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Adherence to the integrated management of childhood illness guidelines in Namibia, Kenya, Tanzania and Uganda: evidence from the national service provision assessment surveys

BMC Health Services Research volume 17, Article number: 822 (2017) Cite this article

Abstract

Background

Integrated Management of Childhood Illness (IMCI) is regarded as a standard public health approach to lowering child mortality in developing countries. However, little is known about how health workers adhere to the guidelines at the national level in sub-Saharan African countries.

Methods

Data from the Service Provision Assessment surveys of Namibia (NA) (survey year: 2009), Kenya (KE) (2010), Tanzania (TZ) (2006) and Uganda (UG) (2007) were analysed for adherence to the IMCI guidelines by health workers. Potential influencing factors included the survey country, patient’s age, the different levels of the national health system, the training level of the health care provider (physician, non-physician clinician, nurse-midwife, auxiliary staff), and the status of re-training in IMCI.

Results

In total, 6856 children (NA: 1495; KE: 1890; TZ: 2469; UG: 1002 / male 51.2–53.5%) aged 2–73 months (2–24 months, 65.3%; median NA: 19 months; KE: 18 months; TZ: 16 months; UG: 15 months) were clinically assessed by 2006 health workers during the surveys.

Less than 33% of the workers carried out assessment of all three IMCI danger signs, namely inability to eat/drink, vomiting everything, and febrile convulsions (NA: 11%; KE: 11%; TZ: 14%; UG: 31%) while the rate for assessing all three of the IMCI main symptoms of cough/difficult breathing, diarrhoea, and fever was < 60% (NA: 48%; KE: 34%; TZ: 50%; UG: 57%). Physical examination rates for fever (temperature) (NA: 97%; KE: 87%; TZ: 73%; UG: 90%), pneumonia (respiration rate/auscultation) (NA: 43%; KE: 24%; TZ: 25%; UG: 20%) and diarrhoea (dehydration status) (NA: 29%; KE: 19%; TZ: 20%; UG: 39%) varied widely and were highest when assessing children with the actual diagnosis of pneumonia and diarrhoea.

Adherence rates tended to be higher in children ≤ 24 months, at hospitals, among higher-qualified staff (physician/non-physician clinician) and among those with recent IMCI re-training.

Conclusion

Despite nationwide training in IMCI the adherence rates for assessment and physical examination remained low in all four countries. IMCI training should continue to be provided to all health staff, particularly nurses, midwives, and auxiliary staff, with periodic re-training and an emphasis to equally target children of all age groups.

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Background

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 [3,4,5]. 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 [4,5,6,7]. 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 [5,6,7]. 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 [10,11,12,13,14,15,16,17]. 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 [17,18,19,20,21,22,23,24,25,26,27,28,29,30]. One major concern emerging from these studies was that health workers often would not adhere to the IMCI guidelines [21,22,23,24, 27, 31,32,33,34,35].

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 [36,37,38,39].

Methods

Selection of IMCI countries

We selected the four Low-and-Middle-Income (LMIC) countries from sub-Saharan Africa because their IMCI programmes were already well established at the time of the national SPA survey and the survey data were accessible for secondary analysis. Kenya, Tanzania and Uganda were quite comparable with regards to their health systems and population structure, whereas Namibia fared much better than these three countries with regards to skilled attendance at birth, mortality rates, numbers of health workers and health expenditure (Table 1) [36,37,38,39,40,41,42,43]. At the time of the SPA surveys IMCI was used in between 60 to 100% of all districts in these countries (Table 1).

Table 1 Background information on the survey countries (corresponding to survey year) [36,37,38,39,40,41,42,43]
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Data collection

Macro International (www.dhsprogram.com), in partnership with the respective ministries of health, conducted the SPA surveys. They employed similar data collection tools across the countries [36,37,38,39]. SPA surveys are facility-based and cross-sectional. They collect information about the service provision of facilities associated with maternal, neonatal, child, and reproductive health services as well as certain infectious diseases programs (sexually transmitted infections, HIV/AIDS, tuberculosis, malaria).

The sampling process has been described in detail elsewhere [36,37,38,39]. In short, the ministry of health provided a list of all health facilities in the country. A representative sample (~ 10–15%) was selected from this list, including all hospitals down to the district hospital level, which resulted in an oversampling of these institutions. The remaining institutions (health centres, dispensaries) were sampled in such a way as to represent different providers and regions of each country. In Namibia all 446 health facilities were included on purpose, although only 411 could be surveyed (92%) (Table 1).

At the selected facilities, only health care providers were included who were present on the day of the survey and had examined and/or provided care to the patients. A maximum of eight providers were selected per institution. The selection of children (and their caretakers) was opportunistic, meaning that they were selected as they came in without any recruitment screening or randomisation. As per study protocol, five patients were to be sampled per provider.

Data selection

As dependent variables, we analysed rates of directly observed adherence to IMCI guidelines by health staff focussing on the main diagnostic components in the IMCI algorithms (treatment and other items will be analysed in a separate paper) [44]. These components were (1) the three IMCI danger signs of ‘inability to eat/drink’, ‘vomiting everything’, and ‘history of febrile convulsions’ as single items and in combination (data on being lethargic, unconscious or convulsing at presentation were not recorded); (2) the three IMCI main symptoms of ‘cough/difficult breathing’, ‘diarrhoea’, and ‘fever’ as single items and in combination; and (3) basic elements of physical examination (measuring temperature and/or feeling for fever, counting respiration rate and/or chest auscultation, and assessing dehydration), all among children aged 2 months or older. Infants younger than 2 months were excluded from the analyses as they were not covered by the main IMCI system, but rather by a separate neonatal IMCI tool which was not part of the surveys [36,37,38,39, 44]. In addition, the time the health staff spent on covering all parts of the IMCI algorithm (assessment, classification, treatment, vaccination, nutrition counselling, caregiver instruction) was retrieved from the data base. The survey observers did not play any part in the consultation process and did not assess whether the diagnosis or treatment was appropriate for the patient.

Independent variables for comparison included the survey country, patient’s age (younger vs. older than 24 months), the different levels of the national health system (hospital, health centre, dispensary), and the training level of the health care provider (physician, non-physician clinician (NPC) (defined as those who have fewer clinical skills than physicians but more than nurses/midwives) [45], nurse-midwife, auxiliary staff (e.g. auxiliary nurse, medical attendant, pharmacist, pharmaceutical technician/assistant, laboratory technologist/technician/assistant, nutritionist/nutrition technician, health education officer)). We further divided the health workers into three different groups according to recent (within the last 12 months), more distant (preceding 13–36 months) or no re-training in IMCI.

To achieve comparability across the different countries, we re-grouped the three levels of the health system in Namibia, Kenya and Uganda into hospital, health centre, and dispensary categories. Health care providers were also grouped into the same categories (in all countries). Details of this process are available on request.

Statistical analysis

Frequencies and rates (median, interquartile range (IQR)) were computed for the respective categories at country, child’s age, health system, provider, and IMCI re-training levels. We used IBM® SPSS® Statistics version 24 for all analyses.

Ethical clearance

Macro International as the copyright holder granted the authors unrestricted access to all survey data, which were completely anonymised, for this secondary analysis after submission of the research proposal. For such an analysis, no approval of an ethical committee is required according to the Good Practice of Secondary Data Analysis, a national guideline for the use of epidemiologic databases in Germany, which was fully adhered to [46].

The surveys themselves had been initiated, planned and approved by the respective Ministry of Health. During the actual surveys, parents and health staff had given informed written consent to direct observation of the assessment process [36,37,38,39].

Results

In the four surveys, 7304 sick child assessments (Namibia: 1578; Kenya: 2049; Tanzania: 2565; Uganda: 1578) were observed; these also included children younger than 2 months. As mentioned earlier, those younger than 2 months were excluded from the analysis. Thus 6856 children with a slight male preponderance, aged 2–73 months (2–24 months: 65.3%), were assessed during the surveys (Table 2).

Table 2 Demographic characteristics of survey participants
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Across the countries, a total of 2006 health service providers of all cadres were observed during their consultations (Table 3). The vast majority of patients were seen by NPCs (Kenya, Tanzania, Uganda) and nurses/midwives (especially in Namibia). The IMCI re-training status was known in only 62% of the health workers. The re-training level varied between the countries with Namibia and Kenya performing worst, and among the different provider strata with good coverage for physicians and NPCs in Tanzania and Uganda, but considerably less coverage for nurses/midwives in these two countries (Table 3).

Table 3 Number of service providers (n), patient assessments per provider (n) and providers’ re-training status in IMCI (percentage)
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Separate assessment rates for the IMCI danger sign ‘inability to eat/drink’ ranged from 34 to 66%, for the danger sign ‘vomiting everything’ from 50 to 66%, and for the danger sign ‘febrile convulsions’ from 17 to 40%. Combined assessment rates for all three IMCI danger signs were less than 33% (Table 4). Uganda yielded the best results.

Table 4 Adherence (percentage) of health workers to IMCI protocols during assessment of danger signs and main symptoms
Full size table

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’.

There was wide variation in the physical examination rates for fever (temperature/feeling for fever), pneumonia (respiration rate/auscultation) and diarrhoea (dehydration), as can be seen in Table 5. These rates were highest for disease-specific elements of physical examination, such as respiration rate/auscultation for pneumonia and dehydration status for diarrhoea (Table 6).

Table 5 Adherence (percentage) of health workers to IMCI protocols during physical examination
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Table 6 Adherence (percentage) of health workers to clinical assessment in pneumonia and diarrhoea
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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 general, health service providers with recent re-training in IMCI (mostly past 12 months; in some categories also past 13 to 36 months) performed better than those without re-training or unknown re-training status. This was a consistent finding in all countries (Table 7). Marked differences were observed for the combined IMCI danger signs and pneumonia assessment. But even then adherence rates were often very low (especially for danger signs, diarrhoea assessment), leaving considerable room for improvement also among health workers with re-training.

Table 7 Adherence (percentage) of staff to the IMCI assessment algorithm in relation to IMCI re-training status
Full size table

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.

Discussion

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% [10,11,12,13,14,15,16, 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, 16,17,18, 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 [21,22,23,24,25,26,27,28,29,30,31, 47,48,49,50]. 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 [50,51,52,53,54]. 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, 13,14,15,16].

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, 60,61,62]. 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, 64,65,66].

Strengths and limitations

The strengths of the surveys and this analysis include the representative national samples from four countries with large numbers of participating health institutions, health workers and patients. The surveys utilised a standardised data collection tool which was comparable across time periods and countries and aligned with the IMCI algorithm, and which covered all levels of the health system and all qualification levels of health workers. Thus the results can be considered to be more representative than other studies which were conducted on a smaller and more selective scale. Furthermore, we believe that these results are closer to the reality than data from intervention studies where special emphasis was placed on IMCI training, performance and supervision.

The limitations of the surveys were the non-randomised approach to the selection of the health workers and the patients and the lack of assessment of the appropriateness of diagnosis and treatment. Still the large numbers of participants and health workers should minimise these limitations. Furthermore, in some countries the data were collected several years ago. Typically it takes a long time (and human and financial resources) to prepare these surveys, to collect the data and to analyse them. Thus, prolonged periods elapse between the surveys in most of the countries. Finally, direct observation may have contributed to increased rates of adherence, but if so, then true adherence rates would be even lower than reported here. Despite these constraints, this analysis provides important insights into the patterns of adherence to IMCI protocols across several sub-Saharan African countries.

Conclusion

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.

Abbreviations

IMCI:

Integrated Management of Childhood Illness

IQR:

Interquartile range

KE:

Kenya

LMIC:

Low-and-Middle-Income Country

NA:

Namibia

NPC:

Non-physician clinician

SPA:

Service provision assessment

TZ:

Tanzania

UG:

Uganda

USD:

US dollars

References

  1. UN. The millennium development goals report. New York: UN; 2015. p. 2015.

    Google Scholar 

  2. GBD 2015 Child Mortality Collaborators. Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1725–74.

    Article  PubMed Central  Google Scholar 

  3. UN. The sustainable development goals report. New York: UN; 2016. p. 2016.

    Google Scholar 

  4. Campbell H, Duke T, Weber M, English M, Carai S, Tamburlini G. Pediatric hospital improvement group. Global initiatives for improving hospital care for children: state of the art and future prospects. Pediatrics. 2008;121:e984–92.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Costello AM, Dalglish SL, on behalf of the Strategic Review Study Team. Towards a grand convergence for child survival and health: a strategic review of options for the future building on lessons learnt from IMNCI. Geneva: WHO; 2016.

    Google Scholar 

  6. Gove S. Integrated management of childhood illness by outpatient health workers: technical basis and overview. The WHO working group on guidelines for integrated Management of the Sick Child. Bull World Health Organ. 1997;75(Suppl 1):7–24.

    PubMed  PubMed Central  Google Scholar 

  7. Chopra M, Binkin NJ, Mason E, Wolfheim C. Integrated management of childhood illness: what have we learned and how can it be improved? Arch Dis Child. 2012;97:350–4.

    Article  PubMed  Google Scholar 

  8. Simoes EA, Peterson S, Gamatie Y, Kisanga FS, Mukasa G, Nsungwa-Sabiiti J, et al. Management of severely ill children at first-level health facilities in sub-Saharan Africa when referral is difficult. Bull World Health Organ. 2003;81:522–31.

    PubMed  PubMed Central  Google Scholar 

  9. Victora CG, Huicho L, Amaral JJ, Armstrong-Schellenberg J, Manzi F, Mason E, et al. Are health interventions implemented where they are most needed? District uptake of the integrated management of childhood illness strategy in Brazil, Peru and the United Republic of Tanzania. Bull World Health Organ. 2006;84:792–801.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. El Arifeen S, Blum LS, Hoque DM, Chowdhury EK, Khan R, Black RE, et al. Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a cluster-randomised study. Lancet. 2004;364:1595–602.

    Article  PubMed  Google Scholar 

  11. Arifeen SE, Hoque DM, Akter T, Rahman M, Hoque ME, Begum K, et al. Effect of the integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial. Lancet. 2009;374:393–403.

    Article  PubMed  Google Scholar 

  12. Chopra M, Patel S, Cloete K, Sanders D, Peterson S. Effect of an IMCI intervention on quality of care across four districts in cape town, South Africa. Arch Dis Child. 2005;90:397–401.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Armstrong Schellenberg J, Bryce J, de Savigny D, Lambrechts T, Mbuya C, Mgalula L, et al. The effect of integrated Management of Childhood Illness on observed quality of care of under-fives in rural Tanzania. Health Policy Plan. 2004;19:1–10.

    Article  PubMed  Google Scholar 

  14. Armstrong Schellenberg JR, Adam T, Mshinda H, Masanja H, Kabadi G, Mukasa O, et al. Effectiveness and cost of facility-based integrated Management of Childhood Illness (IMCI) in Tanzania. Lancet. 2004;364:1583–94.

    Article  PubMed  Google Scholar 

  15. Bryce J, Gouws E, Adam T, Black RE, Schellenberg JA, Manzi F, et al. Improving quality and efficiency of facility-based child health care through integrated Management of Childhood Illness in Tanzania. Health Policy Plan. 2005;20(Suppl 1):i69–76.

    Article  PubMed  Google Scholar 

  16. Amaral J, Gouws E, Bryce J, Leite AJ, Cunha AL, Victora CG. Effect of integrated Management of Childhood Illness (IMCI) on health worker performance in Northeast-Brazil. Cad Saude Publica. 2004;20(Suppl 2):S209–19.

    Article  PubMed  Google Scholar 

  17. Pariyo GW, Gouws E, Bryce J, Burnham G, Uganda IMCI. Impact study team. Improving facility-based care for sick children in Uganda: training is not enough. Health Policy Plan. 2005;20(Suppl 1):i58–68.

    Article  PubMed  Google Scholar 

  18. Huicho L, Dávila M, Campos M, Drasbek C, Bryce J, Victora CG. Scaling up integrated management of childhood illness to the national level: achievements and challenges in Peru. Health Policy Plan. 2005;20:14–24.

    Article  PubMed  Google Scholar 

  19. Huicho L, Dávila M, Gonzales F, Drasbek C, Bryce J, Victora CG. Implementation of the integrated Management of Childhood Illness strategy in Peru and its association with health indicators: an ecological analysis. Health Policy Plan. 2005;20(Suppl 1):i32–41.

    Article  PubMed  Google Scholar 

  20. Naimoli JF, Rowe AK, Lyaghfouri A, Larbi R, Lamrani LA. Effect of the integrated Management of Childhood Illness strategy on health care quality in Morocco. Int J Qual Health Care. 2006;18:134–44.

    Article  PubMed  Google Scholar 

  21. Walter ND, Lyimo T, Skarbinski J, Metta E, Kahigwa E, Flannery B, et al. Why first-level health workers fail to follow guidelines for managing severe disease in children in the coast region, the United Republic of Tanzania. Bull World Health Organ. 2009;87:99–107.

    Article  PubMed  Google Scholar 

  22. Horwood C, Vermaak K, Rollins N, Haskins L, Nkosi P, Qazi S. An evaluation of the quality of IMCI assessments among IMCI trained health workers in South Africa. PLoS One. 2009 Jun 17;4(6):e5937.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Baiden F, Owusu-Agyei S, Bawah J, Bruce J, Tivura M, Delmini R, et al. An evaluation of the clinical assessments of under-five febrile children presenting to primary health facilities in rural Ghana. PLoS One. 2011;6:e28944.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Rowe AK, Osterholt DM, Kouamé J, Piercefield E, Herman KM, Onikpo F, et al. Trends in health worker performance after implementing the integrated Management of Childhood Illness strategy in Benin. Tropical Med Int Health. 2012;17:438–46.

    Article  Google Scholar 

  25. Edward A, Kumar B, Niayesh H, Naeem AJ, Burnham G, Peters DH. The association of health workforce capacity and quality of pediatric care in Afghanistan. Int J Qual Health Care. 2012;24:578–86.

    Article  PubMed  Google Scholar 

  26. Nguyen DT, Leung KK, McIntyre L, Ghali WA, Sauve R. Does integrated management of childhood illness (IMCI) training improve the skills of health workers? A systematic review and meta-analysis. PLoS One. 2013;8:e66030.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Hoque DM, Arifeen SE, Rahman M, Chowdhury EK, Haque TM, Begum K, et al. Improving and sustaining quality of child health care through IMCI training and supervision: experience from rural Bangladesh. Health Policy Plan. 2014;29:753–62.

    Article  PubMed  Google Scholar 

  28. Steinhardt LC, Onikpo F, Kouamé J, Piercefield E, Lama M, Deming MS, et al. Predictors of health worker performance after integrated Management of Childhood Illness training in Benin: a cohort study. BMC Health Serv Res. 2015;15:276.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Edward A, Dam K, Chege J, Ghee AE, Zare H, Chhorvann C. Measuring pediatric quality of care in rural clinics-a multi-country assessment-Cambodia, Guatemala, Zambia and Kenya. Int J Qual Health Care. 2016;28:586–93.

    Article  PubMed  Google Scholar 

  30. Mansoor GF, Chikvaidze P, Varkey S, Higgins-Steele A, Safi N, Mubasher A, et al. Quality of child healthcare at primary healthcare facilities: a national assessment of the integrated Management of Childhood Illnesses in Afghanistan. Int J Qual Health Care. 2017;29:55–62.

    Article  PubMed  Google Scholar 

  31. El-Ayady AA, Meleis DE, Ahmed MM, Ismaiel RS. Primary health care Physicians' adherence and attitude towards integrated Management of Childhood Illness Guidelines in Alexandria governorate in Egypt. Glob J Health Sci. 2015;8:217–24.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Horwood C, Voce A, Vermaak K, Rollins N, Qazi S. Experiences of training and implementation of integrated management of childhood illness (IMCI) in South Africa: a qualitative evaluation of the IMCI case management training course. BMC Pediatr. 2009;9:62.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Mushi HP, Mullei K, Macha J, Wafula F, Borghi J, Goodman C, et al. The challenges of achieving high training coverage for IMCI: case studies from Kenya and Tanzania. Health Policy Plan. 2011;26:395–404.

    Article  PubMed  Google Scholar 

  34. Kiplagat A, Musto R, Mwizamholya D, Morona D. Factors influencing the implementation of integrated management of childhood illness (IMCI) by healthcare workers at public health centers & dispensaries in Mwanza, Tanzania. BMC Public Health. 2014;14:277.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Lange S, Mwisongo A, Mæstad O. Why don't clinicians adhere more consistently to guidelines for the integrated Management of Childhood Illness (IMCI)? Soc Sci Med. 2014;104:56–63.

    Article  PubMed  Google Scholar 

  36. Ministry of Health and Social Services (MoHSS) [Namibia] and ICF Macro. Namibia Health Facility Census 2009. Windhoek: Namibia MoHSS and ICF Macro; 2010.

    Google Scholar 

  37. National Coordinating Agency for Population and Development (NCAPD) [Kenya], Ministry of Medical Services (MOMS) [Kenya], Ministry of Public Health and Sanitation (MOPHS) [Kenya], Kenya National Bureau of Statistics (KNBS) [Kenya], ICF Macro. Kenya Service Provision Assessment Survey 2010. Nairobi, Kenya: National Coordinating Agency for Population and Development, Ministry of Medical Services, Ministry of Public Health and Sanitation, Kenya National Bureau of Statistics, and ICF Macro; 2011.

  38. National Bureau of Statistics (NBS) [Tanzania] and Macro International Inc. Tanzania Service Provision Assessment Survey 2006. Dar es Salaam: National Bureau of Statistics and Macro International Inc.; 2007.

    Google Scholar 

  39. Ministry of Health (MOH) [Uganda] and Macro International Inc. Uganda service provision assessment survey 2007. Kampala, Uganda: Ministry of Health and Macro International Inc.; 2008.

    Google Scholar 

  40. UNICEF. The state of the world’s children 2009. New York: UNICEF; 2009.

    Book  Google Scholar 

  41. UNICEF. The state of the world’s children 2011. New York: UNICEF; 2011.

    Book  Google Scholar 

  42. UNICEF. The state of the world’s children 2012. New York: UNICEF; 2012.

    Book  Google Scholar 

  43. UNICEF. The state of the world’s children 2014. New York: UNICEF; 2014.

    Book  Google Scholar 

  44. WHO. Integrated Management of Childhood Illness (IMCI) chart booklet. Geneva: WHO; 2014.

    Google Scholar 

  45. Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. Lancet. 2007;370:2158–63.

    Article  PubMed  Google Scholar 

  46. Swart E, Gothe H, Geyer S, Jaunzeme J, Maier B, Grobe TG, Ihle P; German Society for Social Medicine and Prevention; German Society for Epidemiology. [good practice of secondary data analysis (GPS): guidelines and recommendations]. Gesundheitswesen 2015;77:120-126.

  47. Biswas AB, Mukhopadhyay DK, Mandal NK, Panja TK, Sinha N, Mitra K. Skill of frontline workers implementing integrated management of neonatal and childhood illness: experience from a district of West Bengal, India. J Trop Pediatr. 2011;57:352–6.

    Article  PubMed  Google Scholar 

  48. Shewade HD, Aggarwal AK, Bharti B. Integrated Management of Neonatal and Childhood Illness (IMNCI): skill assessment of health and integrated child development scheme (ICDS) workers to classify sick under-five children. Indian J Pediatr. 2013;80:448–54.

    Article  PubMed  Google Scholar 

  49. Joshi P, Vatsa M. Knowledge, attitude and performance of IMNCI trained nursing personnel: an evaluative survey. Indian J Pediatr. 2014;81:450–4.

    Article  PubMed  Google Scholar 

  50. Mayhew M, Ickx P, Newbrander W, Stanekzai H, Alawi SA. Long and short integrated Management of Childhood Illness (IMCI) training courses in Afghanistan: a cross-sectional cohort comparison of post-course knowledge and performance. Int J Health Policy Manag. 2015;4:143–52.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Huicho L, Scherpbier RW, Nkowane AM, Victora CG. Multi-country evaluation of IMCI study group. How much does quality of child care vary between health workers with differing durations of training? An observational multicountry study. Lancet. 2008;372:910–6.

    Article  PubMed  Google Scholar 

  52. Goga AE, Muhe LM, Forsyth K, Chopra M, Aboubaker S, Martines J, et al. Results of a multi-country exploratory survey of approaches and methods for IMCI case management training. Health Res Policy Syst. 2009;7:18.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Kumar D, Aggarwal AK, Kumar R. The effect of interrupted 5-day training on integrated Management of Neonatal and Childhood Illness on the knowledge and skills of primary health care workers. Health Policy Plan. 2009;24:94–100.

    Article  PubMed  Google Scholar 

  54. Harerimana JM, Nyirazinyoye L, Ahoranayezu JB, Bikorimana F, Hedt-Gauthier BL, Muldoon KA, et al. Effect of shortened integrated Management of Childhood Illness training on classification and treatment of under-five children seeking care in Rwanda. Risk Manag Healthc Policy. 2014;7:99–104.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Venkatachalam J, Kumar D, Gupta M, Aggarwal AK. Knowledge and skills of primary health care workers trained on integrated management of neonatal and childhood illness: follow-up assessment 3 years after the training. Indian J Public Health. 2011;55:298–302.

    Article  CAS  PubMed  Google Scholar 

  56. Rowe AK, Rowe SY, Holloway KA, Ivanovska V, Muhe L, Lambrechts T. Does shortening the training on integrated Management of Childhood Illness guidelines reduce its effectiveness? A systematic review. Health Policy Plan. 2012;27:179–93.

    Article  PubMed  Google Scholar 

  57. Arifeen SE, Bryce J, Gouws E, Baqui AH, Black RE, Hoque DM, et al. Quality of care for under-fives in first-level health facilities in one district of Bangladesh. Bull World Health Organ. 2005;83:260–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  58. Adam T, Manzi F, Schellenberg JA, Mgalula L, de Savigny D, Evans DB. Does the integrated Management of Childhood Illness cost more than routine care? Results from the United Republic of Tanzania. Bull World Health Organ. 2005;83:369–77.

    PubMed  PubMed Central  Google Scholar 

  59. Adam T, Amorim DG, Edwards SJ, Amaral J, Evans DB. Capacity constraints to the adoption of new interventions: consultation time and the integrated Management of Childhood Illness in Brazil. Health Policy Plan. 2005;20(Suppl 1):i49–57.

    Article  PubMed  Google Scholar 

  60. Gera T, Shah D, Garner P, Richardson M, Sachdev HS. Integrated management of childhood illness (IMCI) strategy for children under five. Cochrane Database Syst Rev. 2016;6:CD010123.

    Google Scholar 

  61. Mohan P, Kishore B, Singh S, Bahl R, Puri A, Kumar R. Assessment of implementation of integrated management of neonatal and childhood illness in India. J Health Popul Nutr. 2011;29:629–38.

    PubMed  PubMed Central  Google Scholar 

  62. Bhandari N, Mazumder S, Taneja S, Sommerfelt H, Strand TA, Evaluation Study IMNCI. Group. Effect of implementation of integrated Management of Neonatal and Childhood Illness (IMNCI) programme on neonatal and infant mortality: cluster randomized controlled trial. BMJ. 2012;344:e1634.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Rakha MA, Abdelmoneim AN, Farhoud S, Pièche S, Cousens S, Daelmans B, et al. Does implementation of the IMCI strategy have an impact on child mortality? A retrospective analysis of routine data from Egypt. BMJ Open. 2013;3:e001852.

    PubMed  Google Scholar 

  64. Bryce J, Victora CG, Habicht JP, Black RE, Scherpbier RW. MCE-IMCI technical advisors. Programmatic pathways to child survival: results of a multi-country evaluation of integrated Management of Childhood Illness. Health Policy Plan. 2005;20(Suppl 1):i5–i17.

    Article  PubMed  Google Scholar 

  65. Goga AE, Muhe LM. Global challenges with scale-up of the integrated management of childhood illness strategy: results of a multi-country survey. BMC Public Health. 2011;11:503.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Mupara LU, Lubbe JC. Implementation of the integrated Management of Childhood Illnesses strategy: challenges and recommendations in Botswana. Glob Health Action. 2016;9:29417.

    Article  Google Scholar 

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Acknowledgments

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Funding

No funding was obtained for this study.

Availability of data and materials

The data that support the findings of this study are available from Macro International but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Macro International.

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Authors and Affiliations

  1. Department of Paediatrics, Witten/Herdecke University, Witten, Germany

    Carsten Krüger

  2. Children‘s Hospital, St. Franziskus Hospital, Robert-Koch-Strasse 55, D-59227, Ahlen, Germany

    Carsten Krüger

  3. MH Statistical Consulting, Marburg, Germany

    Monika Heinzel-Gutenbrunner

  4. Faculty of Health Sciences, School of Nursing, Midwifery & Paramedicine, Curtin University, Perth, Australia

    Mohammed Ali

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  1. Carsten Krüger
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Contributions

CK conceived the idea for the study, collected and analysed the data and wrote the first and subsequent versions of the manuscript. MH-G was responsible for the data analyses and statistical tests, MA contributed to the data analysis and different manuscript versions. All authors contributed to and approved the final version of the manuscript.

Corresponding author

Correspondence to Carsten Krüger.

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Ethics approval and consent to participate

Macro International as the copyright holder granted the authors unrestricted access to all survey data, which were completely anonymised, for this secondary analysis after submission of the research proposal. For such an analysis, no approval of an ethical committee is required according to the Good Practice of Secondary Data Analysis, a national guideline for the use of epidemiologic databases in Germany, which was fully adhered to.

The surveys themselves had been initiated, planned and approved by the respective Ministry of Health. During the actual surveys, parents and health staff had given informed written consent to direct observation of the assessment process.

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Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Krüger, C., Heinzel-Gutenbrunner, M. & Ali, M. Adherence to the integrated management of childhood illness guidelines in Namibia, Kenya, Tanzania and Uganda: evidence from the national service provision assessment surveys. BMC Health Serv Res 17, 822 (2017). https://doi.org/10.1186/s12913-017-2781-3

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BMC Health Services Research

ISSN: 1472-6963

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