Despite considerable progress towards Millennium Development Goal IV, children under five still die in large numbers [1]. The Global Burden of Disease study estimated that in 2015 5.8 million deaths occurred in this age group [2]. Improving quality of care in child health services will be essential for further substantial reductions in under-five child mortality, now included in Sustainable Development Goal III [3–5]. In this regard, outpatient care is particularly important, as it often constitutes the first point of contact between the sick child and the health system [4–7]. Some 10–30% of these children may need hospital admission during the course of their illness, thus good service provision is essential in the outpatient setting [5, 7, 8].

In the 1990s, WHO and UNICEF developed the Integrated Management of Childhood Illness (IMCI) strategy to improve quality of child health care and reduce under-five mortality [5–7]. It has now been introduced into the health systems of over 100 countries [5, 9]. Initial evaluations, conducted in IMCI study areas in Bangladesh, Brazil, South Africa, Tanzania and Uganda, demonstrated improvement in the provision of child care [10–17]. Later on several studies at the local, district and regional level in sub-Saharan Africa, Asia and South America provided mixed results concerning the effects on child health and health workers’ performance [17–30]. One major concern emerging from these studies was that health workers often would not adhere to the IMCI guidelines [21–24, 27, 31–35].

Adherence to guidelines and algorithms is a complex process. It is influenced by contextual factors that may affect the health workers’ extrinsic and intrinsic capacity and/or motivation to adhere to these guidelines [35]. Up till now, little is known about adherence to these guidelines at the national level in sub-Saharan African countries, despite these countries being among the first that introduced IMCI into their national health systems [5, 7]. Therefore, we analysed the situation in Namibia, Kenya, Tanzania and Uganda which adopted the IMCI policy between 1996 and 2000. For the purpose of this study, we analysed representative data from the national Service Provision Assessment (SPA) surveys conducted between 2006 and 2010, on average 10 years after the introduction of IMCI into the respective country [36–39].

Single assessment of the three main IMCI symptoms was better than for the danger signs. The main symptoms ‘cough/difficult breathing’ and ‘fever’ were assessed in more than 81% of patients in all countries. The assessment rate of ‘diarrhoea’ was considerably lower (< 70%). Combined assessment rates for the three IMCI main symptoms were better than for the danger signs, but still lower than 60% (Table 4). Again, Uganda achieved the best results, only surpassed by Namibia for the main symptom ‘cough/difficult breathing’.

Assessment rates of the IMCI danger signs and main symptoms tended to be higher for children younger than 24 months, at hospitals and when performed by higher-qualified staff (physician/NPC) (Table 4). However, this was not a consistent finding in all countries. Interestingly, NPCs performed better than physicians in many of the assessments. Physical examination rates of diarrhoea exhibited a similar pattern, whereas the examination of pneumonia and fever was better when performed by higher-qualified staff irrespective of the child’s age (Table 5).

In all countries, less than 5% of children received a complete/near-complete assessment (11 or 10 items). Health workers in Uganda performed best (median 7 items per child (IQR 5–8)), with Namibia being second (median 6 items per child (IQR 4–7)), whereas in Kenya and Tanzania health workers achieved a median assessment rate of 5 items (IQR 4–7 and 3–7, respectively) per child only. In 55 children, not a single assessment item was performed. In Kenya, physicians performed more items during their assessment than the other health worker groups, whereas in Uganda physicians and NPCs performed better. In Namibia and Tanzania no differences between the health worker cadres were seen.

The median time for conducting the IMCI algorithm was 12 min (IQR 8–28) in Namibia, 9 min (IQR 5–25) in Kenya, 9 min (IQR 5–15) in Tanzania, and 7 min (IQR 5–13) in Uganda. The health workers completed 90% of all assessments within 56 min in Namibia, 80 min in Kenya, 55 min in Tanzania, and 50 min in Uganda.

To the best of our knowledge, our study provides the first analysis of national adherence rates to IMCI protocols in LMICs. Despite nationwide training in and expansion of IMCI to the majority of or all districts in the four countries, the adherence rates for assessment of danger signs, main symptoms and for physical examination remained low. The analysis revealed large differences between the countries, with Uganda performing best in the assessment of danger signs, main symptoms and the examination for diarrhoea. Namibia fared best in the examination of fever and pneumonia. Differences in IMCI coverage or time since introduction cannot explain these inter-country differences fully as these factors were comparable across the countries.

Especially when looking at the combined assessment rates of IMCI danger signs and main symptoms, which form the basis for the next steps in the algorithm, health staff did not perform well. In some cases, adherence was better in children ≤ 24 months, at hospitals and health centres, and when performed by higher-qualified staff (physicians/NPCs), but results varied considerably between and within countries. Recent (< 12 months) re-training in IMCI seemed to have a positive effect on adherence rates, but there was still ample room for improvement.

In comparison to our results, studies in IMCI intervention areas, especially from the early period, yielded considerably better results, sometimes reporting adherence rates of more than 90% [10–16, 18]. Typically, these were controlled studies with large numbers of patients and health care providers, performed at a sub-national level (region or district), often with staff specifically trained in IMCI and regularly supervised. The Tanzanian studies showed adherence rates of 95%, especially in the domains of checking for danger signs and physical examination [13, 14]. The studies from Bangladesh showed considerably higher assessment rates for danger signs and main symptoms (> 80%) [10, 11]. Similar results were observed in studies from South Africa, Brazil, Peru and Morocco, but not in Uganda [12, 16–18, 20].

Later on, most studies were performed with varying cadres of health workers and typically fewer patients at sub-national levels (region, district or local community) in sub-Saharan Africa, Asia and South America. Adherence to the different parts of the IMCI algorithm showed a large variance, with percentages ranging from almost zero to close to 100%, with better adherence often during the assessment of danger signs [21–31, 47–50]. Most studies did not find a significant difference in performance between health workers who were trained in long- (11 days) or short-lasting (5–7 days) IMCI courses [50–54]. Some authors noted a decline in performance and adherence rates depending on the time since the last IMCI (re-) training [27, 47, 55], whereas others could not confirm these results [53, 56]. Although our data were collected on a cross-sectional basis, they still indicate that with less frequent or no IMCI re-training health workers showed reduced adherence rates. However, lack of any pre-service or in-service training was consistently identified as a risk factor for poor adherence [10, 11, 13–16].

Only a few studies examined the effect of health workers’ medical qualifications on adherence rates. In our study, physicians and/or NPCs performed better. In other studies, very often NPCs and other health cadres (e.g. nurses, midwives, auxiliary staff) were more frequently trained in IMCI and performed better than physicians [31, 51, 57]. This is an important finding as these cadres conduct the majority of patient assessments, especially in lower-level health institutions and rural areas.

Contrary to the intention of the IMCI system and not reported hitherto, outpatient departments at hospitals performed better than health centres and dispensaries which are both the intended main target institutions for IMCI implementation. This implies that more efforts have to be directed towards improving the quality of care at these lower-level institutions.

Differing adherence rates according to the age of the child, mainly in favour of the children ≤ 24 months (especially for the assessment of the danger sign of ‘inability to drink’ and main symptom of ‘diarrhoea’), have not been reported yet. As an indirect hint towards age preferences, one other study from Tanzania demonstrated that more time was spent on the assessment of children less than 5 years compared to older children [58]. One may speculate that health workers feel more responsible for younger than for older children or that they assume that the younger age group may be more vulnerable and thus deserving of closer assessment, but this assumption would have to be proven in a qualitative prospective study.

In addition, studies from Brazil [59] and other countries [29, 58] have revealed that frequently health workers did not have the time to perform complete assessments due to the high numbers of patients and the overall work load. In our study, health workers used a median duration of 7–12 min per patient which is comparable to the literature [29, 58, 59]. However, at least 10% of the examinations lasted more than 50 min during the surveys which would be far too long for a routine assessment, especially in situations of high patient numbers. Looking at these data, it seems reasonable to assume that the complex IMCI algorithm needs at least the same amount of time as other assessment approaches, but in some instances may require too many resources. This could explain why health workers in this study did not perform all assessment items in the majority of patients [59].

Due to the nature of the survey data, this analysis was only able to provide quantitative data on adherence rates in the four countries. Lange et al. studied qualitative reasons for poor adherence to the IMCI protocols in Tanzania [35]. They found that health workers were often not convinced that IMCI in itself was a valuable approach, sometimes they had a low intrinsic motivation to follow the protocols or lacked the capacity to apply their knowledge to the respective patient (“know-do gap”), or resorted to simple approaches as a rule of thumb. Lack of re-training, poor remuneration, and the overall poor state of the health system seemed to play a role too, which was also reported in other studies [21, 22, 32].

In light of our findings and the literature, poor/low adherence may be one important reason for not achieving the goal of substantially lowering child mortality in LMICs after introduction of IMCI. A recent meta-analysis, based on studies from Tanzania, India and Bangladesh, revealed that instead of an anticipated 50% reduction of under-five mortality, IMCI may have reduced mortality by only 15% [11, 14, 60–62]. Only one study from Egypt found a marked acceleration in the annual reduction of under-five mortality after the introduction of IMCI into the national health system [63]. Other factors include the lack of sufficient numbers of health workers, lack of IMCI-trained staff, high staff turnover, lack of political support and sufficient investment in the health system, and poor implementation of the community component of IMCI in most LMICs [5, 7, 18, 34, 64–66].

Despite nationwide training in IMCI the adherence rates for assessment and physical examination remained low in all four countries, especially among nurses, midwives and auxiliary staff. The results suggest that adherence rates are particularly low for children older than 24 months and those in non-hospital settings. Also, recent IMCI re-training appears to lead to better adherence rates. In the light of these findings, special attention needs to be directed towards IMCI training of all health staff, with particular emphasis on nurses, midwives, and auxiliary staff, and which is consolidated with periodic re-training. Children of all age groups should be equally targeted for assessment. Our findings call for continuing and increased efforts to improve the standard of paediatric care within the framework of IMCI in LMICs.