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TABLE OF CONTENTS

ABBREVIATIONS AND ACRONYMS LIST OF TABLES : : : FOREWORD: : : : ACKNOWLEDGEMENTS : : : : : : : : : : : : : : : : : : : : : : iii iv v vi

1.0

INTRODUCTION

: : :

1 2 2 3 3 3 6 6 6 6

2.0 OVERVIEW OF IMCI IMPLEMENTATION IN ZAMBIA : : 2.1 Improvement of Health Workers skills : : 2.2 Improvement of Health System 2.3 Improvement of Household and Community Practices 2.4 Monitoring and Evaluation of IMCI Implementation 3.0

: : :

IMCI ORIENT ATION FOR PROVINCIAL HEALTH OFFICE : 3.1 Objectives 3.2 Participants: 3.3 Methods 3.4 Notes to guide the meeting : 3.5 Agenda :

: :

7 8 10 10 10 11 17 19 20 25 29

4.0 GUIDELINES ON PRELIMINARY VISITS TO DISTRICTS NOT YET IMPLEMENTING IMCI : : 4.1 General Objectives : : 4.2 Specific Objectives : : 4.3 Detailed guidelines for District Assessment during Preliminary visits: 15 4.4 Selection of Facilities for Conducting IMCI Training : 4.5 Outcome of Assessment of IMCI training Sites : 5.0 PLANNING FOR IMCI IMPLEMENT ATION AT DISTRICT LEVEL : : 5.1 Planning for Improvement of Health Workers Skills: : 5.2 Planning for Improvement of Health System: : 5.3 Planning for Improvement of Household and Community Practices:

6.0 ANNEXES: : : 35 Annex I Presentations for Orientation in IMCI : 36 Annex II:List of IMCI Recommended Drugs & Other Supplies : 44 Annex III: Checklist for IMCI training materials : 47 Annex IV: Guidance for budgeting for IMCI training course : 49 Annex V: List of other Supplies needed in the Classroom during IMCI Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts i

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Annex VI: Annex VII: Annex VIII: Annex IX: Annex X

Training workshop: : 52 IMCI Supervisory T ools : 54 Guidelines on Report Writing for IMCI Follow-up Visits : 62 Key Family & Community Practices 65 Implementation Steps for Community IMCI 69 List of Contributors 76

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Annex 11 List of Contributors S. Kunda Dr Patrick M. Lunda Kalesha Penelope Dr Kaoma Mary Mrs Joseph Mudenda Mugala Nanthalile Dr Florence P . Mazovu Mary K.Bwalya Dr Siame Magdalene Mrs Vichael Silavwe Kalimbwe K. Derick Ruth C. Makondo Mbambo M. Yungana Rachael K. Simutowe Raphael Mwale Patrick Mwenya Beatrice Kafulubuti Dr Martha K. Mulenga Elicah. K. Kamiji Solwezi General Hospital Solwezi Provincial Health Office MOH - Child Health Unit Health Services and System Program MOH - Nutrition Health Services and System Program Kalomo DHMT World Health Organization MOH Child Health Unit MOH Child Health Unit Livingstone DHMT Kitwe DHMT Lewanika School of Nursing Ndola DHO Chitapa General Hospital Kabwe Urban DHMT Kabwe Provincial Health Office MOH Child Health Unit MOH Child Health Unit

ABBREVIATIONS AND ACRONYMS


AFRO AIDS ARI CARE CHIF CHW C-IMCI DHMT HIV HMIS HSSP ICT IMCI JICA MoH OPD ORT PHO SP UNICEF USAID WHO ZDHS ZIHP Regional Office for Africa Acquired Immuno-Deficiency Syndrome Acute Respiratory Infections Cooperative for Assistance and Relief Everywhere Community Health Innovation Funds Community health Worker Community Integrated Management of Childhood Illness District Health Management T eam Human Immuno-deficiency Virus Health Management Information Systems Health Services and Systems Program Integrated Competence Training Integrated Management of Childhood Illness Japanese International Cooperation Agency Ministry of Health Out-patient Department Oral Rehydration Therapy Provincial Health Office Sulphadoxine-Pyrimenthamine United Nations International Childrens Emergency Fund United States Agency for International Development World Health Organization Zambia Health Demographic Survey Zambia Integrated Health Program

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LIST OF TABLES T able 1: IMCI Performance Indicators for three Health Facility Surveys...11 T able 2: Inpatient sick children case load assessment..19 T able 3: Inpatient sick child treatment standards20 T able 4: Outpatient sick children case load assessment...21 T able 5: Outpatient sick child treatment standards.22

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ANNEX 1: TABLE 2 PROBLEMS WITH FACILITY SUPPORTS (FOUND DURING FIRST FOLLOW-UP VISIT AFTER TRAINING)
District District name Visiting supervisor or Team Problems with facility supports Space and Equipment: 1. No functioning scale 2. No timing device 3. No IMCI chart booklet 4. No mothers card 5. No patient record cards Diarrhoea treatment corner (DTC): 6. No functioning DTC 7. No source of drinking water 8. Not enough supplies (cups, ORS) 9. No DTC register available Immunization: 10. No functioning refrigerator 11. No safety box 12. No MCH-1 cards 13. Poor vaccine conditions 14. Not all vaccines available Clinic and referral services: 15. Clinic not opened as scheduled 16. Immunization sessions not offered daily 17. No referral facility reasonable time Quality of records: 18. No individual patient records or registers kept 19. Records not complete 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) 21. All available except IM chloramphenicol Training: 22. Health facilities with at least 60% of workers managing children trained __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ Total

FOREWORD The Integrated Management of Childhood Illness (IMCI) strategy provides integrated training and support for frontline health workers on management of conditions 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 and treatment, nutrition, HIV/AIDS, immunization and essential drug programme at community level. The prevalence of these conditions demand that special attention be given to this important strategy. IMCI is an effective part of the basic health care package of public health interventions at primary health care level. Although the major stimulus for IMCI came from the needs of curative care, the strategy combines improved management of childhood illness with aspects of nutrition, immunization, and other important disease prevention and health promotion elements. This package if addressed adequately will effectively contribute to the reduction of child morbidity and mortality and hence to the achievement of the Millennium Development Goal (MDG) of child mortality reduction by the year 2015. This document is designed to provide standard guidelines for IMCI which are technically sound and also feasible in the current environment of health care services in Zambia. The guidelines address all the three components of IMCI and are applicable at all levels of health care system. The challenges Zambia faces in child health include the high burden of childhood diseases, a relatively weak health system and high attrition of health workers. Despite these challenges, the Ministry of Health is committed to improving the quality of care provided to both sick and well children as a cornerstone of quality health services. We rely on each other to ensure that these guidelines are implemented.

Dr. Peter Mwaba Permanent Secretary MINISTRY OF HEALTH

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Acknowledgements
The Ministry of Health is grateful to the World Health Organization for the publication from which this guide was developed. Other partners who supported the development of these guidelines include: Cooperative for Assistance and Relief Everywhere (CARE) International Japanese International Cooperation Agency (JICA) United Nations International Childrens Emergency Fund (UNICEF) United States Agency for International Development (USAID) World Health Organization (WHO)

ANNEX: (contd)

TABLE

QUALITY

OF

CASE

MANAGEMENT

(IN

CASES

OBSERVED DURING FIRST FOLLOW-UP VISIT AFTER TRAINING)


District District name Visiting supervisor or Team 20. Caretakers of children given an antibiotic or antimalarial drug who know: how much to give, times per day and number of days 21. Caretakers of children with diarrhoea given ORS who know: to give ORS, mix ORS and amount of ORS to give 22. Caretakers of children who are given an antibiotic or antimalarial and or ORS know how to give treatment 23. caretakers who know all 3 rules of home care ( Fluid, Food, when to return immediately) __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ Total

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ANNEX 1: TABLE 1 QUALITY OF CASE MANAGEMENT (IN CASES OBSERVED DURING FIRST FOLLOW-UP VISIT AFTER TRAINING)
District District name Visiting supervisor or Team 1. Cases assessed for all four general danger signs 2. Cases assessed for the presence of all main symptoms ( cough, diarrhoea, fever and ear problem) 3. Cases assessed for the presence of cough, diarrhoea and fever 4. Cases who weight was checked correctly 5. Cases whose immunization status was correctly checked 6. Severe cases needing referral referred 7. Severe cases who received first dose of antibiotic before referral. 8. Severe cases of malaria who received IM quinine before referral 9. Cases needing an oral antibiotic or antimalarial are prescribed correctly 10. Cases of pneumonia who received a full course of antibiotic at the health facility 11. Cases of acute ear infection who receive a full course of antibiotics at the health facility. 12. Cases of dysentery who received a full course of antibiotics at the health facility 13. Cases of malaria who received a full course of antimalarial at the health facility 14. Cases of diarrhoea with some dehydration who received ORS solution the facility 15. Caretakers of children, not referred, advised on giving extra fluid an continue feeding 16. Caretakers of children, not referred, advised on giving extra fluid and continue feeding and at least 2 signs for when to seek care 17. Cases who should have received an immunization, according to the schedule, and received it the day of the visit 18. Caretakers of children <2 years asked about breast feeding and complementary foods (assess feeding) 19. Caretakers of children <2 years asked about breast feeding and complementary foods who were assessed and whose caretakers were counselled on feeding problems __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ __ of __ Total

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. The Zambia Demographic Health Survey (ZDHS) of 2007 indicates that the Infant Mortality Rate (IMR) and Under-five Mortality rate (U5MR) are 70 and 119 per thousand live births, respectively. These rates are still significantly high despite reduction from the IMR and U5MR of the ZDHS of 2001/2 (95/1000 and 168/1000) 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 the reduction of child morbidity and mortality through the key components which are: 1. Improvement of health worker skills in management of the sick child 2. Support for health systems 3. 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 important cause of child morbidity and mortality . The IMCI strategy encompasses a range of interventions to prevent and manage these major illnesses, both in health facilities and at home. The strategy incorporates many elements of diarrhoeal and acute respiratory infection control programmes, as well as child- related aspects of malaria control and treatment, nutrition, immunisation, and essential drug programmes. An integrated strategy is needed to address the overall health of children for the following reasons: 1. Most sick children present with signs and symptoms of more than one condition. Thus, more than one diagnoses maybe necessary . Health workers need to be prepared to assess for signs and symptoms of all the most common conditions, not simply those of a single illness. 2. When a child has several conditions, therapies for those may need to be combined. Health workers need to be prepared to treat conditions when they occur in combination. 3. Care needs to focus on the child in a holistic approach and not just the diseases and conditions affecting the child. 72 Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 1

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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. T o reduce morbidity and mortality associated with the major causes of disease in children. 2. T o improve health systems that promote effective care of children 3. T o improve household and community practices The purpose of these guidelines is to assist all levels of the health system to plan, implement and monitor IMCI activities. 2.0 OVERVIEW OF IMCI IMPLEMENTATION IN ZAMBIA

Zambia has been implementing the IMCI strategy since 1996. Progress has been made in implementation of the three components of IMCI and indication of improved 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 case management skills and 90 % had received follow up support. All the 72 districts are implementing IMCI in Zambia. This is due to financial and human resource crisis. The Nation Health Strategic plan (2006 to 2010) target is to train 80% of Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 2 Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 71

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T echnical Skills on fever, ITNs, breastfeeding, vitamin A, other key family practices Participatory Needs Assessment & Planning Counselling of Caretakers Other communications activities Other community support activities e.g. drug distribution, availing bed nets etc. Monitoring implementation. .

health workers per health facility in IMCI by 2010 (Saturation). Currently the IMCI training 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 IMCI drugs required at primary health care level. Drugs not available in kits are obtained by individual districts as supplemental drugs using the 4% from total district grant allowed for drug purchase Health workers in districts have been trained to conduct follow-up after training and supervision of IMCI trained health workers. The integrated supervisory checklist includes IMCI indicators and IMCI is part of the routine supportive supervision in districts which are implementing IMCI. 2.3 Household and Community Practices

Review & Evaluation

Document lessons learnt Review Strategies & Re-planning Plan for Scale Up.

The household and community component of IMCI is an integrated child Care approach that aims at improving Key family and community practices that are likely to have the greatest impact on child survival, growth and development. It is key to the provision of equity of access to cost effective and quality health care as close to the family as possible. The component focuses on the 16 ke y family practices but the country has prioritized 6 key practices and districts are encouraged to add based on the common problems affecting mothers and children. The National Community IMCI Strategic plan is in place to assist in the scaling up of Community IMCI (C-IMCI).

2.4

Monitoring and Evaluation of IMCI Implementation

IMCI training and support has been found effective in Zambia. The IMCI Health Facility Survey conducted in 2008 which covered 94 health facilities revealed the following: 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% of the health workers spent more than 50% of their work time on caring for sick children. On assessment, overall 44.2% of the children were checked for three general danger signs. The findings revealed that 77.2 % children were assessed for cough, diarrhoea and fever in rural areas and 92.5 % in urban areas. For other problems (61.3 % rural verses 92.7% urban) and children 2 years of age were assessed for feeding practices (35% verses 55.7%). Five (5.8%) of the 86 Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 70 Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 3

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children in rural areas, and 12 (41.4%) of the 29 children of urban areas were assessed for HIV infection. It was found that 1 in 5 (21.8%) children had more than one classification. The most common classification was malaria (66.7%), followed by pneumonia (18.3%). Overall 50.6% and 12.5% of children were correctly 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 HIV Significantly more children with malaria were correctly treated using IMCI recommendations in urban (78.0%) than rural (50.0%) areas Overall, 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 2008 Rural & Urban (%) ASSESSEMENTS Child Checked for three general 44.2 danger signs Child checked for the presence of 81.9 cough, diarrhoea and fever Child checking for other problems 74.6 Child checked against a growth 32.2 charts Child checked for symptomatic HIV/AIDS Child under 2 years of age assessed for feeding practices CLASSIFICATION Child with pneumonia correctly 50.6 classified Child with some dehydration is 76.9 correctly classified Child with malaria is correctly 59.9 classified Child with anaemia is correctly 12.5 classified Child is correctly classified for 47.0 general danger signs, and 3 major symptoms Child with very low weight is 25 correctly classified Symptomatic HIV infection Unlikely 1.8 TREATMENT Child with pneumonia correctly 76.4

Annex IX IMPLEMENTATION STEPS FOR COMMUNITY IMCI

District entry / Introductory Phase


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

Rural (%) 40.9 77.2 61.3 31.9 5.8 35 50.0 54.6 79.6

Urban (%) 51.5 92.5 92.7 34.3 41.4 37 52.2 75 72.7 4

Training / orientating district resource team on HH/C IMCI Preparation for Implementation
District Baseline Survey Dissemination of Baseline Findings District Level Planning and Budgeting for HH/C IMCI Activities (communication etc). Preparation for implementation at Health Centre Level

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

Pre-visit Neighbourhood Sensitization of Civic and Political leaders Orientation NHCs and CBAs on HH/C IMCI

Neighbourhood Level entry / Introduction of IMCI

Training NHCs and CBAs


Communication Skills including Counseling Community Based Management Information System Monitoring & Supervision Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts

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treated Child with dehydration treated correctly Child with malaria correctly treated using IMCI recommendations Child with anaemia correctly treated Child needing an oral antimalarial is prescribed the drug correctly Child needing antibiotic leaves the facility without one Child needing an oral antibiotic is prescribed the drug correctly Child needing an oral antibiotic and/or an oral antimalarial (does not include anaemia) is prescribed the drug correctly Child with severe illness correctly treated

30 56.2 20.6 94.2 82.9 88.3 65.7

50.0 91.5 83.9 85.5 60.6

78.0 100 81.1 93.8 83.1

26.0

The IMCI health facility results have revealed that despite challenges faced by health workers they have exhibited commitment to improving the care for sick children. The assessment, classification and consequently treatment of the common illnesses, namely malaria and pneumonia by health workers could have been done better. Experience shows that with IMCI training and support health workers who previously did not have adequate clinical skills to manage sick children can manage childhood illnesses according to national standards. It is therefore appropriate to scale up the IMCI course in all the pre-service training institutions.

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3.0

IMCI ORIENTATION FOR PROVINCIAL HEALTH OFFICE

3.1

Objectives

T ake children to complete a full course of immunization before their first birthday; 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.

T o provide information and reach a common understanding of the concepts and practical principles of the IMCI strategy. T o discuss its advantages and implications for the health systems. T o discuss the need and explore options for strengthening the coordination for implementation of the IMCI strategy.

3.2

Participants

Provincial Medical officer Provincial/hospital pharmacist Clinical Care Specialist PNO-MCH Principal Nutritionist Chief Environmental Health officers Data Management Specialist Financial Specialist District Medical officer for host town Heads of health training institutions (e.g. nursing school) Medical superintendent of provincial hospital Local partners, as relevant 3.3 Methods

This may be a - 1 day meeting. For the formal orientation meeting, plan a balance between presentations (to introduce the different aspects of the IMCI strategy), 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 presentation describing the situation in the province. Provide each province with a copy of the IMCI information folder, the joint WHO/UNICEF statement on IMCI, and the brochure: Improving Child HealthIMCI: the integrated approach (WHO/CHD/97.12 Rev .2) (optional, if available). Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 6 Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 67

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Annex VIII

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 of Health for an updated list). 3.4 Notes to guide the meeting

KEY FAMILY & COMMUNITY PRACTICES ADOPTED IN ZAMBIA 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, iron and zinc- in their diet or through supplements; Promote mental and social development by responding to childs need for care and by playing, talking and providing a stimulating environment.

Disease prevention
Dispose of all faeces safely, wash hands after defecation, before preparing meals and before feeding children; Protect children in malaria endemic areas, by ensuring that they sleep under insecticide-treated bednets; Provide appropriate care for HIV/ AIDS affected people, especially orphans, and take action to prevent further HIV infections.

Describe the IMCI strategy and rationale. Focus on the three components and their interventions. Through the orientation, emphasize the need to plan activities in all three components in a balanced way . Suggest identification or formation of a coordination structure for IMCI, such as provincial Child Health working group. When discussing implementation, stress the importance of developing clear plans for improving drug supplies, establishing mechanism for supervision, improving referral pathways, improving family and community practices, linking related programme activities such as breastfeeding counselling training with IMCI training, documenting the IMCI activities , etc, in addition to planning for training of first-level health workers. Throughout the meeting, explore mechanisms for making the IMCI strategy sustainable. Encourage active partner-ships with all health-related partners from the onset of implementation. Address the importance of active collaboration and involvement of all relevant programmes in implementation of training and finding feasible solutions to improve the health system and developing the family and community component. Ongoing activities and existing resources should be used in a coherent way in order to maximize the effect of IMCI beyond training of first-level health workers. As an example, specify how breastfeeding activities complement the IMCI course for 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 IMCI strategy are delivered in their presence. Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 7

Appropriate care at home


Continue to feed and offer more fluids, including breast milk to children when they are sick; Give sick children appropriate home treatments for infections; Protect children from injury and accident and provide treatment when necessary; 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 seek care from appropriate providers; 66

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Provide ample opportunity for discussion and examine how the IMCI strategy relates to the national situation. 3.5 Agenda

Below is an outline for a provincial orientation meeting. It lists the topics that are useful 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 skills of 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 offer Conduct a situation analysis 8 Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 65

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4.0

CONCLUSION State the general impressions of the whole exercise and what was found in the facilities/district.

Ensure consistent health education and promotion messages Strengthening and supporting ongoing community- based interventions Designing new interventions

Discussion 5.0 Annex of District results Tables 1 &v 2 Child survival activities in the province: overview of achievements and ongoing activities Discussion Suggestions for Child Health coordinating structure at provincial level (15minutes) Documentation of IMCI activities Discussion Open 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 on child survival activities in the province. Refer to the standard power point slides for the first 5 presentations (Annex I)

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4.0

GUIDELINES ON PRELIMINARY VISITS TO DISTRICTS NOT YET IMPLEMENTING IMCI:

Provincial staff and others involved with implementation of IMCI will make a Preliminary visit to orient the DHMT on the IMCI strategy and to assess district preparedness (e.g. drug supplies, supervision, referral issues) and encourage further preparations. The Performance Audit format used by Provincial staff in their districts visits should be further developed to enable support to districts in their implementation of IMCI. Written guidelines should be prepared to assist districts with 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

Annex VII GUIDELINES ON REPORT WRITING FOR IMCI INITIAL FOLLOW-UP / SUBSEQUENT HEALTH WORKER CLINICAL PERFORMANCE FOLLOW-UP 1.0 2.0 2.1 Introduction Process ( including DHMT members met, areas visited and monitoring tools used 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.

T o orient the District Health Management T eam in IMCI planning, adequate budgeting and implementation as well as to conduct an assessment of the suitability of available training sites. 4.2 Specific objectives T o provide information on district planning, adequate budgeting and implementation of IMCI T o assess the suitability of the District Hospital and health centres as IMCI training sites. T o assess the health systems for IMCI implementation. T o assess the current status of community child health interventions and the number of key family practices being promoted in the district. 4.3 Detailed guidelines for District Assessment during preliminary visits

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 and other supplies situation (refer to annex II) Assess the functioning of the drug kit system, the supplemental drug purchase system, the distribution of drug/supplies from the DHMT to the health centres and transport availability.

Findings 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 history 2.3 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 ear 2.7 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 status 2.10 Immunization, Deworming and Vitamin A - how many checked immunization status, Deworming and vitamin A supplementation status 2.11 Feeding assessment - how many assessed and identified feeding problems and gave appropriate advice. 3.0 3.1 3.2 Counseling of caretakers - how many gave follow- up dates, advised on when to return immediately and asked checking questions. OBSTACLES IN IMCI IMPLEMENTATION what were the main obstacles sited by health workers in implementing IMCI in the facilities? Facility Review- Did the screening room have all the necessary things to adequately 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?

2.

Present situation as regards to supervision of Health Workers and Community Health Workers

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3.

Plans and budgets for supervision in District Action Plan: frequency of supervisory visits, team composition (inclusion of administrators, clinicians as well as MCH coordinators), and transport availability . T ools used by supervision team; supportive character of the visit, checklist, Facility review, case management observation and caretaker exit interview. Reports of supervisions done. Supervisory capabilities of supervisors: Skills in IMCI supervision, counselling, quality assurance and / or supervisory training.

Referral system, including communication Communication: Availability of telephones, radios, other means of communication and their use. Availability of transport for ferrying sick children to the next level of care T ake 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, and support for management of severe cases. The district needs to support these health facilities to be able to take care of as many severe cases as possible.

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/ financial resource

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A sufficient number of District Health Management T eam (DHMT) members should be trained in IMCI, including the clinical supervisors. It is proposed that at least 60% DHMT members be trained in facility and community 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 Integrated Management of Childhood Illness Orientation and Planning 11 Guidelines for Provinces and Districts

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Financial resources planned for facility and community IMCI training including other support activities. Note committed financial resources from partners.

4.4

Selection of Facilities for Conducting IMCI Training

Ideally all districts that plan to implement IMCI training should have their own training facility. However, not all districts will have suitable facilities in their area. A group of districts may share a training facility which has all the necessary qualities for conducting quality training including clinical practice. Absolute criteria for choosing training facilities are difficult to define. The team will have to weigh the different options and choose between the good and bad aspects. Necessary requirements for the training site are: 1. 2. 3. An inpatient facility with sufficient case load including severe cases; the quality of case management should be up to IMCI standards. For a small group of 6-8 participants an outpatient facility , with sufficient caseload and quality of care. Classrooms, one for each group of 6-8 participants and one space where the whole group can come together at the start and end of the workshop. Lodging with catering facilities, like lunches and teas should be near the classrooms where applicable. Transport between the different facilities. Non residential option should be considered where applicable.

Reviewer:___________ If the child will not be referred, ask the mother or other caretaker the following questions, depending District:_____________ what you found during your examination.. Tick or write response below. For caretaker or the Ask: Tick or write response: Correct? child who should[tick all that Yes No apply] 1. [ ] RECEIVE AN Ask the caretaker to show you the ANTIBIOTIC or 1. 1. ANTIBIOTIC prescription. Then, ask: (or a prescription a. How much will you give? a. _______ dose a. [ ] a. [ ] for one) b. How many times a day will you give it? b. _______ times/day b. [ ] b. [ ] c. For how many days? c. _______ days c. [ ] c. [ ] All 3[*] 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. Then ask: (for a prescription a. How much will give? a. _______ dose a. [ ] a. [ ] for one) b. How many times a day 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. DEHYDRATION when child b. If ORS, how much water will you mix with the ORS? b. [* ] 1 litre b. [ ] [] arrived at facility. [ ] Other: ____________ [ ] Does not know. [ ] Will not give ORS c. How much ORS solution will you give? For Plan A at home (after rehydration in facility), after each stool: Up to 2 yrs 50 - 100 ml 2 yrs to 5yrs 10 yrs. 100 - 200 ml 4. [ ] Should receive an IMMUNIZATION 5. ALL CHILDREN a. Did your child receive an immunization today? If YES, check card or other source to see that the correct immunization was given. a. When your child is sick, should you give much less, about the same, or more FLUID than usual? b. When your child is sick, should you give much less, about the same, or more FOOD or BREASTMILK than usual? c. What signs would indicate that you should bring your child immediately to the health facility? c. [*] Correct amount for age [ ] Other: ____________ [ ] Does not know. c. [ ] c. [ ]

Part 3. CARETAKER INTERVIEW

ANNEX-IV Health Facility_____________

4.

a. [*] Yes and correct a. [ ] less fluid [ ] About the same [*] more fluid b. [ ] less food [ ] About the same [*] more food c. ALL CHILDREN [ ] Not able to drink [ ] Becomes sicker [ ] Develops fever CHILD WITH COUGH OR COLD: [ ] Fast breathing [ ] Difficult breathing CHILD WITH DIARRHOEA: [ ] Blood in stool [ ] Drinking poorly other: _______________

4. a. [*] 5a. [] 5b. [] 5c.

4. a. [ ] 5a. [] 5b. [] 5c.

The facilities should not be very far apart, not more than 10-15 minutes drive and preferably less, to minimize the cost of transport. 4.4.1 Selection of Facilities for Conducting IMCI Training - The Inpatient Facility One of the major objectives of IMCI training is to train front-line health workers in assessing, classifying and referring sick children with severe illnesses. It may not be easy to find children with serious illnesses at the outpatients facilities, while on the other hand one is more likely to see children with serious conditions at the inpatient facilities. On the standard 8-day IMCI training, about 28% of the entire course work is usually devoted for the inpatient clinical practice. Therefore, it is important to Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 12

At least two signs [ ]

[]

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59 Did the health worker give the date for the next immunization? 60 Did the health worker give the date for the next vitamin A supplementation? 61 Did the health worker ask any CHECKING QUESTIONS to the caretaker? 62 NOW record the time consultation ends: ___ ___:___ ___ 63

1= yes 1= yes 1= yes

2= no 2= no 2= no

3= N/A 3= N/A

spend some time in selecting the most appropriate facility for the clinical inpatient practice of the training. Minimal Standard of Care in the Inpatient Ward Inpatient care should be delivered competently. Although participants in the course are not learning inpatient management, they are learning to refer children with severe illness to an inpatient facility in order to reduce mortality . Many have some experience managing inpatients. Ideally, the paediatric ward should practice standard case management of acute respiratory infections (ARI) and diarrhoeal diseases. The inpatient ward should offer provider initiated testing and counseling (PITC) and refer those testing HIV positive for further care. The ward should also follow the recommendations provided for the management of severe malaria and severe malnutrition and other severe illnesses. Appropriate antibiotics and antimalarials should be used correctly; injectable antibiotics should be given routinely for severe pneumonia; antibiotics should not be used to treat coughs or colds; and good nursing procedures should be followed. Children with severe malnutrition, severe malaria, and meningitis should be treated to prevent hypoglycaemia. Immunizations which are due should be given to all unimmunized as appropriate. Rectal diazepam and/or other appropriate anticonvulsants 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 and unable to suckle, the staff should show the mother how to maintain her milk supply by expressing her breast milk. They should help her re-establish breast-feeding as soon as the child gets better. It may be possible, in some setting, for the inpatient instructor and the Course Director to work with the responsible ward staff in advance of the course to improve ward procedures.

Duration of consultation: ___ ___

After the observation, ask the health worker what problems does he/she usually encounter in implementing IMCI at his/her health facility { probe the health worker to get as many obstacles and challenges as possible} 1 . . . . . . . . 4 . . .

5 . . 6 . . .

Assessing the type and quality of services at the facility


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 medical officer in charge of the paediatric ward, checking registers and records and touring around the ward (s). Large facilities may have different wards for various conditions, like neonatal conditions, malnutrition, etc.

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Number of children admitted


All hospitalized children may not have serious or severe illnesses. The first thing to review is whether the facility regularly admits children with severe conditions. This will allow participants to observe certain less common clinical signs, particularly for pneumonia, malnutrition, measles, and signs of serious bacterial infection in young infants. Absolute numbers are not necessary, but some indication of whether it is one case per month, or one per day or 5-10 per day. On the day of the visit, check the ward, register and other records to find out approximate numbers of cases admitted of the following conditions and draw up a similar table. Table 2: In patient sick children case load assessment Conditions Meningitis Pneumonia Some dehydration Persistent diarrhoea Malaria Measles Malnutrition Anaemia HIV and AIDS Bacterial Infections in young infants ( 0 up to 2 months) #Admitted in the last 14 days

46 Did the HW check for HIV status of the child? 47 Did the HW check for HIV status of the mother?

1=yes 2=no 3=N/A 1=yes 2=no 3=N/A

46.a HW: 1= exposed; 2=positive; 3= negative; 4 unknown; 5=N/A 47.a HW:1=positive; 2=negative; 3=unknown; 4=N/A

Part 10: FEEDING ASSESSM ENT for children with malnutrition, anaemia or growth faltering or less than 2 years old. 1=yes 48 Did the HW ask whether the child is on breastmilk? 2= no BF 48.a 1= BF; 2=no 1=yes 49.a ___ ___ times 49 If child is breastfed , did the HW ask how many times in 24 hours? 2=no 1=yes 50 Did the HW ask whether the child takes other food or fluids? 50.a 1= food/fluids; 2= no other food/fluids 2=no 1=yes 51.a ___ ___ times 51 If child takes other food, did the HW ask how many times per day? 52 Did the HW list existing feeding problems? { codes for feeding problems: Circle appropriate codes in 44.a & b} 1= no Exlus. BF; 2= BF< 8 times in 24 hrs; 3= no compl. Foods; 4= gets < meals; 5= bottle feeding; 6= no active feed; 7= shares wth others; 8= eats less when sick; 9= others. 2=no 1=yes 2=no 52.a HW: 1 2 3 4 5 6 7 8 9

52.b Reviewer's classification: 1 2 3 4 5 6 7 8 9

Severe/ complicated

#Admitted in the last quarter(s)

Severe/ Complicated
Part 11: Referal 53 Did the HW decide to refer the child? 1=yes 2=no 53.a If yes, did the health worker give any 1= yes; pre-referal treatments? 2= no

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 Circle 1= Yes( if drug prescribed ) or 2=No ( if no drug is prescribed) except for 164 where you circle appropriate plan. a b c d e f g Antimalarial: .. Antibiotic*: . Diarrhoea treatment PLAN Zinc tablets Vitamin A Iron Immunizations Feeding advice 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 1=Yes 2=No 2=No 2=No A or B or C 2=No 2=No 2=No 2=No 2=No d.1 e.1 3=Not done b.1 c.1 a.1 Copy dosages given by the health worker example; 1 (120mg) tablet in clinic, 1 on after 8 hrs and 1tablet BD x 2 days) a.1 RDT Positive

* State if Cotrimoxazole is indicated for HIV exposed children. Part 13: Health worker/caretaker Interaction

Case management
Inpatient facilities should follow the standard case management protocols for Acute Respiratory Infections (ARI) and diarrhoeal diseases. For example, in order to let participants see the transition from some dehydration to no dehydration, the facility should provide Oral Rehydration Therapy (ORT). In addition, the facility should provide routine childhood vaccinations for all sick children. Level of nursing care should be optimum and basic cleanliness should be maintained. Discuss the few following basic general protocols expected to be operational in all potential inpatient facilities for IMCI training and draw up a similar table: Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 14

55 Did the health worker or someone else in the clinic explain how to give oral medicines at home? 56 Did the health worker explain to the caretaker when to bring the child back for FOLLOW-UP? 57 Did the health worker advice the caretaker when to return IMMEDIATELY? 58 Did the health worker mention any of the signs below any of the following signs?

1= yes 1= yes

2= no 2= no

3= N/A 3= N/A

1= yes 2= no 3= N/A 1= Fever persists 2= Child becomes drowsy or difficult to arouse 3= Child is unable to eat 4= Child is unable to drink 5= Blood in stool 6= Diarrhoea persists 7= Child has fast breathing or difficult breathing 8= Child fails to get better 9= Other: ____________________________

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Part 6: Ear problem 24. Did the HW ask whether the child has an ear problem? 25. If there is an ear problem, did the HW ask whether there is an ear pain? 24. Did the HW ask whether there is ear 26. discharge? 27. If there is discharge, did the HW ask for how long? 28. Did the HW check whether there is ear discharge? 29 Did the HW look for tender swelling behind ear?

1=yes 2=no 1=yes 2=no 1=yes 2=no 1=yes 2=no 1=yes 2=no 1=yes 2=no

24.a 25.a

Signs & symptoms found 1= yes, 2= no 1= yes; 2= no

26.a 27.a 28.a 29.a

1= yes, 2= no ____ ____ days HW: 1= yes; 2= no HW: 1= yes; 2= no

Possible Ear Problem classifications: 1= acute ear infection 2= chronic ear infection 3= no ear infection 4= mastoiditis 30 Health worker's classification: (cirlcle) 1 2 3 4 Reviewer's classification: 1 2 3 4

Table 3: In patient Sick child treatment standards Condition Severe pneumonia Cold or coughs Convulsions Standard case Management Case management at the facility

Part 7 a): Malnutrition 31 Did the HW undress child to look for severe wasting? 32 Did the HW check the feet for Odema? 33 Did the HW determine weight-for-age status?

1=yes 2=no 1=yes 2=no 1=yes 2=no

31.a 32.a 33.a

signs & symptoms found HW: 1= wasted 2= normal HW: 1= Odema 2= normal HW: 1= very low wt 2= not very low wt 3= normal weight

Possible Malnutrition classifications: 1= severe malnutrion 2 Very low wt or GF 3= not very low wt or growth faltering 35 Health worker's classification (circle) 1 2 3 Reviewer's classification 1 2 3 35b Possible Aneamia calssification 1 = Severe anaemia 2 = Anaemia 3 = No anaemia Health worker's classification (circle) 1 2 3 Reviewer's classification 1 2 3

Part 7 b): Anaemia 34 Did the HW checked the palms for pallor?

1=yes 2=no

34.a

HW: 1= severe pallor; 2= some pallor 3= no palmer pallor

Injectable antibiotics NO antibiotics Rectal diazepam (or appropriate anticonvulsant) Severe malaria, meningitis or Apart from specific treatment severe malnutrition. Prevent hypoglycaemia Complicated malaria Injectable Quinine NO coartem or sulphadoxinepyrimethamine (SP) Very severe disease Injectable antibiotic, prevent hypoglycaemia, Keep warm All eligible admitted children Routine scheduled immunizations Vitamin A supplementation deworming and PITC.

Part 8: HIV/AIDS 36 Did the HW check for HIV status of the mother 1=yes and child from the under-five card? 2=no 3= N/A 37 1=yes If the underfive card is not available or has no 2=no information,did the HW ask whether the mother 3=N/A has had an HIV test done? 38 If the underfive card is not available or has no 1=yes information,did the HW ask whether the child 2=no 3=N/A has had an HIV test done? 39 Did the HW check for conditions which may 1=yes suggest HIV infection? 2=no 3=N/A

36.a

Signs & symptoms found 1=positive 2=negative 3=unknown 1=positive 2=negative 3=unknown 1=positive 2=negative 3=unknown {codes for conditions} 1= pneumonia 2=persistent diarrhoe 3=ear discharge(acute or chronic) 4= very low weight 1=oral thrash 2=parotid enlargement 3=generalised persistent lymphadenopathy

Possible classification: 1=confirmed symptomatic HIV infection 2=confirmed HIV infection 3=suspected symptomatic HIV infection 4=Possible HIV/HIV exposed 5=Symptomatic HIV infection unlikely 6=HIV infection unlikely 41 Health worker's classification: (cirlcle)

37.a

Other aspects The caseload and management are paramount in deciding which facility is the best to be used for training. However, a number of facilitating aspects should be discussed 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 participants and inpatient clinical instructor. 2. A person from the health facility who can assist the inpatient clinical instructor and participants during the preparation of the cases and during the training. This is especially important in a situation where an inpatient clinical instructor will 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 may put 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 Outpatient Facilities 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 Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 15

39.a

40 Did the HW look and feel for the signs which 1= yes 2=no suggest HIV infection? 3=N/A

1 2 3 4 5 Reviewer's classification:

Part 9: IMMUNIZATION, VITAMIN A SUPPLEMENTATION AND PMTCT/Peds ART (UNDER-FIVE CARD) 1=yes 42 Did the HW ask for the child's under-five card? 42.a 1= card is available; 2= no card available 2=no 43 If there is <5 card, did the HW check the Immunization status of 1=yes 43.a HW: 1= due for vaccination; 2= not due for vaccinations 2=no the child? 3=N/A 3=N/A 44 Did HW identify what vaccines the child is due for today? 44.a HW: 1= OPV/Pent 1; 2= OPV/Penta 2; 3= OPV/Penta 3 1=yes 2=no 4= Measles; 5= N/A 3=N/A 45 Did the HW check the Vitamin A supplementation status? 45.a HW: 1= due for Vitamin A supp; 2= not due Vitamin A supp; 1=yes 2=no 3=N/A 3=N/A

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application of the IMCI algorithm a routine practice. Few severe cases will be seen in these facilities. Number of children seen Assess the number of children seen at the health facility by drawing up the following table:Table 4: Out patient sick children case load assessment

Initial Follow up After IMCI Training Case Management Observation (2 months up to 5 years)
Health Worker: ___________________; Facility: __________________; District: __________________ Reviewer: ________________ Date: ___/___/___ Instructions: Introduce yourself to the health worker and explain the purpose of the visit. Assure the health worker that this activity is not intended to evaluate him/her, but it is part of the IMCI training that he/she had few weeks ago. REMEMBER: do not shout at or intimidate the health worker. Just sit back and observe how he/she is managing the sick child. Try not to interrupt the health worker-caretaker interaction. Ask questions about classification and treatment at the end of the observation. If the health worker misses a procedure or does it wrongly, wait till he/she finishes with the child. Then do or ask the parts missed by yourself and write the information on appropriate columns or rows. Part 1: General Information (circle the response code) 1. Did HW ask the age of the Child? 2. Someone weighed the child? 3. Someone measured body temperature? 4. Did the HW ask what are the child's problems? {codes for the complaints} 1= cough/DB; 2= diarrhoea; 3= fever/malaria 4= ear problem; 5= measles; 6= others Part 2: General Danger Signs 5. Did the HW ask whether the child is not able to drink or breastfeed? 6. Did the HW ask whether the child vomits everything? 7. Did the HW ask whether the child has had convulsions at home? 1=yes; 2=no 1=yes; 2=no 1=yes; 2=no 1=yes; 2=no Record time consultation begin: ___ ___: ___ 1.1 2.1 3.1 4.1 ____________ months What is the age of the child? ____ ____:___ kg What is the weight of the child? ____ ____:___ 0C What is the body temperature? What reasons did the caretaker give for bringing the child to the clinic today? 1= cough/DB; 2= diarrhoea; 3= fever/malaria 4= ear problem; 5= measles; 6= others Signs & Symptoms found 5.1 1=yes; 2=no 6.1 7.1 1=yes; 2=no 1=yes; 2=no

Condition
T otal children seen Pneumonia Diarrhoea Malaria Measles Ear infections Malnutrition Anaemia Bacterial infection (0 up to 2 months)

# Seen in the last 14 # Seen in the last days quarter (s)

1=yes 2=no 1=yes 2=no 1=yes 2=no

General Danger Sign present? 8 Health Worker's decision: 1= YES 2= NO Reviewer's decision 1=YES 2=NO

Case management Outpatient facilities, which may be either the hospital Out Patient Department (OPD) or health centres, are also expected to follow standard case management protocols for Acute Respiratory Infection (ARI) and diarrhoeal disease. For example, simple coughs and colds should not be treated with antibiotics. The facility should also provide routine childhood vaccinations and growth monitoring and promotion for all sick children. Discuss the following basic general protocols expected to be operational in all potential outpatient facilities for IMCI training and draw up a similar table: Table 5: Outpatient Sick child treatment standards Condition Colds of coughs Dehydration Convulsions Standard case management Case management at the facility

Part 3: Cough or Difficult breathing 9. Did the HW ask whether the child has cough or difficult breathing? 10. If the child has cough or difficult breathing did the HW ask the duration. 11. Did the HW count the breaths in 1 minute? 12. Did the HW check whether the child has chest indrawing (CI)? {by lifting up shirt/dress}

1=yes 2=no 1=yes 2=no 1=yes 2=no 1=yes 2=no

9.a 10.a 11.a 12.a

signs & symptoms found 1=yes; 2=no ____ ____ days HW: 1= fast; 2= normal HW: 1= CI, 2= no CI Signs & symptoms found 1= yes; 2= no __ __ days 1= yes; 2= no HW: 1= thirst/DP 2= normal. HW: 1= normal; 2=slowly; 3=very slowly Signs & symptoms found 1= yes, 2= no ___ ___ days 1=yes, 2=no 1= yes, 2= no

Possible cough or difficult breathing classifications: 1= cough or cold 2= pneumonia 3= severe pnemonia 12 Health worker's classification: (cirlcle code) 1 2 3 Reviewer's decision: 1 2 3 Possible diarrhea classifications: 1= no dehydration; 2= some dehydration 3= severe dehydration; 4= persistent 5= severe persistent; 6= dysentry 18 Health worker's classification: (cirlcle 1 2 3 4 5 6 Reviewer's decision: 1 2 3 4 5 6

Part 4: Diarrhoea 13. Did the HW ask whether the child has 1=yes diarrhoea? 2=no 14. if the child has diarrhoea , did the HW ask for 1=yes how long? 2=no 15. if the child has diarrhoea , did the HW ask if there1=yes 2=no is blood in stool? 16. Did the HW check whether the child is 1=yes thirsty or drinking poorly(DP) by offering some 2=no fluids? 17. Did the HW pinch the skin of the abdomen? 1=yes 2=no Part 5: Fever 18. Did the HW ask whether the child has fever? 19. If the child had fever, did the HW ask for how long the child has had the fever? 19.1 If the child had fever, did the HW do RDT? 20. If the child has fever, did the HW ask whether the child has had measles in the past three months? 21. Did the HW look for stiff neck? 22. Did the HW undress the child to look for generalized rash of measles? 1=yes 2=no 1=yes 2=no 1=yes 2=no 1=yes 2=no 1=yes 2=no 1=yes 2=no

13.a 14.a 15.a 16.a

17.a

18.a 19.a 19.1a 20.a 21.a 22.a

Possible fever & measles classifications: 1= malaria; 2= Very severe febrile diasease 3= measles; 4= eye/mouth complications 5= severe complicated measles

NO antibiotics ORS (pre-referral if severe) Rectal diazepam (appropriate Anticonvulsant). Severe malaria, or severe Apart from specific treatments malnutrition or severe prevent hypoglycaemia Pre-referral anaemia Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts

23 Health worker's classification: (cirlcle 1 2 3 4 5 Reviewer's classification: 1 2 3 4 5

HW: 1= yes; 2= no HW: 1= yes; 2= no

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ANNEX IV B CONTD Assess conditions and tickif box the answer is "YES" or cross After the assessing all conditions, give suggestions on how to solve the identified by ticking all applicable solutions: List below the names of staff who need IMCI training. Staff who are not trained in IMCI should manage adults or others. IMCI trained staff should brief and update other health workers Suggest tasks which could be done by others (e.g. weight & T taking) Are the following items in stock on the day of the follow-up? Drugs in the Pnemonia Amoxycillin Erythromycin Malaria Coartem/Fansidar(SP) Quinine Dysentry Nalidixic Acid Cholera Erythromycin Pre-referal Quinine IM Gentamycin IM Benzylpenicillin Diazepam Injection Paracetamol TEO Others Iron Gentian Violet Vitamin A Mebendazole ORS (Low osmorality) IV solutions 50% dextrose Zinc tablets Paediatric ARVs Water for Injections Septrin Sterile syringes Supplies Cotton swabs Sterile needles IV Sets (pediatric) skin disinfectant DBS Supplies NG tubes (pediatric)
o

Complicated malaria Severe bacterial infections All eligible children

x if the answer is "NO" where the box is not given, out the box write the answer in the space provided.
6. Clinic Staff and IMCI Training
- What is the total number of HWs who manage sick children? ______ - How many of these are trained in IMCI? _________________ Are all sick children attended by an IMCI-trained HW? Did the IMCI-trained HW brief other HWs in the facility? Does the IMCI-trained HW share/involve others in some IMCI tasks?

Injectable Quinine No coartem or SulphadoxinePyrimethamine (SP) Routine scheduled Immunizations and Vit A. supplementation and deworming

Other aspects 1. 2. 3. Room or corner where participants can do the clinical practice, with sufficient space for a weighing scale. The maximum needed size relates to the classroom group of 6-8 A person from the health facility who can assist the facilitators and participants; finding materials like scales, thermometers, cups; assisting with the selection and flow of the patients within the OPD; etc. During the training the facility will see a group of participants every morning for a large part of the morning. The willingness of the staff to assist with the training should therefore be a factor in the decision making.

7. Availability of Drugs and Other Supplies.

. . . . . .

Review rationale use of drugs with persons responsible for prescribing. If transportation is the problem, discuss and identify some alternatives (e.g. combined use of transportation with next visits of supervsor) Report the stock shortages to the DHMT.

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 in situations where this is not possible it is important that participants are accommodated in the same venue preferably government institutions. 2. Each small group of 6-8 participants require one classroom. The room should be big enough to allow for a group table in the middle and small breakaway tables in corners. In the rooms facilities like flip charts/ blackboards, and video/ TV sets (if necessary this can be shared) need to be available. 3. Depending on the distances, vehicles are needed to transport participants, facilitators and inpatient instructor from the place of lodging to the classrooms, 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 to checklist on standard materials required. (annex III)

Are all drugs in "bold" available in stock today?

List of Health workers (HWs) Managing Sick Children who are not Trained in IMCI.
NAME QUALIFICATIONS NAME QUALIFICATIONS

4.5
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Outcome of Assessment of IMCI training Sites


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4.5.1

Follow-up to Decision A

Initial Follow-up After IMCI Training Facility Review


Facility Name_________________ District: ________________ Reviewer: ______________________ Date: ___/___/___ Introduce yourself to the in-charge of the facility. Tell her/him that the purpose of the visit is to give support to the health centre 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 will sit with them to discuss ways of overcoming the identified problemss. Assess conditions and tick box if the answer is "YES" or cross out the box x if the answer is "NO" After the assessing all conditions, give suggestions on how to solve the identified problem by ticking listed solutions. Reorganize space and help in-charge to set up proper examination area. Identify minimun required furniture that could be moved to the examination area. Report the need for missing items (e.g. scale, timer, recording form) to the DHMT.

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 an orientation meeting. Preferably the orientation meetings would take place with several districts together. This makes co-ordination amongst districts and with the province more efficient and improves sharing of knowledge and experience useful for further activities. During the orientation meeting a plan should be developed to implement IMCI training and to further improve all the support functions from the districts to the health facility based implementation. This plan needs to be integrated with the overall district Action Plan. The plan needs to outline all the necessary activities, a time frame, responsible persons, dedicated partners, and expected outcomes/ outputs including a budget (refer to annex IV).

1. Examination Area

Are all care takers able to be seated while waiting? Is there enough space to see and examine patients? HW and caretaker sitting on the same side of the table? Is there functioning weighing scale for sick children? Is there a watch with second hand or timer? Is there a functioning thermometer? Is there an IMCI chart booklet or ITG in examining room? Are there laminated recording forms and mother's cards? Are there supplies for assessing (e.g. water, cup, spoon)? Do children with some dehydration get ORS solution at facility? Is there adequate space to give ORT (ORT corner)? Is there a table for mixing ORS solution or for demonstrations? Are there chairs or clean space for the caretakers to sit? Is there a source of clean water? Are there ORT corner supplies (cups, spoons, jars, buckets)? Is there a health worker assigned to the ORT corner? Is space adequate for Immunizing children? Is there a table for vaccination supplies? Is there a functioning refridgerator/ice pack freezer? Is there a functioning refridgerator thermometer? Is there enough supply of Under 5 Cards? Is correct vaccine condition maintained (2 - 8 degrees)? Are all vaccines available (BCG, OPV, Penta, Measles and TT)?

4.5.2Follow-up to Decision B
The district has fulfilled the criteria for IMCI implementation. The team should recommend that further work should be done on the specific deficient area. After reports of the visit have been shared with DHMT , Provincial Office should take the lead in holding further discussions with the DHMT, to improve the planning for (IMCI) support functions. When improvements have taken place to an acceptable level, given the above criteria, the district will be asked to organize an Orientation Meeting. See process for decision A.

2. ORT Area

Reorganize space and help set up an ORT area. Discuss & suggest ways to get any missing furniture and designate clean floor space for sitting.

3. Immunization Area

Identify an in-charge for ORT corner Determine how to get clean water Report to DHMT of any missing supplies. Reorganize space and help the in-charge in setting up proper immunization area. Report equipment and supply needs to the DHMT.

4. Clinic and Referal Services

Are immunization services available everyday? If not how often are immuniation services available?.........per Are all sick children weighed before assessed? Is temperature measured for all sick children before assessed? Is there an updated and well kept register for referals? How far away is the nearest referal facility?_________ kms. What is the average time taken to get to the nearest referral facility? Is there a radio communication with the DHMT/Hospital? Are sharp boxes available and adequate?

Discuss ways of strengthening routine immunization services for sick children. Discuss ways of measuring the weight and temperature of all sick children before being assessed. Report unsolved problems to DHMT. Does the health worker know whre to refer children for ART services?

5. Quality of record keeping

Are there individual patient records or registers maintained? If yes, select 10 sick children records and assess whether: The assessment results (positive signs & symptoms) are recorded? Any IMCI classifications are recorded? the treatments given are recorded? the follow-up date is recorded?

Identify feasible way to make patient records. Discuss & provide examples of simple charting methods (e.g. recording postive assessment findings, abbreviated classifications) Have the HW practice above method on one case and give feedback.

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5.0

PLANNING FOR IMCI IMPLEMENTATION AT DISTRICT LEVEL

Implementation of IMCI activities requires a well established environment where there is availability of the skilled human resource in IMCI, resources and supplies for strengthening health systems (e.g. drug supplies, supervision, referral issues) and improving key family and community practices. Provincial, district staff and other stakeholders involved in IMCI should strengthen and support implementation of IMCI strategy. In order to achieve impact in reducing childhood mortality rates, districts should ensure that planning and budgeting for IMCI caters for all three components namely: Improving health workers skills, health systems strengthening and improving key family and community practices. 5.1 General Objective

T o increase IMCI training coverage from 64% to 80% by 2011 to attaining saturation levels in all districts; ie 80% of health centre staff trained in IMCI case management and 80% of districts having one CHW per 500 population by the end of 2015. 5.2 Specific objectives T o train at least 80% qualified staff in IMCI per each health facility T o ensure inclusion of at least 80% key IMCI activities in the districts action plans T o implement 80% of the district planned IMCI activities T o put in place the IMCI monitoring and evaluation mechanisms through supportive supervision/ TSS and periodical surveys T o 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 practices 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 Integrated Management of Childhood Illness Orientation and Planning 19 Guidelines for Provinces and Districts

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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 key element of IMCI strategy which aims at improvement of skills of health workers. The course 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 their clinical health training and are working and treat sick children. Health workers are taught how to effectively manage sick children aged zero up to five years in a comprehensive and systematic manner. Training of first-level health workers includes the case management training course for initial skill acquisition and follow-up visits to reinforce skills and help to solve problems. Four to six (4-6) weeks following the IMCI course, district staff should arrange for initial follow-up as part of the training. Supportive supervisory visits to the work site of each participant are undertaken to strengthen case management skills and assist with initial implementation of 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 and supplies, to be shared by the groups: * * Photocopy machine Video player and monitor, preferably on a rolling chart .

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 for frontline 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 screening sick children in a primary health facility trained in IMCI. The national target is to train at least 80% of health workers screening sick children in a primary health facility in IMCI.

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Annex V List of Other Supplies needed in the Classroom during IMCI training Workshop. Supplies needed for each facilitator during facilitator training and each participant during the course: * Name tag and holder * 2 pencils * Paper * Eraser * Ball point pen * Folder or large envelope to collect * Felt tip pen * Clipboard to hold recording forms and to write on during clinical practice * Highlighter Supplies needed for each small group: * Paper clips * 2 rolls transparent tape * Pencil sharpener * Rubber bands * Stapler and staples * 1 roll masking tape of adequate quality 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 small group: * 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) Integrated Management of Childhood Illness Orientation and Planning 52 Guidelines for Provinces and Districts

5.3.2 Pre-service training T o 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 will not effectively change the way sick children are managed. At least 60% of staff screening sick children at a larger health centre and 100% of staff at smaller health centres should go through the IMCI course. A district should be aim to train a sufficient number of staff to cover the health centres in their district within a reasonable amount of time. Similarly, given the support which districts must provide, key staff at district level should be trained in IMCI. Properly oriented districts are in the best position to assure that as IMCI training progresses, there will be enough persons 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 that when the quality of training is compromised, impact is limited. The standard IMCI course lasts 8 days (64 hours). It is recommended that participants arrive at sessions on time and participate fully. Participants should work in small groups of 6 to 8 with each small group having 2 facilitators. Classroom work consists of individual reading and exercises, and group activities. The course also includes outpatient and inpatient clinical sessions during which participants assess 10-15 patients 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 the training site must include 2 or more busy outpatient Clinics and a sizeable inpatient childrens ward; 21

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The accommodation, classroom and clinical practice sites are usually not all located at the same sites, thus, transport is required to get participants from one site to another A team of trainers is needed consisting of i) a course director, ii) an experienced 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 visit to the trained health worker at their work site 4 to 6 weeks following the course. This initial follow-up visit is an integral part of IMCI training.

5.3.6 Where does training take place? 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 institution in collaboration with the district. In either case, capacity for training will have to be strengthened to provide for adequate facilitators, clinical institutions will have to join with neighbouring districts and institutions (e.g. hospitals) to obtain the human and material resources required to put on the course. If training is managed by the training institutes, the same importance should be given to preparing the relevant district for IMCI implementation. Districts should always be involved in the planning of training workshops, as well as selection of appropriate participants. Training costs for IMCI can be reduced if government training institutions are used for accommodation and meals for participants. The cost of IMCI training cost for 24 participants may range from K100 to K120 million. ((Subject to change according to exchange rate) Most of this cost is for accommodation and meals. If government institutions were used for lodging and meals, the cost could probably be reduced by more than 50%. Other costs include transportation, allowances (e.g. out of pocket) etc. The cost of training materials is K400, 000 per participant (K10 million for 24 participants). The cost for training materials may be reduced if participants only keep chart booklets and workbooks while the training modules are kept by training institutions. An exercise workbook with exercises from all modules has been developed for participants to use during the training for reference after training. Provinces should be encouraged to come up with provincial targets in line with national strategic plan.

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Annex IV Guidance on budgeting for IMCI training Course.

5.3.7 What are the possible mechanisms for funding of IMCI training? 1. District funds 2. Pooled funds from districts 3. Local partners.

Example on how to Budget for IMCI Training using an 8 day course. ITEM
Venue (preferably government hostels / Nursing School Transportation costs to and from training site Participant accommodation (# room shared) Facilitator accommodation (# rooms) Breakfast(# persons x 10 days) Lunch (# persons x 9 days) Dinner (# persons x 10 days) Out-of-pocket allowance Transport refunds Photocopying training materials (estimate) Contingency Stationary Drugs for practicals (see list annex 11 optional) TOTAL

5.3.8 Guidance when planning for an IMCI Course and Initial Follow-up after training
Total a) Case management training

Unit Cost

No

Days

9 10 9 9 10 8 -

1. Aim at training at least 60% of health workers who see children at a health centre
2. When planning to train the trainers; one trainer will handle 4 participants meaning you can plan to train 8, 12, 16, 20, 24 participants depending on the resources the district has. Hence if the district plans to train 24 health workers then you need to plan for 6 facilitators, one course director and one inpatient instructor. (see Annex IV for IMCI course budget guide) T arget group for training will include Doctors, Nurses, Clinical Officers, Environmental Health T echnicians, Clinical instructors, Tutors and ideally all staff managing sick children. Districts should ensure that staffs from training institutions, the private sector as well as the hospitals are targeted for these trainings. Potential facilitators can be identified from participants who have undergone case management training and have demonstrated capacity of understanding the course content adequately. These should go through five days facilitation course to be conducted by master trainers from within the provinces. Various districts need to identify from the existing facilitators persons to under go IMCI training of trainers course in order to build capacity at provincial level. 3. The required training materials include: For each participant: Set of 6 modules, Chart booklet, Photograph booklet and participants work book. Course Director Guide, Facilitator Guides, Clinical Inpatient Guide and Outpatient guides for facilitation. T eaching aids including a set of 6 wall charts. The lists of equipment and supplies needed to carry out an IMCI course is shown in Annex V 4. Facilities are required for hands on practice.

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5. The standard training is for 8 days therefore in the budget include accommodation, meals, out of pocket allowances/ DSA where participants are not accommodated. In order to cut down on cost, where possible, it is suggested that out of residence training is considered and where needed, use government institutions, such as nursing schools, for accommodation encouraged. Ensure that training sites have sufficient case load, access to out patient and inpatient departments, acceptable quality of care, and DHMT staff interested and able to conduct a number of courses. Initial Follow up after training Follow-up after training is viewed as an extension of the IMCI training course for first level health workers, and may or may not utilize the existing supervising system. This should take place four to six weeks after initial training to provide support to trained health workers. Districts are reminded to allocate funds for this activity. Visits are usually conducted by an IMCI trained supervisor and a facilitator in an IMCI case management course including the staff from the Provincial Medical Office. b) Objectives of the follow-up visit: T o reinforce IMCI skills and help health workers transfer these skills to clinical work in facilities T o identify problems faced by health workers in managing cases and to help solve these problems T o gather information on the performance of health workers and the conditions that influence performance, in order to improve the implementation of IMCI guidelines.

Core activities to be done during initial follow-up visit: Introduce the follow-up activity Observe case management and reinforce skills Review facility supports Facilitate problem solving with the staff Give feedback to the health worker Complete a summary report of the visit

C) Other additional possible activities are : Caretaker exit Interview (to determine knowledge of how to continue care at home and satisfaction with care received at the facility) Review of Patient Recording Forms (as a way to identify and discuss case management problems) 24 Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 49

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Annex III S/NO 1 2 3. 4. 5. 6. 7. 8. 9. 10. 11 12. 13. 14. 15. 16. 17. 18. 19. 20 22 23. 24. 25. 26. 27. 28. 29 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.

CHECKLIST FOR IMCI TRAINING MATERIALS


DESCRIPTION OF ITEMS Case Record Forms ( 2 months up to 5 years) Case Record Forms (0 up to 2 months) Monitoring check lists, Out- patients(2months up to 5 years) Monitoring Checklists , Out -patient (0 to 2 months) Flip charts /stand Monitoring Checklists In -patient (2months up to 5 years) Monitoring Checklists In-patient (0 up to 2 months) Course Director summary sheets Ball Pens Set of 6 modules and participants workbooks Chart booklets Photo booklets Rubbers(erasers) Big pencil sharpeners Pencils Enlarged Case Record forms(2 months up to 5 years) Set of 6 wall charts Note books (short hand) Name tags Dust coats TV ,DVD and VCR Mothers Cards Highlighters Course evaluation forms Timers or wrist watches with second Hand Training Bags Group checklists(2 months up to 5 years) Group checklist (0 up to 2 months) Clip boards Markers Masking T ape Stick stuff or bolstic Enlarged Plan C (A3 size) Enlarged recording form 2months up to 5 years (A3 size) Enlarged recording form 0 up to 2months (A3 size) Enlarged recording form through cough (A3 size) Enlarged recording form through diarrhoea (A3 size) Enlarged recording form through fever (A3 size) Laminated Job aids (set of three)- Recording forms, mothers card, weight for age chart.

ESTIMATED QUANTITIES 1,000 300 50 30 3 50 20 25 35 27 27 25 30 3 30 6 7 sets 35 35 35 3 sets 50 30 27 24 32 3 3 35 12 5 3 6 6 6 6 6 6 25 48

Practice Exercise (to review guidelines when children are not present during the visit).

It is recommended to pair routine supervisors with IMCI trainers to conduct follow-up visits. Staff recommended to do follow-up visits: Should have completed an IMCI case management training course, and should be trained in IMCI facilitation skills and in conducting follow-up visits Should be district -based and available to conduct visits to health facilities where health workers have been trained. If DHMT has a limited number of supervisors with adequate clinical skills to do followup visits, consider using other IMCI trained staff from other facilities. 5.4 Planning for Improvement of Health Systems

When planning activities to improve health worker skills, also plan activities to strengthen the health system. Consider the current situation and improvements needed. Decide on priorities to be addressed during implementation. Consider the following areas when planning health system improvements: Availability of recommended IMCI essential drugs in right formulation and other supplies. Improvement of referral pathways and services Improvement of organization of workers at the health facilities Improved supervision of health workers Linking IMCI classification and the health information system

5.4.1 Drugs and supplies needed for IMCI The IMCI strategy recommends the use of second-line treatments and pre-referral treatment for severely ill children at the first-level health facility . These treatments have been introduced based on the evidence that a proportion of deaths in severely ill children could be prevented if those children are given an immediate dose of an appropriate antibiotic, instead of delaying that treatment for several hours until the child reaches a referral facility. Within the context of the IMCI strategy, these second-line and pre-referral drugs become essential drugs to cope with the treatment needs of major childhood illness. Previously they have been available at the referral level for use under the supervision of those who are trained in their use. Using the IMCI strategy, workers at first-level health facilities are trained in their use. Implementation of IMCI is most effective if health staff have a steady supply of the drugs. The availability and steady supply of drugs is related to: Availability of drugs; store and stock management; Rational prescription and dispensing of drugs; Compliance/adherence. (For list of IMCI recommended drugs refer to Annex II) 25

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When second-line and pre-referral drugs are available, well-trained and supervised health workers will increase their impact on childhood mortality . IMCI training and close supervision will help to promote the rational prescription and dispensing of these drugs. Districts should plan to purchase supplemental pre referral drugs through the 4% drug budget if these are not adequate through the rural drug kit system. 5.4.2 Improve referral pathways and services During implementation the emphasis is on improving case management at the firstlevel facilities. The case management guidelines for this level assume that referral services exist and are functioning sufficiently for severely ill children to receive care there. Review current pathways and practices for referral of children from first level facilities. Access to quality of care in the referral sites is an important determinant influencing whether children needing effective referral care will receive it. It is recommended that the following be considered in improving the referral system in the district: Distances of health centre to the nearest referral health facility. Availability of required services at referral facility . A list of health centres which have problems with distance, transport and / or communication. A list of hard to reach health centres which need additional support for management of severely ill children who cannot be referred to next level. The district needs to support these health centres to be able to take care of severe cases, while at the facility. How referrals are conducted in the district, both at community and health centre level. Supply of pre-referral drugs and other medical supplies.

The outcome of this discussion should be a section of the district plan including: 1. An agreement of assessment of the situation with regard to referral pathways and referral practices in each of the implementation districts. 2. A description of recommended steps for improving the referral system where there is a problem. 5.4.3 Organization of work in health facilities Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 26 Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 47

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0.5mls syringes Sterile water for diluting IM antibiotics and IM anti-malarias Cotton swabs and clean water Spacers Cannulars-paediatric All appropriate cold chain supplies such as a reliable refrigerator or cold box, immunization cards.

In planning for implementation, health workers often express concerns regarding organization of work in health facilities. Common concerns relate to the duration of consultation if the integrated case management process is fully applied, as well as to distribution of tasks. Districts need to arrange trained staff to continuously orient and share tasks with other staff. The facility organization includes: Weighing sick children before assessment T aking temperature before assessment Screening room with the necessary equipment for assessing children Administration of drug of first dose of prescribed drug at health facility (either in the screening room or dispensary) Counselling Follow-up arrangement ORT-location Functioning ORT corner Vitamin A supplementation, immunization and deworming in OPD Documentation of Vitamin A supplementation, immunization and deworming

5.4.4 Health worker supervision Training alone is not enough T o sustain improved health workers performance, the practices taught in the IMCI course should be reinforced and supported by districts. District capacity needs to be strengthened to support IMCI. In order to effectively support IMCI implementation, the following activities have to be undertaken: Supervision: support, motivation and on-the-job training in management of childhood illness should be carried out by district staff and health centre in charges as part of their on-going, routine, integrated supportive supervision. In addition to supervision, other district supports are also essential to the success of IMCI: improved drug management, clinic organization, personnel management and planning.

Supervision that includes observation of case management is an important means of strengthening and sustaining health workers skills. T asks that are part of a followup visit are aimed specifically at improving health workers skills and are relevant for routine supervision as well. When planning for follow-up after training it is recommended that district supervisors be involved in follow-up visits and thus they need to be trained to perform these tasks. Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 46 Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 27

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Initial follow-up supervision visit takes place 4-6 weeks after training as part of IMCI training. It reinforces as well as transfers skills from class to working environment after training. This follow-up visit should be backed with routine supervision by PMO/ DHO. It could be integrated in the existing provincial/district province supervisory tool. (Refer to IMCI Supervisory tools- Annex VI) Following current MOH Performance Assessment visit, identify health worker skills that require reinforcing. Staff oriented in IMCI should be part of the supervision/ technical support team. In facilities where there is a supervisor who has been trained in IMCI case management and facilitation skills, that supervisor should reinforce the health workers skills as they implement IMCI activities. Districts are encouraged to identify a focal person for coordinating IMCI activities which includes training supportive supervision and report writing . 5.4.5 Report writing Report writing cannot be overemphasized. Districts are expected to submit reports twice yearly after conducting supportive visits. Districts are also expected to provide reports on trainings conducted. This will assist the country to keep an inventory of those trained and those needing to be trained. (For report writing districts, should refer to Annex VII) 5.4.6 Linking IMCI classifications and the health information system The IMCI strategy and the disease surveillance component of a health information management system (HMIS) have different purposes. The IMCI guidelines are designed to improve the treatment of individual ill children and use classification and not diagnosis. HMIS is designed to detect the occurrence of specific diseases. As a result, some IMCI classifications may have no corresponding HMIS classification (for example, mastoiditis); and some IMCI classifications may satisfy the case definitions for two or more HMIS classifications (for example, very severe febrile illness may satisfy the HMIS case definition for both malaria and meningitis). In these instances, IMCI and HMIS classifications are incompatible. Since health workers have the dual responsibility for treating children and disease surveillance, IMCI-HMIS incompatibilities may lead to confusion among health workers. Linking of IMCI classifications and diagnoses in the HMIS need to be done. Use of data at point of collection is very important in terms of planning, generating activities and review of success and failures. There are a number of HMIS indicators that are derived from IMCI e.g. the number of pneumonia, non-pneumonia, bloody diarrhoea cases etc.

o Injectable 150 mg/ ml ( in 2 ml ampoules using quinine salt) o T ablet 300mg Antipyretic & Analgesic: o Paracetamol T ablet (500 mg) or o Paracetamol T ablet (100 mg) o Codeine T ablet 30mg o Paracetamol Syrup 100mg/5mls o Morphine Syrup 5mg/5mls Other drugs Vitamin A Zinc Tablets Mebendazole/Albendazole tablets Nystatin suspension Iron/folate Diazepam Salbutamol Tab and Inhaler Ciprofloxacin Ear drops Tetracycline eye ointment Gentian Violet (GV) paint

Small bottles of safe, soothing cough remedy (optional) Adequate supplies of BCG, OPV, DPT-Hep B- Hib and Measles

Vaccines:

Other supplies Sugar Cloth for wicking draining ears Large drum ( 5,10,or 15 litre size) with cover and side tap for holding large quantities of ORS in ORT corner Food to give patients on Plan B Nasogastric tubes-paediatric Disposable sterile syringes and sterile needles: 5 ml sterile syringes and sterile needles 2 ml sterile syringes and sterile needles AD Syringes 0.05mls syringes Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 45

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Annex II LIST OF IMCI RECOMMENDED DRUGS AND OTHER SUPPLIES

5.5

Planning for Improvement of Household and Community Practices

Antibiotics: Cotrimoxazole
Adult tablet (80 mg trimethoprim + 400 mg sulphamethoxazole Paediatric tablet (20 mg trimethoprim + 100 mg sulphamethoxazole ) Syrup (40 mg trimethoprim + 200 mg sulphamethoxazole)

Improving household and community practices is one of the three components of the IMCI strategy, which is an intervention included in National Health Strategic Plan. Community IMCI (C-IMCI) is an integrated child health care approach that aims at improving key family practices that are likely to have the greatest impact on child care for survival, growth and development. The vision of MOH in the National Health strategic plan is to implement the vision of basic health care package. C-IMCI is key to the provision of equity of access to cost effective and quality health care as close to the family as possible. The objectives of C-IMCI include: Improve growth and development of children by promoting exclusive breastfeeding, appropriate complementary feeding, micro -nutrients and psychosocial stimulation. Improve family and community level preventive activities for common childhood illnesses, injuries and abuse. Improve management of sick children at home. Improve appropriate and timely care seeking behaviours especially when a sick child needs additional assistance out side the home (home referral, this involves early seeing or recognition of illness, seeking for appropriate treatment and advice). Promote a suitable or an enabling environment at household and community level for child survival, growth and development (this involves streamlining gender issues, livelihood, feeding, food security, resource allocation etc). Key household and Community practices

Amoxycillin T ablet (250 mg) Syrup (125 mg per 5 ml)

Chloramphenicol Intramuscular (1000 mg vial) Gentamicin Intramuscular o (2ml vial containing 20 mg) or BenzyIpenicillin o (2ml vial containing 80 mg)

o (600 mg vial (1 000 000 units) or (3mg vial (5 000 000 units) Nalidixic Acid T ablets (250 mg) Erythromycin T ablets (250 mg) Syrup (125mg/5mls)

5.5.1

C-IMCI seeks to address household practices that are key for child survival, growth and development. They have been categorized into four main areas: 1. Growth promotion and development

Antimalarials: Artemether + Lumefantrine (coartem) tablets Sulfadoxine and Pyrimethamine tablets (500 mg sulfadoxine + 25mg pyrimethamine) Quinine o Injectable 300 mg/ ml (in 2 ml ampoules using quinine salt) or 44

This category includes behaviours whose impact is seen mainly in helping the child to grow and develop physically and mentally, and include behaviours that target nutrition and psycho-socio development. 2. Disease prevention Behaviours in this category are practiced in the household before the onset of a disease to provide protection against disease. Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 29

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3. Home Management Home management behaviours are those behaviours which take place in the home to help a child when it is realized that the child is sick or is in any way unwell. This includes behaviours performed as soon as the child begins to show signs of ill health or injury. 4. Care seeking and compliance Care seeking behaviour includes those behaviours that involve going out of the home to seek health care. (See details on Key practices on Annex VIII) 5.5.2 The role of the province / district in planning for C-IMCI. It is proposed that provinces encourage districts to plan and implement C-IMCI following recommended steps and guidelines for planning and implementation (refer to Annex IX) for standard guidelines on C-IMCI) starting with a few key family practices from which they build on the minimum of the six family and household key interventions, e.g. districts can start with Growth monitoring and add on Malaria prevention, Water and sanitation, HIV/ AIDS prevention, Immunization or Exclusive Breastfeeding. Etc. Currently the MOH planning circle has an input from the community . 5.5.3 Inter-sectoral collaboration. Inter-sectoral collaboration is encouraged for C-IMCI to be successful. This involves advocacy on some aspects of C-IMCI like behavioural change for example, traditional leaders could be used to change some of the beliefs and taboos, which could have an impact on child health. Another example could be inter-ministerial collaboration for water and sanitation, social welfare, Agriculture and Education. The optimization of multi-sector-based platform for C-IMCI requires: Partnership among the health structures and communities Accessibility and quality of care and information supply by community care providers Promotion of key practices, which have impact on child survival, growth and development.

5.5.4 Support systems For C- IMCI activities to be sustained there is need to develop a system that will link and support the Child Health Interventions. The support required may need logistics like weighing scales, registers, stationery , community Health Worker (CHW) kits, Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 30 Integrated Management of Childhood Illness Orientation and Planning Guidelines for Provinces and Districts 43

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Roles of the Provincial Level


Roles of the district level

Orientation of District Health Management Teams Set up provincial coordination structures Support planning, implementation and documentation. Develop a Monitoring & Evaluation plan for the province Mobilisation of resources Situation analysis of key practices before introduction of C-IMCI
7

Orientation of district partners and Health Centres in Community IMCI and participatory methodologies. Consultation with key stakeholders, identify key resources, and Technical Support. Strengthen coordination through formation of community IMCI working group. Strengthen planning, implementation, documentation and Monitoring & Evaluation plan Support Health Centres to implement C-IMCI.
8

bicycles etc. Supervision of community based activities is cardinal in monitoring the quality of service being offered at the community level. It is proposed that the province encourages districts to identify supervisors from technical staff to coordinate and monitor community level activities. 5.5.5 Mobilization of resources for community activities DHMTs should provide technical support for effective use of community basket funds Provincial Medical Offices to encourage District Health Management T eams on provision of information on Income Generating Activities. (IGAs) The DHMT should guide the community on effective use of user fees. The provinces can also advice the district to seek other sources of funding from local partners.

Roles of the health centre


Roles of the community

Act as a link between the Community-based Organizations and District Health Management Teams. Ensure consistent health education and promotion messages. Strengthen and support on-going activities Review and develop implementation plans. Undertake Participatory Learning for Action/Participatory Rapid Appraisal with communities. Organize and ensure that monthly health centre Community IMCI working group meetings take place. Monitoring & Evaluation and support activities of the Community Based Organizations

Participation in: priority setting,

planning, implementation management monitoring of community intervention .

Support Community Based Agents/Community Based Organizations e.g. identify method of motivation and remuneration. Mobilize resources e.g. for referral, Insecticide Treated Nets Mobilize caretakers for service utilisation, e.g. immunisation 10

5.5.6 Motivation strategies Income generation activities that have direct effect on the community should be explored. The province and the districts should come up with ways of motivating the CHWs e.g. a prize for a hard working group or a group that has maintained standards. Motivation strategies may include provision of free medical services, inclusion of CHWs in national events that have monetary incentives, provision of identity cards, regular refresher courses, meetings etc. 5.5.7 Referral and communication.

Mobilization of resources

Sustainability of C-IMCI

Provincial Health Offices to encourage District Health Management Teams on provision of information on community resource mobilization 10% minimum from monthly grant and 1015% community allocation from user fees for urban districts still collecting user fees. Sources from partners.
11

Harmonization of community plans with the District and National level planning to ensure allocation of resources. Building of partnerships with all the players. Capacity building of local structures and communities to promote sense of ownership. Linking the health systems and community based-approach to child healthcare delivery. Supportive supervision and Monitoring Motivation through Income generating activities.
12

The province should encourage districts to assist communities and other stakeholders to come up with ways of quickening home referral as well as innovation on community transport and communication. 5.5.8 Monitoring and Evaluation Innovative ways of utilizing data at community level should be encouraged at point of service delivery . Provinces and districts should be able to evaluate community interventions through peer review.

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Improvement of household and community practices


Definition of Community IMCI
Community IMCI is defined as an integrated child care approach that aims at improving key family and community practices that are likely to have the greatest impact on child survival, grow th and development
1

Key Practices: Growth Promotion and Development


Breastfeed infants exclusively up to 6 months Starting at about six months of age, feed children complementary foods, while continuing to breastfeed up to 2 years or longer. Provide children with adequate amounts of micronutrients (vitamin A/iron). Promote childs mental and social development.
2

Key Practices: Disease Prevention


Key Practices: Home Management

Ensure and maintain a clean home environment at all times Ensure children/pregnant women sleep under recommended Insecticide Treated Nets. Prevent child abuse/neglect and take appropriate action when it has occurred. Adopt and sustain appropriate behaviours regarding prevention and care for HIV/AIDS infected/affected people
3

Continue to feed and offer more fluids to children when they are sick. Give sick children appropriate home treatment for illness. Take appropriate actions to prevent and manage child injuries and accidents.

Key Practices: Care Seeking and Compliance to treatment and advice


Operational framework for implementation


Optimisation of the multi-sector-based platform requires: Partnership among the health structures and the communities. Accessibility and quality of care and information supply by community care providers Promotion of the key practices, which have impact on child survival, growth and development.
6

Take children for full immunisation before 1 year. Recognise when sick children need treatment outside the home Follow recommendations by health workers in relation to treatment, follow-up and referral. Ensure that every pregnant woman receives the recommended antenatal visits, tetanus toxoid vaccination and micronutrient supplementation. Ensure that men actively participate in provision of childcare, and are involved in reproductive health
5

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Improve service quality and organization at health facility-con/t


Documentation of Vit A devise a way of documenting Vit. A supplementation in OPD. Counselling OPD should have a system for specific aspects of counselling. This could be done by the health worker seeing sick children or could be done by designated health workers.

Improve service quality and organization at health facility-con/t

Plan For Supervision- strengthen inhouse supervision of health worker performance at clinic level which will compliment District Health Management Team support visits. Health worker performance reports should be submitted quarterly as the Health Management Information System (HMIS) using report guidelines
8

Improve service quality and organization at health facility-con/t

Improve referral pathways and services


IMCI guidelines are aimed at improving care at first level referral facilities. Sick children with severe classifications should be urgently referred to next level of care. Mechanisms for getting referred children to next level of care must be improved Quality of care at referral health facilities must also be improved

Districts can plan for joint exchange supervision with nearby districts or exchange supervision between health centres. This also helps in maximizing meagre resources available in districts.

Identify/develop methods for sustainable finance and ensure equity of access


As part of the basic health care package, Child Health should be a priority in districts Allocation of appropriate budget lines for child health is necessary Interventions must be structured with the aim of reaching every child

Link IMCI and Health Information Systems


IMCI case management results in children having particular classifications as opposed to diagnosis. Classifications assist health workers of different levels to decide the most appropriate action needed for each child. Since HMIS uses diagnosis, IMCI classifications have to be harmonized with diagnosis for capturing health information

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IMCI Overview and rationale


CAUSES OF 3,8 MILLION DEATHS OF CHILDREN UNDER 5 YRS EACH YEAR IN AFRICA. WHO 1996
Other 22% Pueumonia 30%

Frequency of Presenting Symptoms of 450 Children Frequency of presenting complaints

of 450 children Gondar, Ethiopia Gondar, Ethiopia, 1994


Percentage of all children
10 20 30 40 50 60

Improving the health system to deliver IMCI


Improve availability of drugs and supplies Improve service quality and organization at health facility Improve referral pathways and services Identify/develop methods for sustainable finance and ensure equity of access Link IMCI and Health Information Systems

1

Improve availability of drugs and supplies


8 essential oral drugs are recommended in IMCI case management, including antibiotics and antimalarial drugs Injectable drugs for pre-referral treatment should also be available, including X-pen, Chloramphenical, Gentamycin and Quinine Drugs and supplies needed for effective implementation of IMCI case management need to be available in health facilities

Fever Cough Diarrhoea Ear problems

Underlying malnutrition 50% AIDS related 30%


Measles 13%

NB: Excluding perinatal deaths


Malaria 15% Diarrhoea 20%

Skin lesions Abdominal pain Eye discharge Dental problems Neck swelling Generalized swelling Anorexia Rectal prolapse Headaches (Not recorded) Source: WHO/CHD/HQ/Geneva

Cove

red in

IMCI

ARI Separate disease specific clinical guidelines and training materials Diarrhoea Measles Malaria Malnutrition HIV &AIDs National programmes conduct disease specific training courses " Integration " of clinical guidelines by the health worker

Vertical health programmes and an individual health worker


ARI

Improve service quality and organization at health facility

Improve service quality and organization at health facility-con/t

The quality of care provided for sick children has to be of good standard e.g.
No misuse of antibiotics etc

severely ill children treated promptly & appropriately referred

to next level of care.

Health facility organization should be improved for health workers to apply skills of IMCI case management e.g.
Weighing

CDD

Integrated clinical guidelines and training materials

National Programmes collaborate in integrated training courses

INTEGRATED CLINICAL CASE MANAGEMENT

Separate disease specific National programmes clinical guidelines and training conduct disease specific materials training courses

"Integration" of clinical guidelines by the health worker

all sick children should have their weight checked before being screened. Taking temperature- all sick children should have their temperature checked before being screened 3

Administration of drugs- clinic can either give stat doses in the screening room and subsequent doses collected from the dispensary or merely explain in the screening room and drugs collected from the dispensary or all full course given in the screening room Oral Rehydration Therapy (ORT)-location identify suitable location for ORT with all necessary requirements. The ORT corner could be integrated with other services and serve as a family health corner and be managed by a skilled 4 staff

IMCI and an individual health worker

OBJECTIVES OF IMCI:

Improve service quality and organization at health facility-con/t

Improve service quality and organization at health facility-con/t


Follow-up arrangement-

Integrated clinical guidelines National programmes collaborate in and training materails integrated training courses

Integrated clinical case management

To improve the quality of care provided to children under five years at family, community and first - level health facilities f To reduce childhood mortality

Vitamin A / immunisation in Out Patient Department (OPD): OPD should have vaccines to immunize sick children as appropriate and give Vitamin A supplementation, to compliment Maternal and Child Health (MCH) services Screening room: Should include necessary equipment and supplies to assess a child properly e.g cups , spoons , stat doses of drugs, job aids, Oral Rehydration Salts (ORS), hand washing basin or tap, towel, hand washing soap etc
5

Health centres could design a follow-up program i.e. follow-up casess could be seen in the afternoons or designated staff could see follow up cases separately from initial visits cases
6

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Target group
Target group for training includes - Doctors - Nurses - Clinical officers - Environmental Health Technicians - Clinical instructors - Tutors and ideally all staff managing sick children.

Required training materials


For each participant - Set of 6 modules - Chart booklets - Photograph booklet For facilitation of the training - Course Directors Guide, facilitator guide for modules, Outpatient guide and inpatient clinical guide - One set of 6 modules per participant - Wall charts and other facilitator aids 4
Age groups and Integrated Management of Childhood Illness

Important elements of improving child health


improving management of sick children improving nutrition immunization other disease prevention prevention of injuries

Young infant

2 months

Child

5 years

improving psychosocial support and stimulation

Site of training
Ensure that training sites have sufficient case load for clinical practice Training sites for classes must have easy access to out patient and inpatient departments for clinical practice Health facilities used for clinical practice must have acceptable quality of care

Follow up after training


Recommended to take place four (4) to six (6) weeks after initial training in IMCI case management skills. Undertaken by IMCI trainers in collaboration with provincial and/or District Health officers/supervisors Objectives: - To reinforce IMCI skills and help health workers transfer these skills to clinical work in facilities - To identify problems faced by health workers in managing cases and to help solve these problems - To gather information on the performance of health workers and the conditions that influence performance, in order to improve the implementation of IMCI guidelines 6

COMPONENTS OF IMCI
IMCI-1 f

Interventions for integrated management of childhood illness


FAMILYand COMMUNITY
Community home / based interventions to improve nutrition Insecticide-impregnated Bed nets Early case management Appropriate care seeking Compliance with treatment

Improving case management skills of health workers Improving the health system to deliver IMCI Improving family and community practices

IMCI-2 f

Response to sickness Prevention of disease Promotion of Growth

IMCI

IMCI-3 f

Vaccination Complementary feeding Breastfeeding counselling Micronutrient supplementation

Case management of
ARI, diarrhoea, measles, malaria, malnutrition and other serious infections

HEALTHSERVICES

IMCI components and intervention areas


Improving Health System

Advantages of IMCI
Focuses on care of the child as a whole and not on the reason for the visit. Ensures the early identification of all seriously ill children Ensures integrated management of all prevalent illnesses that the child may present. Includes the application of preventive measures along with treatment for detected illnesses and health problems Includes actions to improve parental practices in caring for the child at home Can be adapted to the local epidemiological situation

Improving family and community practices

District planning and management Availability of IMCI drugs Organization of work at health facilities Quality improvement and supervision at health facilities Referral pathways and services HIS IMCI and health sector reforms

Improving health workers skills


Case management guidelines and standards Training of facility-based public health providers IMCI roles for private providers Maintenance of competence among trained health workers

Care seeking, Nutrition Home case management Adherence to recommended treatment Community involvement in health planning and monitoring

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Status of IMCI in Zambia


Achievements in IMCI - I
1997 Districts Facilitators Training Sites Initial F-up HW Trained 6 32 2 54% 156 1999 19 66 8 70% 735 2002 2004 2006 2008 34 110 9

Achievements in IMCI II
1997 1999 300+ 60 21 2002 2004 2006 CHWs trained GMP ? ? 2,000+ ? 1,000+ ? 103 112

IMCI Strategy adopted in 1995 Adaptation of generic materials & training 1996 1999, all districts had adopted IMCI as key strategy to reduce child morbidity & mortality All 72 districts currently are currently implementing IMCI
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Tutors/ lecturers Trained

80% 80% 1,711 2064


7 8

In-service IMCI Case Management Training


Pre-Service IMCI Training


Experience Gained in Scaling up IMCI in Zambia

Challenges & Constraints of Scaling up IMCI

First training course held in May 1996 By September 2009, 4 800 health workers had been trained 85% of trained health workers have had initial follow-up visits by IMCI trainers & supervisors
3

Discussions started 1999 IMCI Pre-service working group formed in 1999 Orientation meeting in 2000 Lecturers/Tutors trained 103 (Cumulative) from various health training schools (2009)
4

Nationwide expansion of IMCI strategy required to maximise impact on child morbidity Current status shows inadequate coverage of existing interventions With limited resources, targeting areas of most need is vital during expansion Partnerships have increased financial resources at country level Human resource constraints adversely affects scaling up of IMCI implementation
9

Major challenges

Accelerating nationwide expansion of IMCI Implementation of all components of IMCI, particularly improvement of health systems & CIMCI Weak health system Inadequate financial investment in IMCI and other child health strategies Inadequate health workers to effectively implement strategy

Key Constraints

10

Pre-Service IMCI Training


Health System Strengthening

Guidance for planning IMCI case Management Training


Guidance for planning the course contd


Duration of the standard training course is now 8 days (minimum 64 hours) Proportion of time in clinical sessions: 30% Average number of patients managed per participant: at least 10 15 Each participant receives his/her own copy of the chart booklet

IMCI incorporated in RN & EN school curriculum 15 Pre-service institutions are conducting IMCI training -Chainama College, Post-basic Nursing (PBN), Lusaka (UTH), Ndola, Kitwe, Solwezi, Mukinge, L/stone, St.fransis, Chipata, Chilonga, Kasama, Mansa and St. Pauls Chainama College of Health Sciences Training of Medical Licentiates started in December 2002 (11day training) PBN having IMCI concepts taught during regular teaching periods New RN curriculum is already in use
5

At inception of IMCI, essential drug kits adjusted to include most IMCI drugs required at primary health care level Drugs not available in kits obtained by individual districts using :

Supplemental drugs 4% allowed for drug purchase in grant

Supervision, referral & health system issues strengthened in IMCI implementing districts IMCI monitoring tools incorporated in routine supervisory checklist

Aim at training at least 60% of health workers who see children at a health centre One facilitator will handle 4 participants meaning you can plan to train 8,12, 16, 20, 24 participants depending on the resources the district has To train 24 health workers you need to plan for 6 facilitators, one course director and one inpatient instructor Include accommodation, meals and out of pocket allowances Consider non-residential training to reduce the costs

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