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Ghulam Farooq Mansoor, Paata Chikvaidze, Sherin Varkey, Ariel Higgins-Steele, Najibullah Safi, Adela Mubasher, Khaksar Yusufi, Sayed Alisha Alawi, Quality of child healthcare at primary healthcare facilities: a national assessment of the Integrated Management of Childhood Illnesses in Afghanistan, International Journal for Quality in Health Care, Volume 29, Issue 1, February 2017, Pages 55–62, https://doi.org/10.1093/intqhc/mzw135
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Abstract
To assess quality of the national Integrated Management of Childhood Illness (IMCI) program services provided for sick children at primary health facilities in Afghanistan.
Mixed methods including cross-sectional study.
Thirteen (of thirty-four) provinces in Afghanistan.
Observation of case management and re-examination of 177 sick children, exit interviews with caretakers and review of equipment/supplies at 44 health facilities.
Introduction and scale up of Integrated Management of Childhood Illnesses at primary health care facilities.
Care of sick children according to IMCI guidelines, health worker skills and essential health system elements.
Thirty-two (71%) of the health workers were trained in IMCI and five (11%) received supervision in clinical case management during the past 6 months. On average, 5.4 out of 10 main assessment tasks were performed during cases observed, the index being higher in children seen by trained providers than untrained (6.3 vs 3.5, 95% CI 5.8–6.8 vs 2.9–4.1). In all, 74% of the 104 children who needed oral antibiotics received prescriptions, while 30% received complete and correct advice and 30% were overprescribed, and more so by untrained providers. Home care counseling was associated with provider training status (41.3% by trained and 24.5% by untrained). Essential oral and pre-referral injectable medicine and equipment/supplies were available in 66%, 23%, and 45% of health facilities, respectively.
IMCI training improved assessment, rational use of antibiotics and counseling; further investment in IMCI in Afghanistan, continuing provider capacity building and supportive supervision for improved quality of care and counseling for sick children is needed, especially given high burden treatable childhood illness.
Introduction
Globally, most deaths in children under 5 years of age (child U-5) occur in developing countries and are from preventable or treatable causes such as prematurity, low birth weight, pneumonia, diarrhea, malaria, measles and malnutrition [1]. Reduction in deaths due to these causes rests on the capacity of the countries’ health systems to deliver quality interventions at health center and community levels [2, 3].
According to United Nations’ estimates, Afghanistan has achieved significant reductions in mortality rates of U-5 children, infants and newborns from 181, 123 and 53 in 1990 to 91, 66 and 36 per 1000 live births in 2015 [1, 3]. In spite of this progress, child mortality and morbidity rates in Afghanistan remain among the highest in the world [4]. Infectious diseases such as diarrhea, pneumonia and measles account for more than half (54%) of deaths among children U-5 [1, 3].
In the 1990s, World Health Organization (WHO) and United Nations Children's Fund (UNICEF) developed a new strategy called the Integrated Management of Childhood Illness (IMCI), a strategy widely considered as technically sound to reduce child deaths and the frequency and severity of child illness and disability, and to promote healthy growth and development [5–7]. IMCI includes interventions to improve: health worker skills; key elements of the health system; and family and community health practices. In addition, it addresses the management of acute respiratory infections, diarrhea, malaria, measles and malnutrition by combining curative, preventive and health promotion strategies [8]. IMCI is intended to lead to improved identification of illnesses, ensures appropriate and where necessary combined treatment of major illnesses, as well as rationalizes referral of severely sick children [9]. Furthermore, it incorporates significant disease prevention mechanisms through promotion of breastfeeding, counseling on nutrition and immunization of children [10]. A recent systematic review found that IMCI may lead to fewer deaths among children from birth to 5 years of age. Effects of IMCI on other issues, such as illness or quality of care, were mixed, and some evidence was of very low certainty [11].
IMCI was promoted early on in rebuilding Afghanistan's health system. The approach was integrated into the national health policy document called the Basic Package of Health Services (BPHS) in 2003, which had been developed to address maternal and child health issues; a year later after a review of pilot results by stakeholders the program was scaled up, and by the end of 2014, around 4658 doctors and nurses were trained on IMCI, an amount covering 100% of provinces and over 95% of districts nationally [12]. In line with the WHO position statement on ensuring continuum of care and increased coverage [13], the community component of IMCI (cIMCI) was adopted and scaled up in 2008. As a result, 17 000 out of ~30 000 (56.7%) community health workers (CHWs) were trained on the approach [12]. This combination of facility and community-based approaches to IMCI ensured a continuum of care, increased coverage and potentially improved quality of care for sick children in rural and remote areas. In 2014, IMCI was integrated in the training curricula for resident students in the Kabul Medical University.
No comprehensive assessment of its performance has been conducted since IMCI's introduction. Some studies have assessed elements of IMCI in Afghanistan such as referral [14], training courses [15] and determinants of quality in care [16]. We conducted a health facility survey between December 2014 and February 2015 to assess implementation of IMCI at facility level and produce recommendations for service quality improvement and increased utilization. Specific objectives were to assess: the quality of care delivered to sick children and quality of counseling given at outpatient health facilities and caretakers’ understanding of home treatment for their sick children; the availability of key health system support elements such as drugs, equipment and supervision; and to identify principle barriers to effective integrated case management for sick children.
Methods
The overall purpose of this study is to assess implementation of IMCI in select health facilities. WHO standard IMCI survey methodology and tools [2] were adapted, after review and field test by the IMCI technical working group, to collect qualitative and quantitative data. Assessment included: observing case management of sick children attending to first-level facilities the day of survey; exit interviews with caretakers; re-examination of the sick child by a member of the data collection team qualified practicing clinician and IMCI trainer, whose classification was considered the ‘gold standard’; and reviewing availability of IMCI standard medical equipment and supplies [2]. The assessment was conducted by an independent consultant, with technical support and oversight from the Ministry of Public Health (MoPH), WHO and UNICEF.
Thirteen provinces were purposively selected to represent regional, ethnic and security context (Fig. 1). A total of 44 out of 603 health facilities providing the BPHS and IMCI in the 13 provinces were selected using systematic random sampling and applying the Probability Proportionate to Size (PPS) method by province and type of health facility. In each selected health facility on average four children were enrolled; health facilities caring for less than four children a day were excluded.
Exit interviews were conducted with caretakers of the children; and availability of equipment and supplies was assessed. The sample size follows WHO recommendations and is based on 95% limits of confidence and 10% margin of error for the national level results.
STATA version 14 was used for data analysis. Descriptive statistics were produced with 95% confidence intervals on standard key indicators related to assessment, treatment counseling and health system support elements; comparative analysis was performed to assess any difference by training status of health workers; chi-square or Fisher's Exact test was performed as appropriate to assess statistical significance.
Ethical considerations
The study protocol was approved by the Institutional Review Board of the Afghanistan MoPH. The surveyors explained objectives of the study to the facility manager, and requested his/her facility to participate in the assessment. Every caretaker was approached and objectives of the study, as well as potential risks and benefits were explained. Written consent of the caretaker was ensured before enrolling a child in the study. Identifying information of participants was kept anonymous.
Results
A total of 177 children 2–59 months were observed being cared for by health-care workers, 173 caretakers participated in exit interviews and 44 health facilities were assessed for essential IMCI equipment and medical supplies. Four health facilities were not accessible due to active fighting in the area and were replaced by four similar types and nearest health facilities.
Respondent characteristics
Median age of children observed was 18 months; about two-thirds (62%) were 2–23 months old. Proportion of boys and girls in the sample was 55% (n = 98) and 45% (n = 79).
About 1 in 10 (11%; n = 5) of the health workers were female, 49% (n = 22) were medical doctors, and the rest (51%; n = 23) were nurses or assistant doctors. More than two-thirds of health workers (71%; n = 32) who cared for sick children were trained in IMCI (Table 1). About 1 in 10 (11%; n = 5) of the trained health workers were at least once supervised in clinical case management of a sick child during the past 6 months (Table 2).
Children assessed by facility type . | Number . | % . |
---|---|---|
Basic Health Center | 86 | 49 |
Comprehensive Health Center | 59 | 33 |
Sub Health Center | 24 | 14 |
District Hospital | 8 | 5 |
Children assessed by location of health facility | ||
Urban health facilities | 36 | 20 |
Rural health facilities | 141 | 80 |
Age of children treated | ||
2–11 months | 56 | 32 |
12–23 months | 53 | 30 |
24–35 months | 28 | 16 |
36–47 months | 22 | 12 |
48–59 months | 18 | 10 |
Sex of children | ||
Male | 98 | 55 |
Female | 79 | 45 |
Health worker caring for sick children | ||
Sex | ||
Female | 5 | 11 |
Male | 40 | 89 |
Type | ||
Doctor | 22 | 49 |
Nurse | 22 | 49 |
Assistant doctor | 1 | 2 |
Training status | ||
Trained | 32 | 71 |
Not trained | 13 | 29 |
Time of training | ||
Trained in recent 4 years | 22 | 49 |
Trained earlier than last 4 years | 10 | 22 |
Caretaker | ||
Sex | ||
Female | 155 | 90 |
Male | 18 | 10 |
Relation to child | ||
Mother | 138 | 80a |
Father | 15 | 9a |
Other | 20 | 12a |
Children assessed by facility type . | Number . | % . |
---|---|---|
Basic Health Center | 86 | 49 |
Comprehensive Health Center | 59 | 33 |
Sub Health Center | 24 | 14 |
District Hospital | 8 | 5 |
Children assessed by location of health facility | ||
Urban health facilities | 36 | 20 |
Rural health facilities | 141 | 80 |
Age of children treated | ||
2–11 months | 56 | 32 |
12–23 months | 53 | 30 |
24–35 months | 28 | 16 |
36–47 months | 22 | 12 |
48–59 months | 18 | 10 |
Sex of children | ||
Male | 98 | 55 |
Female | 79 | 45 |
Health worker caring for sick children | ||
Sex | ||
Female | 5 | 11 |
Male | 40 | 89 |
Type | ||
Doctor | 22 | 49 |
Nurse | 22 | 49 |
Assistant doctor | 1 | 2 |
Training status | ||
Trained | 32 | 71 |
Not trained | 13 | 29 |
Time of training | ||
Trained in recent 4 years | 22 | 49 |
Trained earlier than last 4 years | 10 | 22 |
Caretaker | ||
Sex | ||
Female | 155 | 90 |
Male | 18 | 10 |
Relation to child | ||
Mother | 138 | 80a |
Father | 15 | 9a |
Other | 20 | 12a |
aRounded off to upper number.
Children assessed by facility type . | Number . | % . |
---|---|---|
Basic Health Center | 86 | 49 |
Comprehensive Health Center | 59 | 33 |
Sub Health Center | 24 | 14 |
District Hospital | 8 | 5 |
Children assessed by location of health facility | ||
Urban health facilities | 36 | 20 |
Rural health facilities | 141 | 80 |
Age of children treated | ||
2–11 months | 56 | 32 |
12–23 months | 53 | 30 |
24–35 months | 28 | 16 |
36–47 months | 22 | 12 |
48–59 months | 18 | 10 |
Sex of children | ||
Male | 98 | 55 |
Female | 79 | 45 |
Health worker caring for sick children | ||
Sex | ||
Female | 5 | 11 |
Male | 40 | 89 |
Type | ||
Doctor | 22 | 49 |
Nurse | 22 | 49 |
Assistant doctor | 1 | 2 |
Training status | ||
Trained | 32 | 71 |
Not trained | 13 | 29 |
Time of training | ||
Trained in recent 4 years | 22 | 49 |
Trained earlier than last 4 years | 10 | 22 |
Caretaker | ||
Sex | ||
Female | 155 | 90 |
Male | 18 | 10 |
Relation to child | ||
Mother | 138 | 80a |
Father | 15 | 9a |
Other | 20 | 12a |
Children assessed by facility type . | Number . | % . |
---|---|---|
Basic Health Center | 86 | 49 |
Comprehensive Health Center | 59 | 33 |
Sub Health Center | 24 | 14 |
District Hospital | 8 | 5 |
Children assessed by location of health facility | ||
Urban health facilities | 36 | 20 |
Rural health facilities | 141 | 80 |
Age of children treated | ||
2–11 months | 56 | 32 |
12–23 months | 53 | 30 |
24–35 months | 28 | 16 |
36–47 months | 22 | 12 |
48–59 months | 18 | 10 |
Sex of children | ||
Male | 98 | 55 |
Female | 79 | 45 |
Health worker caring for sick children | ||
Sex | ||
Female | 5 | 11 |
Male | 40 | 89 |
Type | ||
Doctor | 22 | 49 |
Nurse | 22 | 49 |
Assistant doctor | 1 | 2 |
Training status | ||
Trained | 32 | 71 |
Not trained | 13 | 29 |
Time of training | ||
Trained in recent 4 years | 22 | 49 |
Trained earlier than last 4 years | 10 | 22 |
Caretaker | ||
Sex | ||
Female | 155 | 90 |
Male | 18 | 10 |
Relation to child | ||
Mother | 138 | 80a |
Father | 15 | 9a |
Other | 20 | 12a |
aRounded off to upper number.
Health system support indicators . | N . | % Unless otherwise stated . | 95% CI . |
---|---|---|---|
1. Stakeholders satisfied with the child health services | 173 | 43.9 | 36.5–51.4 |
2. Health facilities with at least 60% of workers managing children are trained in IMCI | 44 | 59.1 | 44.0–74.2 |
3. Health facilities with at least one healthcare worker trained in IMCI | 44 | 79.6 | 64.5–89.3 |
4. Health facility received at least one supervisory visit that included observation of case management during the previous 6 months | 44 | 11.4 | 1.6–21.1 |
5. Health facilities with all eight essential oral medicine available | 44 | 65.9 | 51.3–80.5 |
6. Index of availability of essential oral treatments (mean out of eight) | 44 | 7.4 | 7.2–7.6 |
7. Health facilities with all four pre-referral injectable medicines available | 44 | 22.7 | 9.8–35.6 |
8. Index of availability of injectable (antibiotic) for pre-referral medicine (mean out of four) | 44 | 2.6 | 2.5–2.7 |
9. Health facility has the equipment and supplies to support full vaccination services | 44 | 88.6 | 78.9–98.4 |
10. Health facilities with available childhood vaccines | 44 | 93.2 | 85.4–101 |
Health system support indicators . | N . | % Unless otherwise stated . | 95% CI . |
---|---|---|---|
1. Stakeholders satisfied with the child health services | 173 | 43.9 | 36.5–51.4 |
2. Health facilities with at least 60% of workers managing children are trained in IMCI | 44 | 59.1 | 44.0–74.2 |
3. Health facilities with at least one healthcare worker trained in IMCI | 44 | 79.6 | 64.5–89.3 |
4. Health facility received at least one supervisory visit that included observation of case management during the previous 6 months | 44 | 11.4 | 1.6–21.1 |
5. Health facilities with all eight essential oral medicine available | 44 | 65.9 | 51.3–80.5 |
6. Index of availability of essential oral treatments (mean out of eight) | 44 | 7.4 | 7.2–7.6 |
7. Health facilities with all four pre-referral injectable medicines available | 44 | 22.7 | 9.8–35.6 |
8. Index of availability of injectable (antibiotic) for pre-referral medicine (mean out of four) | 44 | 2.6 | 2.5–2.7 |
9. Health facility has the equipment and supplies to support full vaccination services | 44 | 88.6 | 78.9–98.4 |
10. Health facilities with available childhood vaccines | 44 | 93.2 | 85.4–101 |
Health system support indicators . | N . | % Unless otherwise stated . | 95% CI . |
---|---|---|---|
1. Stakeholders satisfied with the child health services | 173 | 43.9 | 36.5–51.4 |
2. Health facilities with at least 60% of workers managing children are trained in IMCI | 44 | 59.1 | 44.0–74.2 |
3. Health facilities with at least one healthcare worker trained in IMCI | 44 | 79.6 | 64.5–89.3 |
4. Health facility received at least one supervisory visit that included observation of case management during the previous 6 months | 44 | 11.4 | 1.6–21.1 |
5. Health facilities with all eight essential oral medicine available | 44 | 65.9 | 51.3–80.5 |
6. Index of availability of essential oral treatments (mean out of eight) | 44 | 7.4 | 7.2–7.6 |
7. Health facilities with all four pre-referral injectable medicines available | 44 | 22.7 | 9.8–35.6 |
8. Index of availability of injectable (antibiotic) for pre-referral medicine (mean out of four) | 44 | 2.6 | 2.5–2.7 |
9. Health facility has the equipment and supplies to support full vaccination services | 44 | 88.6 | 78.9–98.4 |
10. Health facilities with available childhood vaccines | 44 | 93.2 | 85.4–101 |
Health system support indicators . | N . | % Unless otherwise stated . | 95% CI . |
---|---|---|---|
1. Stakeholders satisfied with the child health services | 173 | 43.9 | 36.5–51.4 |
2. Health facilities with at least 60% of workers managing children are trained in IMCI | 44 | 59.1 | 44.0–74.2 |
3. Health facilities with at least one healthcare worker trained in IMCI | 44 | 79.6 | 64.5–89.3 |
4. Health facility received at least one supervisory visit that included observation of case management during the previous 6 months | 44 | 11.4 | 1.6–21.1 |
5. Health facilities with all eight essential oral medicine available | 44 | 65.9 | 51.3–80.5 |
6. Index of availability of essential oral treatments (mean out of eight) | 44 | 7.4 | 7.2–7.6 |
7. Health facilities with all four pre-referral injectable medicines available | 44 | 22.7 | 9.8–35.6 |
8. Index of availability of injectable (antibiotic) for pre-referral medicine (mean out of four) | 44 | 2.6 | 2.5–2.7 |
9. Health facility has the equipment and supplies to support full vaccination services | 44 | 88.6 | 78.9–98.4 |
10. Health facilities with available childhood vaccines | 44 | 93.2 | 85.4–101 |
Most caretakers (90%; n = 155) were female and biological mothers of sick children (80%; n = 138) (Table 1).
Assessment of the sick child
Of the 10 main assessment tasks included in the assessment index, on average 5.4 tasks were performed during examination of a child, the index being higher in children seen by trained health workers in IMCI than untrained (6.3 vs 3.5, 95% CI 5.8–6.8 vs 2.9–4.1, respectively) (Table 3). More than half (54%; n = 96) were assessed for three main symptoms of cough, diarrhea and fever. Over a quarter (28%; n = 50) were assessed for three general danger signs inability to drink, vomiting and convulsions. More than a quarter (28%; n = 30) below 2-year-old children were assessed for feeding practices. About a third (34%; n = 60) were weighed and checked against growth chart (Table 3). Forty-one percent were assessed for their vaccination status however when the data collector checked 95% of the children had been vaccinated or were not due for vaccination. Signs assessed less frequently included edema of both feet (13%; n = 23) and palmar pallor (16%; n = 29) to detect clinical severe malnutrition and anemia. Trained health workers consistently outperformed untrained health workers in assessment of sick child (Table 5).
. | Denominator . | % Except otherwise stated . | 95% CI . |
---|---|---|---|
A. Assessment of the sick child by health worker | |||
1. Child checked for three danger signs | 177 | 28.3 | 21.6–35.0 |
2. Child checked for cough, diarrhea and fever | 177 | 54.2 | 46.8–61.7 |
3. Child weighed and checked against growth chart | 177 | 34.5 | 27.4–41.5 |
4. Child vaccination status checked | 177 | 41.2 | 33.9–48.6 |
5. Index of integrated assessment (Mean out of 10) | 177 | 5.4 | 5.0–5.8 |
a. Assessment index by trained health worker | 123 | 6.3 | 5.8–6.8 |
b. Assessment index by untrained health worker | 55 | 3.5 | 2.9–4.1 |
6. Child <2 years of age assessed for feeding practices | 109 | 27.5 | 19.0–36.0 |
7. Child checked for fever | 177 | 62 | 54.1–68.5 |
8. Child checked for pedal edema | 177 | 13 | 8.8–18.9 |
9. Child checked for palmar pallor | 177 | 16 | 11.6–22.7 |
B. Classification and treatment of the sick child | |||
10. Agreement between provider's and surveyor's classifications of the conditions related to cough or difficult breathing, diarrhea and fever | 171 | 42.9 | 35.6–50.3 |
11. Children given injectable medicine | 177 | 2.3 | 0.8–5.9 |
12. Children needed antibiotic/antimalarial | 177 | 58.8 | 51.3–65.8 |
13. Children needing antibiotics/antimalarial were given them | 104 | 74 | 64.6–81.6 |
14. Children who are prescribed antibiotic with correct frequency and duration | 104 | 52.9 | 43.8–61.6 |
15. Children who are prescribed antibiotic with correct amount, frequency and duration | 104 | 29.8 | 21.7–39.4 |
16. Children who are given the first dose of antibiotic/antimalarial at health facility | 104 | 9.6 | 5.2–17.1 |
17. Children with diarrhea who were given ORS | 55 | 49.1 | 35.8–62.5 |
18. Children with diarrhea who were given Zinc | 55 | 27.3 | 16.9–40.9 |
19. Children not needing antibiotic who are not prescribed any antibiotic | 70 | 70 | 59.0–81.0 |
C. Vaccination status and counseling of the sick child | |||
20. Caretaker of sick child is advised to give extra fluids and continue feeding (home care counseling) | 174 | 36 | 29.3–43.7 |
21. Children needing vaccinations leaves the facility with all needed vaccinations taken | 177 | 94.4 | 90.9–97.8 |
22. Caretaker of a child who is prescribed ORS, and/or an oral antibiotic, and/or an oral antimalarial who knows how to give the treatment | 112 | 32.1 | 23.4–40.1 |
a. Antibiotic/antimalarial alone | 99 | 28.3 | 19.3–37.3 |
b. ORS alone | 36 | 80.6 | 67.0–94.1 |
23. Caretaker advised on her/his own health | 174 | 8.5 | 5.2–13.6 |
24. Child needing referral who is referred to a higher level of the health system | 3 | 66.7 | 0.3–99.9 |
. | Denominator . | % Except otherwise stated . | 95% CI . |
---|---|---|---|
A. Assessment of the sick child by health worker | |||
1. Child checked for three danger signs | 177 | 28.3 | 21.6–35.0 |
2. Child checked for cough, diarrhea and fever | 177 | 54.2 | 46.8–61.7 |
3. Child weighed and checked against growth chart | 177 | 34.5 | 27.4–41.5 |
4. Child vaccination status checked | 177 | 41.2 | 33.9–48.6 |
5. Index of integrated assessment (Mean out of 10) | 177 | 5.4 | 5.0–5.8 |
a. Assessment index by trained health worker | 123 | 6.3 | 5.8–6.8 |
b. Assessment index by untrained health worker | 55 | 3.5 | 2.9–4.1 |
6. Child <2 years of age assessed for feeding practices | 109 | 27.5 | 19.0–36.0 |
7. Child checked for fever | 177 | 62 | 54.1–68.5 |
8. Child checked for pedal edema | 177 | 13 | 8.8–18.9 |
9. Child checked for palmar pallor | 177 | 16 | 11.6–22.7 |
B. Classification and treatment of the sick child | |||
10. Agreement between provider's and surveyor's classifications of the conditions related to cough or difficult breathing, diarrhea and fever | 171 | 42.9 | 35.6–50.3 |
11. Children given injectable medicine | 177 | 2.3 | 0.8–5.9 |
12. Children needed antibiotic/antimalarial | 177 | 58.8 | 51.3–65.8 |
13. Children needing antibiotics/antimalarial were given them | 104 | 74 | 64.6–81.6 |
14. Children who are prescribed antibiotic with correct frequency and duration | 104 | 52.9 | 43.8–61.6 |
15. Children who are prescribed antibiotic with correct amount, frequency and duration | 104 | 29.8 | 21.7–39.4 |
16. Children who are given the first dose of antibiotic/antimalarial at health facility | 104 | 9.6 | 5.2–17.1 |
17. Children with diarrhea who were given ORS | 55 | 49.1 | 35.8–62.5 |
18. Children with diarrhea who were given Zinc | 55 | 27.3 | 16.9–40.9 |
19. Children not needing antibiotic who are not prescribed any antibiotic | 70 | 70 | 59.0–81.0 |
C. Vaccination status and counseling of the sick child | |||
20. Caretaker of sick child is advised to give extra fluids and continue feeding (home care counseling) | 174 | 36 | 29.3–43.7 |
21. Children needing vaccinations leaves the facility with all needed vaccinations taken | 177 | 94.4 | 90.9–97.8 |
22. Caretaker of a child who is prescribed ORS, and/or an oral antibiotic, and/or an oral antimalarial who knows how to give the treatment | 112 | 32.1 | 23.4–40.1 |
a. Antibiotic/antimalarial alone | 99 | 28.3 | 19.3–37.3 |
b. ORS alone | 36 | 80.6 | 67.0–94.1 |
23. Caretaker advised on her/his own health | 174 | 8.5 | 5.2–13.6 |
24. Child needing referral who is referred to a higher level of the health system | 3 | 66.7 | 0.3–99.9 |
. | Denominator . | % Except otherwise stated . | 95% CI . |
---|---|---|---|
A. Assessment of the sick child by health worker | |||
1. Child checked for three danger signs | 177 | 28.3 | 21.6–35.0 |
2. Child checked for cough, diarrhea and fever | 177 | 54.2 | 46.8–61.7 |
3. Child weighed and checked against growth chart | 177 | 34.5 | 27.4–41.5 |
4. Child vaccination status checked | 177 | 41.2 | 33.9–48.6 |
5. Index of integrated assessment (Mean out of 10) | 177 | 5.4 | 5.0–5.8 |
a. Assessment index by trained health worker | 123 | 6.3 | 5.8–6.8 |
b. Assessment index by untrained health worker | 55 | 3.5 | 2.9–4.1 |
6. Child <2 years of age assessed for feeding practices | 109 | 27.5 | 19.0–36.0 |
7. Child checked for fever | 177 | 62 | 54.1–68.5 |
8. Child checked for pedal edema | 177 | 13 | 8.8–18.9 |
9. Child checked for palmar pallor | 177 | 16 | 11.6–22.7 |
B. Classification and treatment of the sick child | |||
10. Agreement between provider's and surveyor's classifications of the conditions related to cough or difficult breathing, diarrhea and fever | 171 | 42.9 | 35.6–50.3 |
11. Children given injectable medicine | 177 | 2.3 | 0.8–5.9 |
12. Children needed antibiotic/antimalarial | 177 | 58.8 | 51.3–65.8 |
13. Children needing antibiotics/antimalarial were given them | 104 | 74 | 64.6–81.6 |
14. Children who are prescribed antibiotic with correct frequency and duration | 104 | 52.9 | 43.8–61.6 |
15. Children who are prescribed antibiotic with correct amount, frequency and duration | 104 | 29.8 | 21.7–39.4 |
16. Children who are given the first dose of antibiotic/antimalarial at health facility | 104 | 9.6 | 5.2–17.1 |
17. Children with diarrhea who were given ORS | 55 | 49.1 | 35.8–62.5 |
18. Children with diarrhea who were given Zinc | 55 | 27.3 | 16.9–40.9 |
19. Children not needing antibiotic who are not prescribed any antibiotic | 70 | 70 | 59.0–81.0 |
C. Vaccination status and counseling of the sick child | |||
20. Caretaker of sick child is advised to give extra fluids and continue feeding (home care counseling) | 174 | 36 | 29.3–43.7 |
21. Children needing vaccinations leaves the facility with all needed vaccinations taken | 177 | 94.4 | 90.9–97.8 |
22. Caretaker of a child who is prescribed ORS, and/or an oral antibiotic, and/or an oral antimalarial who knows how to give the treatment | 112 | 32.1 | 23.4–40.1 |
a. Antibiotic/antimalarial alone | 99 | 28.3 | 19.3–37.3 |
b. ORS alone | 36 | 80.6 | 67.0–94.1 |
23. Caretaker advised on her/his own health | 174 | 8.5 | 5.2–13.6 |
24. Child needing referral who is referred to a higher level of the health system | 3 | 66.7 | 0.3–99.9 |
. | Denominator . | % Except otherwise stated . | 95% CI . |
---|---|---|---|
A. Assessment of the sick child by health worker | |||
1. Child checked for three danger signs | 177 | 28.3 | 21.6–35.0 |
2. Child checked for cough, diarrhea and fever | 177 | 54.2 | 46.8–61.7 |
3. Child weighed and checked against growth chart | 177 | 34.5 | 27.4–41.5 |
4. Child vaccination status checked | 177 | 41.2 | 33.9–48.6 |
5. Index of integrated assessment (Mean out of 10) | 177 | 5.4 | 5.0–5.8 |
a. Assessment index by trained health worker | 123 | 6.3 | 5.8–6.8 |
b. Assessment index by untrained health worker | 55 | 3.5 | 2.9–4.1 |
6. Child <2 years of age assessed for feeding practices | 109 | 27.5 | 19.0–36.0 |
7. Child checked for fever | 177 | 62 | 54.1–68.5 |
8. Child checked for pedal edema | 177 | 13 | 8.8–18.9 |
9. Child checked for palmar pallor | 177 | 16 | 11.6–22.7 |
B. Classification and treatment of the sick child | |||
10. Agreement between provider's and surveyor's classifications of the conditions related to cough or difficult breathing, diarrhea and fever | 171 | 42.9 | 35.6–50.3 |
11. Children given injectable medicine | 177 | 2.3 | 0.8–5.9 |
12. Children needed antibiotic/antimalarial | 177 | 58.8 | 51.3–65.8 |
13. Children needing antibiotics/antimalarial were given them | 104 | 74 | 64.6–81.6 |
14. Children who are prescribed antibiotic with correct frequency and duration | 104 | 52.9 | 43.8–61.6 |
15. Children who are prescribed antibiotic with correct amount, frequency and duration | 104 | 29.8 | 21.7–39.4 |
16. Children who are given the first dose of antibiotic/antimalarial at health facility | 104 | 9.6 | 5.2–17.1 |
17. Children with diarrhea who were given ORS | 55 | 49.1 | 35.8–62.5 |
18. Children with diarrhea who were given Zinc | 55 | 27.3 | 16.9–40.9 |
19. Children not needing antibiotic who are not prescribed any antibiotic | 70 | 70 | 59.0–81.0 |
C. Vaccination status and counseling of the sick child | |||
20. Caretaker of sick child is advised to give extra fluids and continue feeding (home care counseling) | 174 | 36 | 29.3–43.7 |
21. Children needing vaccinations leaves the facility with all needed vaccinations taken | 177 | 94.4 | 90.9–97.8 |
22. Caretaker of a child who is prescribed ORS, and/or an oral antibiotic, and/or an oral antimalarial who knows how to give the treatment | 112 | 32.1 | 23.4–40.1 |
a. Antibiotic/antimalarial alone | 99 | 28.3 | 19.3–37.3 |
b. ORS alone | 36 | 80.6 | 67.0–94.1 |
23. Caretaker advised on her/his own health | 174 | 8.5 | 5.2–13.6 |
24. Child needing referral who is referred to a higher level of the health system | 3 | 66.7 | 0.3–99.9 |
Diagnosis/classification of the child illness
SN . | Gold standard classification . | Number . | % . |
---|---|---|---|
1 | Child with danger signs | 2 | 1 |
Acute respiratory condition | 156 | 88 | |
2 | Severe pneumonia/severe illness | 3 | 2 |
3 | Pneumonia | 35 | 20 |
4 | Common cold | 118 | 67 |
Diarrheal conditions | 58 | 33 | |
5 | Diarrhea with severe dehydration | 0 | 0 |
6 | Diarrhea with moderate dehydration | 2 | 1 |
7 | Diarrhea with no dehydration | 44 | 25 |
8 | Sever persistent diarrhea | 0 | 0 |
9 | Persistent diarrhea | 3 | 2 |
10 | Dysentery | 9 | 5 |
Febrile conditions | 116 | 66 | |
11 | Severe febrile illness | 2 | 1 |
12 | Suspected malaria | 48 | 27 |
13 | Fever malaria unlikely and fever no malaria | 66 | 37 |
14 | Measles | 2 | 1 |
Ear conditions | 43 | 24 | |
15 | Acute ear infection | 39 | 22 |
16 | Chronic ear infection | 4 | 2 |
Throat conditions | 13 | 7 | |
17 | Throat abscess | 0 | 0 |
18 | Streptococcal sore throat | 10 | 6 |
19 | Viral Sore throat | 3 | 2 |
Nutrition conditions | 6 | 3 | |
20 | Severe malnutrition | 1 | 1 |
21 | Low weight | 3 | 2 |
22 | Severe pallor | 1 | 1 |
23 | Anemia | 1 | 1 |
Other conditions | 3 | 2 | |
24 | Other skin rashes/allergy | 2 | 1 |
25 | Other conjunctivitis | 1 | 1 |
Total | 177 | 100 | |
Average classifications per child | 2.3 | ||
Child needing referral | 3 | 2 | |
Child needing antibiotic | 104 | 58 |
SN . | Gold standard classification . | Number . | % . |
---|---|---|---|
1 | Child with danger signs | 2 | 1 |
Acute respiratory condition | 156 | 88 | |
2 | Severe pneumonia/severe illness | 3 | 2 |
3 | Pneumonia | 35 | 20 |
4 | Common cold | 118 | 67 |
Diarrheal conditions | 58 | 33 | |
5 | Diarrhea with severe dehydration | 0 | 0 |
6 | Diarrhea with moderate dehydration | 2 | 1 |
7 | Diarrhea with no dehydration | 44 | 25 |
8 | Sever persistent diarrhea | 0 | 0 |
9 | Persistent diarrhea | 3 | 2 |
10 | Dysentery | 9 | 5 |
Febrile conditions | 116 | 66 | |
11 | Severe febrile illness | 2 | 1 |
12 | Suspected malaria | 48 | 27 |
13 | Fever malaria unlikely and fever no malaria | 66 | 37 |
14 | Measles | 2 | 1 |
Ear conditions | 43 | 24 | |
15 | Acute ear infection | 39 | 22 |
16 | Chronic ear infection | 4 | 2 |
Throat conditions | 13 | 7 | |
17 | Throat abscess | 0 | 0 |
18 | Streptococcal sore throat | 10 | 6 |
19 | Viral Sore throat | 3 | 2 |
Nutrition conditions | 6 | 3 | |
20 | Severe malnutrition | 1 | 1 |
21 | Low weight | 3 | 2 |
22 | Severe pallor | 1 | 1 |
23 | Anemia | 1 | 1 |
Other conditions | 3 | 2 | |
24 | Other skin rashes/allergy | 2 | 1 |
25 | Other conjunctivitis | 1 | 1 |
Total | 177 | 100 | |
Average classifications per child | 2.3 | ||
Child needing referral | 3 | 2 | |
Child needing antibiotic | 104 | 58 |
SN . | Gold standard classification . | Number . | % . |
---|---|---|---|
1 | Child with danger signs | 2 | 1 |
Acute respiratory condition | 156 | 88 | |
2 | Severe pneumonia/severe illness | 3 | 2 |
3 | Pneumonia | 35 | 20 |
4 | Common cold | 118 | 67 |
Diarrheal conditions | 58 | 33 | |
5 | Diarrhea with severe dehydration | 0 | 0 |
6 | Diarrhea with moderate dehydration | 2 | 1 |
7 | Diarrhea with no dehydration | 44 | 25 |
8 | Sever persistent diarrhea | 0 | 0 |
9 | Persistent diarrhea | 3 | 2 |
10 | Dysentery | 9 | 5 |
Febrile conditions | 116 | 66 | |
11 | Severe febrile illness | 2 | 1 |
12 | Suspected malaria | 48 | 27 |
13 | Fever malaria unlikely and fever no malaria | 66 | 37 |
14 | Measles | 2 | 1 |
Ear conditions | 43 | 24 | |
15 | Acute ear infection | 39 | 22 |
16 | Chronic ear infection | 4 | 2 |
Throat conditions | 13 | 7 | |
17 | Throat abscess | 0 | 0 |
18 | Streptococcal sore throat | 10 | 6 |
19 | Viral Sore throat | 3 | 2 |
Nutrition conditions | 6 | 3 | |
20 | Severe malnutrition | 1 | 1 |
21 | Low weight | 3 | 2 |
22 | Severe pallor | 1 | 1 |
23 | Anemia | 1 | 1 |
Other conditions | 3 | 2 | |
24 | Other skin rashes/allergy | 2 | 1 |
25 | Other conjunctivitis | 1 | 1 |
Total | 177 | 100 | |
Average classifications per child | 2.3 | ||
Child needing referral | 3 | 2 | |
Child needing antibiotic | 104 | 58 |
SN . | Gold standard classification . | Number . | % . |
---|---|---|---|
1 | Child with danger signs | 2 | 1 |
Acute respiratory condition | 156 | 88 | |
2 | Severe pneumonia/severe illness | 3 | 2 |
3 | Pneumonia | 35 | 20 |
4 | Common cold | 118 | 67 |
Diarrheal conditions | 58 | 33 | |
5 | Diarrhea with severe dehydration | 0 | 0 |
6 | Diarrhea with moderate dehydration | 2 | 1 |
7 | Diarrhea with no dehydration | 44 | 25 |
8 | Sever persistent diarrhea | 0 | 0 |
9 | Persistent diarrhea | 3 | 2 |
10 | Dysentery | 9 | 5 |
Febrile conditions | 116 | 66 | |
11 | Severe febrile illness | 2 | 1 |
12 | Suspected malaria | 48 | 27 |
13 | Fever malaria unlikely and fever no malaria | 66 | 37 |
14 | Measles | 2 | 1 |
Ear conditions | 43 | 24 | |
15 | Acute ear infection | 39 | 22 |
16 | Chronic ear infection | 4 | 2 |
Throat conditions | 13 | 7 | |
17 | Throat abscess | 0 | 0 |
18 | Streptococcal sore throat | 10 | 6 |
19 | Viral Sore throat | 3 | 2 |
Nutrition conditions | 6 | 3 | |
20 | Severe malnutrition | 1 | 1 |
21 | Low weight | 3 | 2 |
22 | Severe pallor | 1 | 1 |
23 | Anemia | 1 | 1 |
Other conditions | 3 | 2 | |
24 | Other skin rashes/allergy | 2 | 1 |
25 | Other conjunctivitis | 1 | 1 |
Total | 177 | 100 | |
Average classifications per child | 2.3 | ||
Child needing referral | 3 | 2 | |
Child needing antibiotic | 104 | 58 |
Treatment of child conditions
Description of indicators . | Trained (N = 123a) . | Untrained (N = 54a) . | P-value . |
---|---|---|---|
Assessment | |||
1. Child checked for three danger signs | 38.21 | 5.56 | <0.001 |
2. Child checked for cough, diarrhea and fever | 60.98 | 38.89 | 0.007 |
3. Child weighed and checked against growth chart | 44.72 | 11.11 | <0.001 |
4. Child vaccination status checked | 50.41 | 20.37 | <0.001 |
Classification and treatment | |||
5. Correct classification | 40.65 | 48.15 | 0.353 |
6. Child needing antibiotic is given first dose at HF N = 65 and 39, respectively | 9.2 | 10.3 | 0.56 |
7. Child needing antibiotics/antimalarial who is given them | 70.77 | 79.49 | 0.326 |
8. Overuse of antibiotic (N = 56 and 14, respectively) | 21.43 | 64.29 | 0.002 |
9. Child with diarrhea who is given ORS (N = 29 and 26, respectively) | 44.83 | 61.54 | 0.215 |
10. Child with diarrhea who is given Zinc (N = 29 and 26, respectively) | 24.14 | 30.77 | 0.581 |
11. Child needing referral who is referred to a higher level of the health system (N = 2 and 1, respectively) | 100 | 0 | 0.333 |
Counseling | |||
12. Caretaker of sick child is advised to give extra fluids and continue feeding (home care counseling) (N = 121 and 53) | 41.32 | 24.53 | 0.034 |
13. HW gives advice on caretaker's health (N = 121 and 53) | 10.17 | 5.56 | 0.395 |
Description of indicators . | Trained (N = 123a) . | Untrained (N = 54a) . | P-value . |
---|---|---|---|
Assessment | |||
1. Child checked for three danger signs | 38.21 | 5.56 | <0.001 |
2. Child checked for cough, diarrhea and fever | 60.98 | 38.89 | 0.007 |
3. Child weighed and checked against growth chart | 44.72 | 11.11 | <0.001 |
4. Child vaccination status checked | 50.41 | 20.37 | <0.001 |
Classification and treatment | |||
5. Correct classification | 40.65 | 48.15 | 0.353 |
6. Child needing antibiotic is given first dose at HF N = 65 and 39, respectively | 9.2 | 10.3 | 0.56 |
7. Child needing antibiotics/antimalarial who is given them | 70.77 | 79.49 | 0.326 |
8. Overuse of antibiotic (N = 56 and 14, respectively) | 21.43 | 64.29 | 0.002 |
9. Child with diarrhea who is given ORS (N = 29 and 26, respectively) | 44.83 | 61.54 | 0.215 |
10. Child with diarrhea who is given Zinc (N = 29 and 26, respectively) | 24.14 | 30.77 | 0.581 |
11. Child needing referral who is referred to a higher level of the health system (N = 2 and 1, respectively) | 100 | 0 | 0.333 |
Counseling | |||
12. Caretaker of sick child is advised to give extra fluids and continue feeding (home care counseling) (N = 121 and 53) | 41.32 | 24.53 | 0.034 |
13. HW gives advice on caretaker's health (N = 121 and 53) | 10.17 | 5.56 | 0.395 |
aN for children cared for by trained and untrained health workers is 123 and 54 unless otherwise stated for some indicator.
Description of indicators . | Trained (N = 123a) . | Untrained (N = 54a) . | P-value . |
---|---|---|---|
Assessment | |||
1. Child checked for three danger signs | 38.21 | 5.56 | <0.001 |
2. Child checked for cough, diarrhea and fever | 60.98 | 38.89 | 0.007 |
3. Child weighed and checked against growth chart | 44.72 | 11.11 | <0.001 |
4. Child vaccination status checked | 50.41 | 20.37 | <0.001 |
Classification and treatment | |||
5. Correct classification | 40.65 | 48.15 | 0.353 |
6. Child needing antibiotic is given first dose at HF N = 65 and 39, respectively | 9.2 | 10.3 | 0.56 |
7. Child needing antibiotics/antimalarial who is given them | 70.77 | 79.49 | 0.326 |
8. Overuse of antibiotic (N = 56 and 14, respectively) | 21.43 | 64.29 | 0.002 |
9. Child with diarrhea who is given ORS (N = 29 and 26, respectively) | 44.83 | 61.54 | 0.215 |
10. Child with diarrhea who is given Zinc (N = 29 and 26, respectively) | 24.14 | 30.77 | 0.581 |
11. Child needing referral who is referred to a higher level of the health system (N = 2 and 1, respectively) | 100 | 0 | 0.333 |
Counseling | |||
12. Caretaker of sick child is advised to give extra fluids and continue feeding (home care counseling) (N = 121 and 53) | 41.32 | 24.53 | 0.034 |
13. HW gives advice on caretaker's health (N = 121 and 53) | 10.17 | 5.56 | 0.395 |
Description of indicators . | Trained (N = 123a) . | Untrained (N = 54a) . | P-value . |
---|---|---|---|
Assessment | |||
1. Child checked for three danger signs | 38.21 | 5.56 | <0.001 |
2. Child checked for cough, diarrhea and fever | 60.98 | 38.89 | 0.007 |
3. Child weighed and checked against growth chart | 44.72 | 11.11 | <0.001 |
4. Child vaccination status checked | 50.41 | 20.37 | <0.001 |
Classification and treatment | |||
5. Correct classification | 40.65 | 48.15 | 0.353 |
6. Child needing antibiotic is given first dose at HF N = 65 and 39, respectively | 9.2 | 10.3 | 0.56 |
7. Child needing antibiotics/antimalarial who is given them | 70.77 | 79.49 | 0.326 |
8. Overuse of antibiotic (N = 56 and 14, respectively) | 21.43 | 64.29 | 0.002 |
9. Child with diarrhea who is given ORS (N = 29 and 26, respectively) | 44.83 | 61.54 | 0.215 |
10. Child with diarrhea who is given Zinc (N = 29 and 26, respectively) | 24.14 | 30.77 | 0.581 |
11. Child needing referral who is referred to a higher level of the health system (N = 2 and 1, respectively) | 100 | 0 | 0.333 |
Counseling | |||
12. Caretaker of sick child is advised to give extra fluids and continue feeding (home care counseling) (N = 121 and 53) | 41.32 | 24.53 | 0.034 |
13. HW gives advice on caretaker's health (N = 121 and 53) | 10.17 | 5.56 | 0.395 |
aN for children cared for by trained and untrained health workers is 123 and 54 unless otherwise stated for some indicator.
Overall, over half (49%; n = 27) of the 55 diarrhea cases with some or no clinical signs of dehydration and or dysentery were given Oral Rehydration Solution (ORS) and 27.3% were given Zinc. Two out of three (67%) children needing urgent referral were referred to a higher level health facility. These results were not statistically significant by training status of health workers. (Table 5)
Counseling provided on sick child to the caretaker
In 9.6% (n = 10) of the children who needed antibiotics, the health worker attempted to administer the first dose of antibiotic at the health facility. Over one-third of caretakers (36%; n = 63) were given two key home care messages ‘giving extra fluids and continuing feeding’ (Table 3); trained health workers outperformed untrained ones on this indicator (41% vs 25%, P = 0.034, Table 5). As a result of advice received from the health worker, about a third (32.1%; n = 36) of the caretakers, whose child was given an antibiotic, antimalarial or ORS were able to describe correctly how to give that to the child (Table 3). In 38% (n = 13) of the children with diarrhea the caretaker was correctly advised on how to give ORS. However, 80% of caretakers knew how to administer ORS to the child (Table 3). In 15 cases (8.5%), the caretaker received some advice on her/his own health.
Health systems
Less than half of the caretakers (44%; n = 76) were satisfied with the health services provided, while 56% (n = 97) who were not satisfied would like to see availability of medicines and equipment, increased staff number, improved behavior of health worker and reduced waiting time of patients.
On average, the health facilities had 7.4 out of 8 essential recommended oral medicines (antibiotic for pneumonia and dysentery, antimalarial, ORS, Vitamin A, mebendazole, iron and aspirin/paracetamol), which were available at the time of assessment. Basic supplies and equipment needed for IMCI implementation were available at 45% of facilities.
Discussion
This national IMCI service quality survey is the first ever effort by the MoPH and its partners to produce a much needed baseline of evidence for strategic decisions to improve performance of the program, launched more than a decade ago in Afghanistan. While this study focused on health facility dimensions of IMCI, it included health worker knowledge, perceptions on quality of care by the caretaker and key health system support elements. Further research in Afghanistan is needed to examine elements of community-based provision of IMCI as well as newborn care, quality of services, service provider training and retention of trained human resources to have more complete understanding of under-5 child care at PHC level. [10].
Our results showed that in spite of the reported 100% provincial and 95% of district coverage of IMCI, 80% of health facilities have at least one healthcare worker trained in IMCI, which allows for providing quality and standardized care to the sick children. In addition, only 71% of health workers caring for sick children on the day of assessment were trained in IMCI. This means that there is still a long way for 100% scale up of IMCI in the PHC and further innovative ways are required to increase coverage. A study in Kenya and Tanzania concluded that lower cost methods of IMCI training need to be promoted [17]. In line with these findings, a study in Afghanistan found similar performance between health workers trained in 10- and 7-day courses on IMCI, and recommended standardizing a 7-day course [15]. This course can be considered when training duration and curriculum is revisited by policy and program managers [17]. In the longer run, adoption of WHO IMCI distance learning modules may also be an option [18].
Other findings related to health system support include inadequate availability of basic equipment, supplies and essential medicines especially pre-referral injectable medicine. Essential medical equipment such as baby scales, timer to count the respiratory rate, supplies to mix ORS, equipment for anthropometric measurement and thermometers are available in less than half of health facilities. Strengthening stakeholder accountability for ensuring uninterrupted availability of the IMCI standard medical commodities, supplies and medicines by MoPH are therefore recommended under MoPH oversight.
Routine supervision, in terms of both frequency and content, appeared largely inadequate to support health workers practicing IMCI in facilities. A qualitative study in Benin identified poor coordination; lack of motivation; health workers’ resistance and less priority given to IMCI supervision as key obstacles to improved IMCI supervision [19]. To improve supervision, it recommended that the managers should monitor supervision in practice, understand the evolving influences on supervision, use resources and authority to remove obstacles and promote supervision [19]. Further, a randomized controlled trial in Benin confirmed that increased supervisory visits were associated with better care [20]. Afghanistan should strongly consider implementing the WHO recommended model for post-training follow-up visits and regular supervision for service quality assurance [21]. Our study also highlighted that assessment of sick child, as it is recommended by the IMCI guideline, is not optimal. This has usually resulted in inaccurate classification and treatment of sick child. Healthcare providers trained on IMCI are more likely than those not trained to conduct a systematic assessment of a child's condition. Inadequate supervision may have contributed to this poor performance. Our results clearly depict the added value of IMCI, however with shortcomings in compliance to the guidelines. A randomized control trial of IMCI in Benin demonstrated that training is useful but insufficient to achieve high quality pneumonia case management and hence recommends supplementing that by quality supervision [20]. It is therefore recommended to continue provider capacity building through initial and refresher trainings on IMCI with focus on hard to reach geographic areas. Refresher training needs to focus on priority areas that were revealed to be performing sub-optimally. All these trainings need to be supplemented with effective supportive supervision.
There were few reported cases of children in the survey with severe malnutrition and low weight-for-age (n = 3; 2%) or anemia (n = 2; 1.3%), while a national population-based survey reveals acute severe malnutrition 4% and anemia being 44.9% in children aged 0–59 months [22]. This could be attributed to the poor assessment practices of health workers for malnutrition and anemia; another explanation could be that only children with mild illnesses are brought to primary healthcare facilities, while severe cases are taken to either private practitioners or secondary level public health facilities. In addition, anemia diagnosis in this assessment was made based on clinical signs, while in a recent national nutrition survey (2013) diagnosis was done through hemoglobin test.
Most antibiotic prescriptions were in line with established guidelines in terms of frequency and duration of administration, but tended to overlook correct dose of treatment. Thirty percent of children were prescribed antibiotics irrationally. Importantly, the first dose of medicine was rarely (9.6%) given to the child at the health facility. These deviations might be due to efforts by health workers to avoid stock-out of medicine, which is looked for by national monitoring system. Given the leading causes of death among child U-5 in Afghanistan is pneumonia and diarrhea (41% combined), case management is an important life-saving component of IMCI and should be further strengthened.
Only 27.3% of children with diarrhea were given Zinc while updated guidelines recommend every child with diarrhea should take Zinc supplement [23]. To address the low level of use of Zinc and ORS used to treat children with diarrhea in this study and observed in national surveys, the MoPH and partners are supplying health posts with Zinc and ORS co-packs as well as training CHWs across the country, starting in 2016.
Counseling of caretakers by health workers was not optimal. Home care counseling on two key messages ‘continuing liquid and feeding to sick child’ was provided to only about one-third of caretakers. Trained health workers outperformed those not trained in providing home care counseling to sick children. In this study a substantial minority of caretakers, who were mostly female, got counseling on their own health while guidelines recommend using the opportunity to counsel mother of the sick child about her own health. This is a missed opportunity and this as a contact point could be better utilized for the improvement of mothers’ knowledge of her own healthcare practices.
IMCI implementation in the country is confined to public health facility and health post at community level. Private sector has never been targeted for expansion of the strategy. Our results showed that most cases presented to PHC facilities had mild to moderate conditions. This could be confirmed by the low percentage of malnutrition and anemia in the sampled children. A multi-country evaluation of the strategy recommends a shift in delivery from relying solely on public facilities to a wide range of channels including community-based and private sectors [13]. The WHO position statement on IMCI confirms its effectiveness for improved quality of care and coverage for reaching the MDG4 and Sustainable Development Goal 3 and hence asks states to work in partnership and align resources for IMCI [13, 24].
Limitations
The accessibility and security criterion for selection of health facilities meant the exclusion of facilities located in the insecure areas, which in some cases tended to be in more remote areas, hence our results might reflect a more positive picture. The IMCI training coverage, with its key follow-up requirements, has been incomplete in Afghanistan and the findings of this survey need to be interpreted within this context.
Conclusions
The results of this study confirm a positive effect of IMCI on improved assessment, rational use of antibiotics and counseling on home care, and it therefore supports further investment in IMCI in Afghanistan. Specifically, our findings point to the importance of improving the availability and quality of health system elements such as trained human resources and standard medical commodities, continuing provider capacity building, including shorter IMCI training course, targeted refresher trainings supplemented with robust supportive supervision for improved care for sick children and counseling for caretakers. In addition, expansion to private health sector and integration of IMCI into pre-service education to additional Medical Universities in the country could offer a sustainable long-term approach to benefit child health. Afghanistan and other states with a high burden of communicable childhood illnesses and limited resources need to adopt and streamline available resources for all three components of IMCI in order to improve health status of children and contribute to meeting national and global targets for child survival and development.
Acknowledgements
This assessment was designed and planned by the Child and Adolescent Health Department General Directorate of Preventive Medicine of the Ministry of Public Health of the Islamic Republic of Afghanistan, with technical input from the IMCI working group, the Afghanistan National Public Health Institute (ANPHI) and Kabul Medical University. We would like to acknowledge their efforts and that of all the survey team for accomplishment of the study, as well as facility managers and caretakers of children for consenting to their participation in this important study.
Funding
This work was supported by funding and technical support of World Health Organization (WHO); Agha Khan Foundation (AKF) and United Nation's Children Fund (UNICEF).