabadi G, Mukasa O, et al.
Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania. Lancet. 2004;364(9445):1583-94.
67. Arifeen SE, Hoque DM, Akter T, Rahman M, Hoque ME, Begum K, et al. Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial. Lancet. 2009;374(9687):393-403. Epub 2009/08/04.
68. El Arifeen S, Blum LS, Hoque DM, Chowdhury EK, Khan R, Black RE, et al. Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a cluster-randomised study. Lancet. 2004;364(9445):1595-602.
69. Bryce J, Victora CG. Ten methodological lessons from the multi-country evaluation of integrated Management of Childhood Illness. Health policy and planning. 2005;20 Suppl 1:i94- i105.
70. Bryce J, Gouws E, Adam T, Black RE, Schellenberg JA, Manzi F, et al. Improving quality and efficiency of facility-based child health care through Integrated Management of Childhood Illness in Tanzania. Health policy and planning. 2005;20 Suppl 1:i69-i76.
71. Amorim DG, Adam T, Amaral JJ, Gouws E, Bryce J, Victora CG. Integrated Management of Childhood Illness: efficiency of primary health in Northeast Brazil. Rev Saude Publica.
2008;42(2):183-90. Epub 2008/04/01.
72. Adam T, Manzi F, Schellenberg JA, Mgalula L, de Savigny D, Evans DB. Does the Integrated Management of Childhood Illness cost more than routine care? Results from the United Republic of Tanzania. Bulletin of the World Health Organization. 2005;83(5):369-77.
73. Adam T, Amorim DG, Edwards SJ, Amaral J, Evans DB. Capacity constraints to the adoption of new interventions: consultation time and the Integrated Management of Childhood Illness in Brazil. Health policy and planning. 2005;20 Suppl 1:i49-i57.
74. Victora CG, Huicho L, Amaral JJ, Armstrong-Schellenberg J, Manzi F, Mason E, et al. Are health interventions implemented where they are most needed? District uptake of the integrated management of childhood illness strategy in Brazil, Peru and the United Republic of Tanzania.
Bulletin of the World Health Organization. 2006;84(10):792-801.
75. Gouws e, Bryce J, Pariyo G, Armstrong SJ, Amaral J, Habicht JP. Measuring the quality of child health care at first-level facilities. Social Science and Medicine. 2005;61(3):613-25.
76. UNICEF. The state of the worlds children 2011: adolescence an age of opportunity. New York: UNICEF; 2011; Available from: http://www.unicef.org/sowc/.
144 HORWOOD CM
77. World Health Organization. IMCI Adaptation Guide. Geneva: World Health Organization 2002. Available from:
http://www.who.int/child_adolescent_health/documents/pdfs/imci_adaptation_guide_1a.pdf.
78. South Africa National Department of Health. 2000 National HIV and syphillis
seroprevalence survey of women attending public antenatal clinics in South Africa. Pretoria: SA Department of Health, 2000.
79. Qazi SA, Muhe LM. Integrating HIV management for children into the Integrated Management of Childhood Illness guidelines. Transactions of the Royal Society of Tropical Medicine & Hygiene. 2006;100(1):10-3.
80. World health organization. Acquired immunodeficiency syndrome. Weekly epidemiology record. 1986;6(1):69-73.
81. World health organization: Regional office for Africa. Consultative meeting on HIV adaptation in IMCI: 16-18 August 2000 Durban, South Africa. Harare: World Health Organisation:
Regional office for Africa, 2000.
82. Horwood C, Liebeschuetz S, Blaauw D, Cassol S, Qazi S. Diagnosis of paediatric HIV infection in a primary health care setting with a clinical algorithm. Bulletin of the World Health Organization. 2003;81(12):858-66.
83. Lulseged S MY, Qazi S, Mason E. . Validation of the HIV component of the Integrated management of Childhood Illness in Addis Ababa, Ethiopia. Communicable Diseases Bulletin for the African Region. 2004;2(3):9-10.
84. World Health Organization. IMCI chart booklet for high HIV settings. Geneva: World Health Organization; 2008. Available from:
http://www.who.int/child_adolescent_health/documents/9789241597388/en/index.html.
85. SA National Department of Health. Integrated Management of CHildhood Illness: national report of South African health facility survey. Pretoria: Department of Health, 2001.
86. Victora CG, Hanson K, Bryce J, Vaughan JP. Achieving universal coverage with health interventions. Lancet. 2004;364(9444):1541-8.
87. Binkin N, Chopra M, Simen-Kapeu A, Westhof D. Do improvements in outreach, clinical, and family and community-based services predict improvements in child survival? An analysis of serial cross-sectional national surveys. BMC Public Health. 2011;11:456. Epub 2011/06/11.
88. Lewin S, Lavis JN, Oxman AD, Bastias G, Chopra M, Ciapponi A, et al. Supporting the delivery of cost-effective interventions in primary health-care systems in low-income and middle- income countries: an overview of systematic reviews. Lancet. 2008;372(9642):928-39. Epub 2008/09/16.