Insight into implementation of facility-based integrated management of childhood illness strategy in a rural district of Sindh, Pakistan

Figures & data

Fig. 1 Embedded design.

Table 1 Profile of the Matiari district (year 2009)

Total population	661,000
Total area	1,491 km^2
Major occupation	Agriculture
Total union councils	19
Total thesils	3
Total health facilities	44
Taluka hospitals	3
Rural Health Centers (RHCs)	5
Basic Health Units (BHUs)	20
Government dispensaries	15
Maternal and Child Health Center (MCH)	1
(Information received from EDO-H Office Matiari)

Table 2 Characteristics of study respondents

Characteristics	Stakeholders^1 (N=8)	Trained physicians (N=8)
Age
30–35	2	2
35–40	2	1
40–45	4	5
Sex
Male	7	6
Female	1	2
Years of experience
1–3	3	2
3–5	2	4
>5 years	3	2
Training in IMCI
Trained	3	8
Untrained	5	0

1 Stakeholders at provincial level included, key personnel involved in planning and policy making (decision makers), whereas at district level it included personnel involved in implementation of health care programs (implementers).

Table 3 An example of the analysis method

Analyzing units	Condensed analyzing units	Codes
If there is one designated provider in an isolated clinic, he will be able to give better attention for providing care to under-five-year-old children	Need of separate designated provider for better management	Designated providerBetter management
I am not told what I can do, how to monitor IMCI implementation; still not clear what is my job description specific to strategy …	Lack of clarity about IMCI implementation	Unclear role
For trained doctors, the system does not even have reporting forms and supplies. If you can't implement, you don't practice, you forget and you don't deliver.	Unavailability of reporting forms and supplies	Absence of supplies

Table 4 Availability of essential equipments and supplies at PHC facilities

S. no.	Items	BHUs (n=8) (%)	RHCs (n=5) (%)	Govt. dispensaries (n=3) (%)	Total (n=16) (%)
1	Weighing scale 1–5 years	100	100	100	100
2	Weighing scale for baby (>1 year)	87.5	100	100	93.8
3	Supplies to mix ORS (cups and spoons)	0	20	0	6.3
4	Source of clean water	100	100	100	100
5	Thermometer	100	100	100	100
6	Towel (tepid sponge)	0	0	0	0
7	NG tube	0	20	0	6.3
8	IV infusion set	87.5	100	33.3	81.3
9	IV cannula (22–24 G)	87.5	100	33.3	81.3
10	Intramuscular syringe (5 cc)	75	60	100	75
11	Small-sized syringe (1–2 cc)	0	40	0	12.5
12	Nebulizer mask	37.5	60	0	37.5
13	Oxygen cylinder	37.5	80	0	43.8
14	Stock cards/drug log book	75	80	100	81.3
15	Mother's counseling cards	0	0	0	0
16	IMCI chart booklet/ wall charts	50	40	33.3	43.8
17	IMCI recording forms (under 2 months)	62.5	80	0	56.3
18	IMCI recording forms (2 months to 5 years)	75	80	0	62.5
19	Referral forms/slips	75	60	33.3	62.5
20	Growth cards	62.5	100	0	62.5
	Vaccination supplies
	Items	BHUs (n=8)	RHCs (n=5)		Total (n=12)*
21	Vaccination cards	75	100		83.3
22	Vaccination register	87.5	100		91.7
23	Appropriate needles and syringes for all vaccines	87.5	100		91.7
24	Danger/safety box	87.5	100		91.7
25	Functioning fridge	87.5	100		91.7
26	Ice packs	87.5	100		91.7
27	Polio vaccines	87.5	100		91.7
28	BCG	62.5	100		75
29	Pentavalent	87.5	100		91.7
30	Measles	25	100		50

* Excluding government dispensaries which do not have mandate for vaccination supplies and one RHC which was found to be closed on the day of visit and on subsequent visit.

Table 5 Availability of IMCI drugs at PHC facilities

S. no.	Categories	BHUs (n=8) (%)	RHCs (n=5) (%)	Govt. dispensaries (n=3) (%)	Total (n=16) (%)
1	ORS packets	100	40	100	81.3
2	First-line antibiotic for pneumonia and ear infection: Cotrimoxazole	75	80	100	81.3
3	Second-line antibiotic for pneumonia and ear infection: Amoxicillin	75	60	100	75
4	First-line antibiotic for dysentery and cholera: Nalidixic acid	0	0	0	0
5	Second-line antibiotic for dysentery: Metronidazole	100	100	100	100
6	Second-line antibiotic for cholera: Chloramphenicol	12.5	0	33.3	12.5
7	First-line antibiotic for malaria: Cholorquine	100	40	100	81.3
8	Second-line antibiotic for malaria: Sulfadoxine pyimethamine	75	20	100	62.5
9	Antibiotic for eye infection: Cholramphenicol ointment	0	0	0	0
10	Antibiotic for streptococcal sore throat: Benzathine penicillin or amoxicillin	87.5	80	100	87.5
11	Antibiotic for PSBI* Ampicillin or benzyl penicillcin and gentamicin	12.5	40	0	18.8
12	Bronchodilator for wheezing: Nebulized salbutamol	12.5	0	0	6.3
13	Bronchodilator for fast breathing: Oral salbutamol	87.5	100	100	93.8
14	Paracetamol	100	80	100	93.8
15	Vitamin A	0	0	0	0
16	Multivitamin/mineral supplements	100	60	66.7	81.3
17	Iron or folate tablets (ferrous sulphate)	75	20	0	6.3
18	Iron syrup (ferrous fumarate)	0	20	0	6.3
19	Deworming drug: Pyrantel Pamote	0	0	0	0
20	Gentian violet	0	0	33.3	6.3
21	Normal saline	87.5	100	100	93.8
22	Dextrose water	75	100	100	87.5
Pre-referral drugs
23	Urgent referral: Cholramphenicol	0	0	0	0
24	Sever Malaria: Quinine	0	20	0	6.3
25	Dehydration: Ringers Lactate	87.5	100	100	93.8
26	Convulsions: Diazepam or Paraldehyde	37.5	60	66.7	50
27	Sterile water for injection	62.5	80	33.3	62.5

* possible severe bacterial infection

Table 6 Themes, categories, and codes describing the perceptions by stakeholders and physicians concerning factors influencing IMCI implementation in Matiari district, Sindh, Pakistan

Themes	Categories	Codes
Factors supporting IMCI implementation	Knowledge and perception about IMCI strategy	• Holistic approach  • Practical and useful  • Significant strategy  • Improved child health  • Best option
Factors constraining IMCI implementation	Separate under-five clinic at PHC facilities	• Facilitate implementation  • Designated provider  • Better attention  • Better management
	Lack of clear understanding of IMCI strategy	• Unclear understanding  • Program for infants only  • Lack of knowledge  • Unclear with objective
	Lack of planning for IMCI implementation	• No planning  • Emphasis on training  • Poor planning  • Non-involvement of pediatricians
	Ambiguity in roles and responsibilities toward IMCI implementation	• Uncertainty  • Communication gap  • Lacked awareness  • Unclear role  • No guidance received  • No job description  • Helplessness  • Emphasized MNCH program to assist  • Non-involvement  • How to monitor  • What to do
	IMCI – a time-consuming task	• Increase patient flow  • Problematic to practice  • More time needed  • More documentation  • Disagreement by stakeholders
	Emphasis on training vs. logistic support	• More attention on training  • Absence of supplies  • Unavailability of drugs  • Restrict practice  • No counseling cards, chart booklets and recording forms  • Issues in purchase of medicines
	Lack of monitoring and supervisory mechanism	• No supervision  • Expressed need for supervision  • Lack of district facilitators’ training  • Assessment of recording forms
	Inefficient referral system	• Weak referral system  • Lack of feedback  • Lack of transport  • Financial constraints  • Unavailable referral slips

Table 7 District planning for IMCI implementation (29)

1.Improvement in skills of health staff

• IMCI training courses  • Follow-up visits after training  • How to build district training capacity  • Improvement of health workers’ skills at referral level

2. Improvement in the health system

• Availability of the drugs needed for IMCI at facilities  • Organization of work at health facilities  • Improving referral pathways and services  • Supervision  • Linking IMCI classifications and the HIS

3. Improvement in family and community practices

4. Documentation of early implementation

5. District budget

Table

Interview guide for physicians (Abridged version)

1. What is your understanding of IMCI strategy?  • Objective of the strategy  • Significance of the strategy

2. In your experience, which factors influence application of IMCI guidelines in managing under-five cases at your work place?  • Support received  • Constraints observed

3. In your experience, what problems are faced by physicians while referring under-five cases according to IMCI guidelines?

4. How do you perceive the role and significance of monitoring and supervision for trained IMCI doctors working at PHC facilities?

5. In your opinion, how can you better implement IMCI strategy at your work place?  • Recommendations for the effective implementation of IMCI at first level care facilities

Interview guide for policy makers/planners & implementers (Abridged version)

1. What is your understanding of IMCI strategy?  • Objective of the strategy  • Significance of the strategy

2. What roles do you play in your current designation for implementation of IMCI strategy at public-sector primary health care facilities in Matiari district?

3. In your best judgment, what factors influence IMCI implementation at public-sector PHC facilities in Matiari district?  • Supports for implementation  • Constraints influencing implementation

4. In your opinion, what is the role and significance of monitoring and supervision of trained IMCI doctors working at PHC facilities in ensuring effective IMCI implementation?

5. In your view what mechanisms are in place for monitoring and supervision for trained IMCI doctors in Matiari?

6. In your view, what policy and planning initiatives have been taken in Matiari district to ensure effective IMCI implementation?

7. What policy-level initiatives would you recommend for effective implementation of IMCI strategy at public-sector PHC facilities in Matiari?

Department of Child and Adolescent Health and Development, WHO. IMCI Planning Guide. Gaining experience with the IMCI strategy in a country. Available from: http://www.who.int/maternal_child_adolescent/documents/chs_cah_99_1/en/ [cited 1 May 2013].

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