The Implementation of Integrated Management of Childhood Illness ...

The Implementation of Integrated
Management of Childhood Illness in the
Monkey Bay Health Zone in Malawi
Final Report
November, 2005
Sigurður Ragnarsson, stud. med.
University of Iceland Faculty of Medicine
Supervisor: Geir Gunnlaugsson, Dr. Med. Sc., MPH
A collaboration of the Icelandic International Development
Agency and the University of Iceland Faculty of Medicine.

Table of Contents
Abstract ....................................................................................................................................4
List of Abbreviations.............................................................................................................5
1. Introduction ....................................................................................................................6
a. Millennium Development Goals ..............................................................................6
b. Reasons for High Child Mortality in the World.....................................................8
c. Preventing Child Mortality .......................................................................................9
d. Integrated Management of Childhood Illness......................................................10
i. Rationale for an Integrated Approach ...............................................................10
i. IMCI and its Components ...................................................................................12
ii. Implementation of IMCI in Developing Countries..........................................14
iii. The IMCI Classifications......................................................................................14
iv. Evaluation of the IMCI.........................................................................................18
2. Objectives......................................................................................................................20
3. Material and Methods.................................................................................................21
a. The Setting .................................................................................................................21
i. Malawi....................................................................................................................21
ii. Mangochi District..................................................................................................23
iii. Monkey Bay health zone......................................................................................23
b. Collection of Data .....................................................................................................25
i. Location ..................................................................................................................25
ii. Time ........................................................................................................................26
iii. Interviews with Health Workers ........................................................................26
iv. Children Attending the Outpatient Department .............................................26
v. Interviews with Mothers......................................................................................27
vi. Drugs and Equipment at the Health Facility....................................................27
vii. Children admitted to MBCH...............................................................................27
c. Data Processing .........................................................................................................27
d. Ethical Permission.....................................................................................................28
4. Results............................................................................................................................29
a. Health Care Workers................................................................................................29
b. Health Facility Attendance......................................................................................29
c. Diagnoses ...................................................................................................................33
i. Malaria....................................................................................................................34
ii. Pneumonia .............................................................................................................35
iii. Other Respiratory Tract Infections.....................................................................36
iv. Diarrhoea................................................................................................................37
v. Ear Infection...........................................................................................................38
d. Drugs ..........................................................................................................................38
e. Interviews with Mothers..........................................................................................39
5. Discussion .....................................................................................................................41
a. Health Facility Attendance......................................................................................41
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. Diagnoses ...................................................................................................................43
i. Respiratory Infections ..........................................................................................43
ii. Malaria....................................................................................................................44
iii. Malaria versus Pneumonia...................................................................................44
iv. Diarrhoea................................................................................................................45
v. Ear Infection...........................................................................................................46
vi. Malnutrition and anaemia...................................................................................46
c. Health Care Workers................................................................................................47
d. Drugs ..........................................................................................................................48
e. Interviews with Mothers..........................................................................................48
Conclusion .........................................................................................................................49
Acknowledgments...............................................................................................................51
References .............................................................................................................................52
Annexes..................................................................................................................................57
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Abstract
Introduction
The under-five (U5) mortality in the world today exceeds 10 million children per year. The majority of
these deaths are the result of preventable diseases, e.g. malaria, acute respiratory infections,
diarrhoea, measles, compounded with malnutrition. Most of these deaths occur in developing
countries, in particular sub-Saharan Africa. The Integrated Management of Childhood Illness (IMCI) was
developed for settings where child mortality is high and where simple and inexpensive solutions are
needed. IMCI enables, with the help of a flow-chart, health care workers in outpatient settings to
classify the health problems in U5s and provide them with appropriate care and treatment.
Objective
Describe and analyse the outpatient settings for children in a sub-Saharan country with focus on the
implementation of IMCI.
Methods
The study was conducted in the Monkey Bay health zone in Malawi. The Icelandic International
Development Agency (ICEIDA) has been supporting the health sector in the area since the year 2000. In
the area there are five health facilities. Two of them are run by the government and offer services free
of charge while three are run by the Christian Health Association of Malawi (CHAM) and charge user
fees. Data about all children’s attendances and illness classifications during March 2005 was collected
from Outpatient Registers in each of the health facilities. Drug inventories were taken at each health
centre. Health workers who consult children were interviewed about IMCI. Guardians of 11 children
were interviewed at the Monkey Bay Community Hospital (MBCH).
Results
State run facilities were more frequented than those run by CHAM. Based on population data in the
catchment areas of each the health facilities, the population of all ages was 1.45 times more likely (RR,
95% CI: 1.43-1.47) to visit a state-run facility than a CHAM-run facility. Children were 1,22 times more
likely (RR, 95% CI 1.18-1.26) to be brought to a state run health facility than a CHAM-run one. At the
government-run facilities, about ¼ of the attendees were U5s compared to about half in the private
and user-charging health facilities. Around 4/5 of all classifications for sick children less than five
years were dealt with in the IMCI. More than half of all the attending children were classified as
having malaria while pneumonia and other respiratory tract infections were used classifications for
about 1/3 of attending children. One case of malnutrition was reported and seven cases of anaemia.
Eight out of ten health workers who consult children in the Monkey Bay area are trained in IMCI;
seven use the IMCI guidelines in practice. The drug inventories revealed that most oral IMCIrecommended
drugs were in stock while intramuscular antibiotics were not.
Discussion
The relatively higher attendance to the government-run facilities may indicate that patients prefer
facilities that do not charge for services despite occasional drug shortages. The majority of attendees
less than five years of age presented with problems that are dealt with in the IMCI flow-chart which
supports the notion that IMCI is appropriate in the setting. The high number of malaria cases may
indicate mis-classifications. The low number of anaemia and malnutrition classifications calls for
improvement in assessment of children regarding these conditions. It is important that all health
workers receive IMCI training, appropriate supervision and are given necessary equipment and
support to adequately attend sick children.
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List of Abbreviations
ARI………………………… acute respiratory infection
CHAM…………………….. Christian Health Association of Malawi
CI…………………………... confidence interval
CO…………………………. Clinical Officer
HC…………………………. health centre
HIV/AIDS………………… Human Immunodeficiency Virus/
Acquired Immunodeficiency Syndrome
ICEIDA……………………. Icelandic International Development Agency
IMCI……………………….. Integrated Management of Childhood Illness
MA…………………………. Medical Assistant
MDG……………………….. Millennium Development Goal
MBCH……………………... Monkey Bay Community Hospital
OPD………………………... Out-Patient Department
ORS………………………… Oral Rehydration Salts
RR………………………….. relative risk
SP…………………………... sulphadoxine pyrimethamine
U5………………………….. children under five years of age
UNICEF…………………… United Nations Children′s Fund
WHO………………………. World Health Organization
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1. Introduction
In the world today, there are 2.2 billion children less than 18 years of age. Every day,
29,000 children aged under five die from causes that are largely preventable (1). This
results in 10.6 million deaths in a single year, which equals the total number of
children younger than five living in France, Germany, Greece, and Italy (1). Around
99% of these deaths occur in developing countries and three quarters occur in sub-
Saharan Africa and South Asia alone (2, 3). The majority of these deaths can be
prevented by simple interventions such as breastfeeding, safe drinking water,
adequate sanitation, and immunizations (4).
a. Millennium Development Goals
At the United Nations Millennium Summit in September 2000, the General
Assembly adopted a series of eight Millennium Development Goals (Table 1-1).
These goals have a central focus on children and emphasise the realisation of
children′s rights (1). Each Millennium Development Goal (MDG) is associated with
one or more targets. The fourth MDG aims at reducing child mortality. Its target is to
reduce the under-five mortality rate, the probability of dying between birth and
exactly five years of age per 1,000 live births, by 2/3 in the years between 1990 and
2015. This is a difficult task and is, importantly, also reliant on the other goals as they
are mutually supportive (5).
Table 1-1: Millennium Development Goals (5).
Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6
Goal 7
Goal 8
Millennium Development Goals
Eradicate extreme poverty and hunger
Achieve universal primary education
Promote gender equality and empower women
Reduce child mortality
Improve maternal health
Combat HIV/AIDS, malaria and other diseases
Ensure environmental sustainability
Develop a global partnership for development
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Since 1970 there has been a considerable decrease in under-five mortality in the
world, from 17 million per year to 10.6 million this year. Between 1970 and 1990,
there was a 40% reduction in child mortality (Figure 1-1). However, between 1990
and 2000 the decrease was merely 12% (6), or a reduction from 94 to 81 per 1,000 live
births (5). Latin America and the Caribbean is on track in achieving the fourth MDG
and a significant achievement has been made in several countries in East Asia (1).
However, in 2005, 17% of developing countries and 24% of the least developed
countries have either had increased or unchanged under-five mortality since 1990.
This slowdown of child mortality reduction is occurring in countries that struggle
with one or more of the three major threats to childhood: high rates of poverty,
conflict or HIV/AIDS and thus already have a very high child mortality (1, 3). The
greatest slowdown in child mortality reduction is occurring in Africa (Figure 1-1).
Figure 1-1: Reduction in global child mortality in the period 1970-2000 (6).
At the same time Africa is experiencing slowdown in child mortality, the greatest
reduction in child mortality is occurring in industrialised nations (Figure 1-2). Thus,
the difference in mortality rates is increasing and is now 29 times higher in sub-
Saharan Africa compared to industrialised countries instead of a 20 times difference
in 1990 (2, 6). It is of great concern that the mortality reduction is slowing down and
coming to a halt in many places in Africa. Clearly a 12% per decade decrease in
mortality rate is insufficient to reduce under-five mortality by 2/3 before the year
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2015 and the fourth MDG is thus seriously off track. Presently, out of the eight
MDGs, it is regarded as the furthest from being achieved (1).
Figure 1-2: Differences in child mortality rate changes (2).
b. Reasons for High Child Mortality in the Worldd
Of the 10.6 million under-five deaths that occur every year, half occur in only six
countries and 90% occur in 42 countries (7). In these countries there are common
factors that are a huge burden and facilitate and aggrevate disease for example by
increasing susceptibility to any kind of infection: maternal and childhood
undernutrition, unsafe sex, poor water, hygiene and sanitation and indoor
smoke (8). Evidently, this leads to an increase in child mortality.
Figure 1-3 shows the major causes of under-five death in the world.
Approximately 70% of all childhood deaths are associated with one or more of the
following conditions: acute respiratory infection (ARI), diarrhoea, measles, and
malaria. Malnutrition augments the incidence and morbidity of these diseases (9). It
has recently been shown that undernutrition is an underlying cause of
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over half of all deaths associated with
diarrhoea, pneumonia, malaria, and
measles (10, 11). These diseases are
preventableto a greater or lesser extent
(1). Although HIV/AIDS has not yet
become one of the major contributors to
child mortality in the world, its
contribution is very high in sub-Saharan
Africa and is ever increasing (12).
Figure 1-3: The Major causes of under-five
deaths (2). *ARI, acute respiratory infection.
c. Preventing Child Mortality
Breastfeeding, oral rehydration therapy, insecticide-treated materials, antibiotics,
antimalarials, vaccines, complementary feeding, vitamin A are all simple
interventions that are either effective in fighting disease or increase resistance to
diseases. Jones et al. showed that two-thirds of under-five deaths could be prevented
if these and other simple interventions would be accessible to 99% of the population
in the world (4). They showed as well that around a fourth of under-five deaths
could be prevented if effective nutrition interventions were provided universally.
Furthermore, effective and integrated case-management of children could save 33%
of total deaths each year.
In the past, health interventions have mostly been of the most benefit to the welloff
(13). If interventions aimed at reducing child mortality are to be effective, health
systems in developing countries need to be capable to deliver them to the people
who need them the most. Interventions need to be effective, directly aimed at the
poor, and be sustainable (13, 14). Furthermore, the delivery strategies for the these
interventions must as well be effective, efficient, sustainable, and managed by
qualified and motivated people (14).
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d. Integrated Management of Childhood Illness
i. Rationale for an Integrated Approachh
Over the last few decades, the World Health Organisation and other parties have
run programmes in developing countries that have had as their main objective to
reduce the prevalence and severity of various childhood diseases such as diarrhoea
and acute respiratory infections (6). These single-issue or “vertical programmes”
have been run with the aim to improve the diagnosis and treatment for these
diseases in a quick and inexpensive way.
A malaria eradication programme was launched in the 1950s and abandoned in
the 1970s because of increased resistance of the parasite (15). The Expanded
Programme on Immunization (EPI) was launched in the mid 1970s with the goal to
increase immunization coverage (6). Subsequently the Programme for the Control of
Diarrhoeal Diseases was started with the aim of providing oral rehydration therapy to
children with diarrhoea, aiming to reduce mortality as a result of the disease (15).
This programme was followed by a programme aimed to improve diagnosis and
treatment of acute respiratory infections (ARI). In the early 80s UNICEF launched its
child survival programme under the acronym GOBI (Growth monitoring, Oral
rehydration therapy, Breastfeeding promotion, and Immunization) which was
intended to strengthen the collaboration of the above mentioned vertical
programmes (15).
With the implementation of the vertical programmes it became increasingly clear
that treatment with oral rehydration therapy alone, or focusing on ARI, was not
sufficient to adequately reduce deaths caused by these diseases. Appropriate
antibiotic treatments for dysentery and persistent diarrhoea would need to be
integrated into the treatment regimen (16). Furthermore, it was recognised that the
high immunization coverage attained by the vertical immunization programmes was
not sufficient in reducing deaths caused by measles. The measles immunization
reduces the risk of dying at the age of maximum exposure to measles but as time
passes by the gain in survival probability diminishes (17). Rather, a better
management of malnutrition, diarrhoea, and respiratory infections that are usually
underlying the high measles mortality was required for the reduction of the disease
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(16). The vertical programmes were furthermore shown to reduce the efficiency of
the overburdened and undermanned health systems, which called for a different
approach to child health care delivery (18).
Sick children usually present with signs of diarrhoea, ARI, malaria, measles
and/or malnutrition, and 70% of under-five deaths are related to these diseases. (16).
For example, signs and symptoms of malaria and pneumonia overlap considerably
(19). Hence, these findings indicate the need for approaches that combine treatments
for two or more diseases (16).
It is generally accepted that co-morbidity may lead to synergism, i.e. the rate of
mortality from having two diseases is greater than the mortality rates of each of the
diseases combined (7). Epidemiologic synergism has most clearly been shown in
children with both malnutrition and an infectious disease, where mortality is clearly
elevated (20). An approach that addresses the nutritional needs as well as treating
the present condition of children is clearly beneficial.
Maternal perception of an acute respiratory infection plays a decisive role in
whether the mother seeks treatment for her child (21, 22). Findings have suggested
that mothers were not always taking children to a health facility when needed. The
mother′s decision whether to seek treatment for her child influences its chances of
surviving in situations of severe disease. This suggested that increased health
education for the community was needed and launching campaigns that would
increase self-referral of children who need antibiotic therapy was crucial (21).
Finally, providing health care to children should not have the single aim of
reducing the incidence of a limited number of diseases. The child should be
approached as a whole, considering immunizations, the nutritional needs, and other
possible underlying conditions for the present illness (6).
In response to many of the above mentioned considerations, the United Nations
Children′s Fund (UNICEF) and the World Health Organisation (WHO) initiated in
1992 the Integrated Management of Childhood Illness concept (IMCI) (2). The IMCI
combines effective treatments that have the potential to reduce childhood mortality
and interventions that aim at improving healthy growth and development of
children under the age of five (6).
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i. IMCI and its Components
The IMCI expresses as simply as possible what needs to be done by a health care
worker to treat sick children in a first-level health facility with the goal of reducing
the likelihood of mortality and disability (18). IMCI is intended for first-level
facilities because children who have diseases that are potentially fatal are usually
first brought to such facilities (9). In order to ensure an effective introduction and
implementation of IMCI in every country, three components of the IMCI programme
have been defined: i) improvements in case-management skills of health workers by
providing locally adapted guidelines and promoting their use; ii) improvements in
the health system that ensure effective management of childhood illnesses; and iii)
improvements in family and community health-related behaviour (16). Each of the
components are adapted to the needs of each country (23).
The IMCI concept assumes that there is usually more than one condition causing
illness in children (2). Therefore, signs and symptoms of the most life-threatening
and common diseases are checked on each visit to the health centre. When IMCI was
developed, as few clinical signs as possible were used and a fine balance hit between
sensitivity and specificity (9). The case-management guidelines direct the health
worker through a series of steps that enable him or her to classify the disease, to give
a treatment, to counsel the guardian, and to make other provisions in controlling the
present illness and preventing future illnesses (Table 1-2).
Table 1-2: IMCI Case Management Steps (9).
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
IMCI Case Management Steps
Assess the child by identifying any danger signs, asking for cough or
difficult breathing, diarrhoea, fever, and ear problem. Carry out further
assessments when relevant. Review the nutritional and immunization
status in all children.
Classify the child′s illnesses using the IMCI flow-chart. Classify illness
into one of the following: needs urgent referral, needs specific medical
treatment and advice, or needs simple advice on home management.
Identify specific treatments. Usually the children have more than one
disease, which calls for an integrated treatment plan.
Give practical treatment instructions (teach the guardian to administer
drugs, increase fluid intake, etc.). Teach the guardian about symptoms
and signs that indicate that the child should be brought back and when
tell the guardian when to return for follow-up.
Assess the feeding and counsel the mother on feeding problems.
When the child returns for follow-up, give instructions for various
medical conditions.
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The case-management guidelines are set up in a flow chart that guides the health
worker to ask simple questions on the child′s disease in a step-by-step process. An
example of the flow-chart is given in Figure 1-4. In the first IMCI case management
step, the guidelines stress the importance of identifying danger signs in children so
that those who require immediate referral are sent without delay (16). Subsequently,
the child is assessed and classified according to presenting symptoms. After
systematic classification the health worker arrives at one or more disease
classifications and one of the following actions are taken: the child is referred or
admitted to a hospital, treatment is initiated at the outpatient department, or the
child is sent home with an advice when to return for follow-up. In addition, the
nutritional status is assessed, the immunization status is checked and due
immunizations are given (16). Counselling plays an important role in IMCI. The
guardian is counselled about breast-feeding and complementary feeding, care for
sick children at home, and when the child is to be brought for follow-up. At last, the
guardian′s understanding of the advice is checked.
Figure 1-4: IMCI case management guidelines: Assess, classify, and identify treatment. General
danger signs and cough or difficulty breathing (24).
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ii. Implementation of IMCI in Developing Countries
The IMCI is applicable in every developing country that has an under-five
mortality rate of >40 per 1000 live births and where there is transmission of
Plasmodium falciparum malaria (9). The IMCI guidelines are adapted to each country,
taking into account local epidemiology of diseases, drug resistance, and available
essential drugs (16). In 1995, a small number of countries showed interest in
implementing the approach. However, in the first few years more than 60 countries
started implementing IMCI (16) and currently, more than 100 countries are
practicing IMCI on a small or large basis (6).
iii. The IMCI Classifications
1. Acute Respiratory Infections
Acute Respiratory Infections (ARI) are the major cause of death in children under
five and accounts for more than 2 million deaths per year (6). Pneumonia is the most
serious of the ARI but can be treated at health centres with relatively inexpensive
antibiotics (2). However, the major drawback is that children are not always brought
to health centres. In many countries, only half of children with ARI are taken to a
health care provider. Besides directing a health worker to treat ARI, the IMCI also
teaches guardians the signs of ARI and what signs in a child indicate that it should
be taken to a health care provider (2). As shown in Figure 1-4, the IMCI classifies an
illness to be pneumonia in the presence of coughing or difficulty in breathing as well
as rapid breathing. Rapid breathing is defined as respiratory rate above 60 per
minute for children less than two months, above 50 per minute for children aged 2-
11 months, and above 40 per minute for children aged one to four years (24). Hence,
the IMCI relies on a few clinical criteria for the detection of pneumonia and does not
rely on the use of stethoscopes.
2. Malariaa
The Plasmodium species causes 300-500 million cases of malaria per year (2). It is
the most important parasitic infection in humans and accounts for more than a
million deaths every year (25), 94% of which occur in Africa (26). In Africa alone,
malaria is the second leading cause of deaths in children under five years of age (26).
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The childhood deaths resulting from malaria declined from the 1960s until 1990.
Since 1990, childhood deaths caused by malaria have been increasing at the same
time as drug resistance has become widespread (27). Presently, reducing the
incidence of malaria is a major priority for the international community. According
to the IMCI guidelines, in places where malaria is endemic but parasitological
diagnosis is unavailable, children who present with fever should be given
antimalarials even though other diagnoses such as pneumonia are regarded more
likely (25). The malaria classification in the IMCI flow-chart is shown in Figure 1-5.
Figure 1-5: IMCI case management guidelines for fever: Assess, classify, identify treatment (24).
3. Measless
Measles is an important cause of child mortality and various disabilities, such as
blindness, severe malnutrition, chronic lung disease, and neurological dysfunction
(2). The immunosuppression and vitamin A deficiency that occurs as a result of
measles leads to a much greater susceptibility to the other conditions that are dealt
with in IMCI. The IMCI emphasises detection of measles and instructs the health
worker to give vitamin A. The measles classification in the IMCI guidelines is shown
in Figure 1-5.
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4. Diarrhoea
Deaths due to diarrhoea have decreased greatly in the past few decades, while at
the same time oral rehydration therapy has been introduced and its use become
widespread (28, 29). However, diarrhoea still is the second leading cause for underfive
deaths in the world, causing more than 2 million under-five deaths a year (2, 6).
A further reduction may be achieved by ensuring that people have access to clean
water, sanitation, better home management of a sick child, and increased awareness
of the importance to seek health care when a child suffers from diarrhoea (2).
In case of acute diarrhoea, the IMCI guidelines assist the health worker to grade
the severity of dehydration correctly and consequently adequately rehydrate the
child (Figure 1-6) (24). Further, it helps the health worker to identify cases of
persistent diarrhoea. The mainstay of diarrhoea treatment consists of oral
rehydration therapy but antibiotics as well when appropriate.
Figure 1-6: IMCI case management guidelines for diarrhoea: Assess, classify, and identify
treatment (24).
5. Ear Infectionn
If an ear infection is not treated properly it can lead to mastoiditis and/or
deafness. Acute otitis media, chronic suppurative otitis media, impacted wax and
foreign bodies are the most common causes of deafness in Africa (30). Thus, even
16

though ear infection is not one of the major contributors of child mortality, it is
important to prevent the complications that result thereof.
In the IMCI, the “ear infection” classification includes mastoiditis, and acute and
chronic otitis media (Figure 1-7) (24). The classification is based on easily detected
signs such as ear pain, ear discharge, and tender swelling behind the ear (24). The
classification does not require the use of otoscopes (31).
Figure 1-7: IMCI case management guidelines: Assess, classify, and identify treatment. Ear
problem (24).
6. Malnutrition and Anaemiaa
In Africa alone, 32 million children are malnourished (2). Children may be
undernourished because of lack of access to food, poor feeding practices and/or
infection (28). In 2004, Caulfield et al. found that 60% of deaths caused by diarrhoea,
52% of deaths due to pneumonia, 45% of deaths due to measles, and 57% of deaths
due to malaria are a result of undernutrition (10). Therefore, an important part of
IMCI is to assist the health care worker in classifying malnutrition, give correct
treatments, and counsel the mother about feeding practices.
Anaemia is a common problem in Africa. It is very often associated with
micronutrient deficiencies such as vitamin A deficiency and iron deficiency (32).
Worm infestations caused by the hookworm and Trichuris contribute to anaemia and
iron deficiency (33). Furthermore, a major contributor to anaemia in African children
is malaria (34). For instance, a study in Kenya showed that 2/3 of anaemic children
had a P. falciparum infection (18).
Therefore, the IMCI guidelines recommend treating anaemia and malnutrition by
giving iron and vitamin A, a benzimidazole and an antimalarial (24), thus
17

treating/preventing the major conrtibuting factors to malnutrition and anaemia
(Figure 1-8).
Figure 1-8: IMCI case management guidelines: Assess, classify, and identify treatment.
Malnutrition and anaemia (24).
iv. Evaluation of the IMCII
The dvelopment of the IMCI guidelines was mostly based on practices that have
been scientifically proven to be effective. When scientific studies were not available,
expert opinion was sought from specialists in the appropriate field (9). A study
conducted in Kenya in 1997, compared the performance of a minimally trained
health worker using IMCI with a paediatric specialist (18). The study provided a
technical validation of the IMCI. It was concluded that the algorithm was sensitivite
enough for different diseases with the exception of diarrhoea and referral for
hospital admission (18). The researchers proposed that a training course would be
necessary in order to ensure the efficacy of the programme. Thus, training courses in
IMCI are held across the world in countries that implement IMCI.
The IMCI cannot be successful unless health workers in developing countries
embract the idea and apply it. The fear that health workers are not using the IMCI
18

guidelines after training seems unnecessary as health workers have changed their
practices through training in IMCI (16). Further, health workers that attend to
children have welcomed a systematisation in assessing and treating sick children
(16).
While the IMCI guidelines were largely based on research and studies have
provided a technical validation of the algorithm, the effectiveness, impact and
relative cost of IMCI must likewise be assesed. Presently, a Multi-Country
Evaluation of IMCI is being conducted in five countries in three different regions of
the world: Bangladesh, Brazil, Peru, Tanzania, and Uganda (23). Its purpose is to
examine the effectiveness, cost, and impact of IMCI in these five countries.
Schellenberg et al. reported, in 2004, the first results that confirm a child mortality
reduction as a result of the implementation of IMCI (35). Their study, which is a part
of the Multi-Country Evaluation of IMCI, showed a 13% lower child mortality in two
districts implementing IMCI than in two districts that did not implement IMCI.
Another study has shown that IMCI was not more expensive than the standard
health care provided in control districts (36).
The IMCI programme will not be successful unless the quality of services is
assured. Gouws et al. recently suggested a new set of indices to measure the quality
of child health-care at first-level facilities (37). These four indices have the highest
validity and reliability of hitherto proposed indices and include: A. integrated child
assessment; B. availability of vaccines; C. availability of oral and injectable drugs; D.
primary health care worker′s knowledge of correct case management for severe
illness and young infants. The first and last indices can be improved by
implementation of IMCI and the other two are essential for proper functioning of the
IMCI algorithm (37).
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2. Objectives
Describe and analyse the outpatient settings for children in a sub-Saharan
country with a focus on the implementation of Integrated Management of
Childhood Illness. In particular:
• Describe and analyse the patient flow through primary health care
facilities.
• Identify and analyse the causes for children′s attendances to the
primary health care facilities.
• Assess what impact user fees have on health care seeking.
• Outline and discuss health workers’ experience of the implementation
of IMCI.
• Evaluate the access to IMCI-recommended drugs at the primary health
care level.
• Describe the satisfaction of caretakers of sick children who seek care at
the primary health care level
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3. Material and Methods
a. The Setting
i. Malawi
The Republic of Malawi is located in
southern Africa, east of Zambia (see Figure
3-1). The country is land locked but is
situated along Lake Malawi, which is an
important source of food as well as being the
country′s most striking physical feature.
Furthermore, the lake holds 24,400 sq km of
the total 118,480 sq km surface area (39).
Malawi is divided into three regions: the
Northern, Central, and Southern regions.
There are 27 districts in the country: six
districts are in the Northern, nine in the
Central, and 12 in the Southern Region (40).
The major problems that the country is facing
are poverty, difficult political and economic
situation, population growth, increasing
pressure on agricultural lands, malaria and
HIV/AIDS (39). The United Nations
Development Programme ranks Malawi no.
Figure 3-1: Map of Malawi (38)
165 of 177 on the Human Development Index
scale (41).
Despite high mortality rates due to HIV/AIDS and the lower life expectancy and
higher infant mortality that result thereof, estimates hold that the population is
increasing (Table 3-1) (39). The population structure is characteristic for developing
21

countries in Africa, i.e. around half of the population is children and a small
proportion is elderly people. The fertility rate is high and one out of five children
dies before the age of five (42).
Table 3-1: Malawi demographic figures (39, 42, 43).
Population
Age structure
Life expectancy
Child mortality
Fertility rate
1998 census 9.9 million
Current estimate
12 million
Population growth rate 2.06%
Children (0-14 years) 46.9 %
Adults (15-64 years) 50.4 %
Elderly (over 65 years) 2.8 %
37 years
Infant mortality
103 per 1,000 live births
Under five mortality 190 per 1,000 live births
6.0 births per woman
HIV prevalence 14.2 %
Malawians have access to a state-run health care system. Every Malawian should,
therefore, have the chance of free health care and basic health services. This is a
difficult task to execute in a country where the funds and human resources in the
health sector are limited. In addition to the government-run health facilities, there
are numerous private clinics and hospitals in Malawi. These are either supported by
the government or entirely run by private funds. In general, these private facilities
charge for health services (44).
The primary level of health care is provided by health centres and rural hospitals
which do not have medical doctors but have staff with clinical training (e.g. Medical
Assistants and Clinical Officers) and nurse technicians (45). Medical assistants (MAs)
have two years of training in diagnosis and treatment. A secondary school degree is
a prerequisite for their education. Most MAs work on primary level of health care or
at district level. Clinical Officers (COs) are trained for four years in diagnosis and
treatment. Their training is more intense than that of MAs and involves training in
Ceasarean sections. Nurse technicians have two years of higher-level education but
do not graduate with a degree. By completing one more year of education, the nurse
technicians are upgraded to nurse/midwife-technicians (45).
In all 27 districts there are district hospitals. The district hospitals have more
sophisticated diagnostic equipment. They also have a medical doctor and can
22

perform surgical procedures. Illnesses that cannot be treated at the district level are
referred to one of the three central hospitals, which have the best trained health
workers (medical doctors, nurses with university degrees, etc.) and the most
advanced diagnostic equipment (44).
In Malawi, IMCI is implemented on a national level. It was introduced in 1998
and a second edition of the guidelines was released in 1999 (46).
ii.
Mangochi District
Mangochi District is located in the
southern part of Malawi. Based on the
1998 census, it is estimated that the
population of Mangochi district is now
around 730,000 (47).
The Government of Malawi runs 23
health facilities and two hospitals in the
Figure 3-2 Mangochi District Hospital
district, Mangochi District Hospital and
Monkey Bay Community Hospital (48).
Mangochi District Hospital (Figure 3-2) is the principal referral hospital for all health
facilities in Mangochi District. It is a 279 bed hospital that has the capacity to
perform surgical procedures and employs clinicians, nurses, and one medical doctor
(49). Around 400 patients attend the outpatient department every day (personal
communication, Lovísa Leifsdóttir, technical advisor at MBCH).
In Mangochi, 109/179 health care workers are trained in IMCI, or 64% (personal
communication, Joyce Chausa, IMCI coordinator in Mangochi District). The
implementation of IMCI in Mangochi has fared well. The major problems and
obstacles are high turn over of staff, poor communication among health facilities,
and lack of equipment and drugs (personal communication, Joyce Chausa).
iii. Monkey Bay health zonee
Monkey Bay is a town in northern Mangochi district, which is situated on a
peninsula that cuts through the southernmost part of Lake Malawi (see Figure 2-1).
The Monkey Bay health zone is an area around Monkey Bay with a population of
23

around 110,000 that has five health facilities. These are either run by the government
of Malawi or by the Christian Health Association of Malawi (CHAM) (Table 3-2).
The government-run facilities are entirely non-paying while the CHAM facilities
charge for drugs and treatment.
Table 3-2: Health facilities in the Monkey Bay health zone (45)
Health facility Type of facility Run by Population of encatchment area
Monkey Bay Community hospital 41 241
Government
Nankumba Health centre
17 600
Malembo Health centre 17 825
Nankhwali Health centre CHAM
8 382
Nkopé Health centre
40 918
Total: 125 966
The Icelandic International Development Agency (ICEIDA) has, since the year 2000,
supported the health sector in the Monkey Bay health zone in various ways (50). The
building of a new hospital, the Monkey Bay Community Hospital, was funded by
ICEIDA as well as the installation of equipment into the hospital. Further, with the
support of ICEIDA, transport between the health facilities in the zone has been
improved by the purchase of motorbikes and an ambulance, telecommunication
equipment has been installed in the five health facilities, and staff members in the
five health facilities have been funded to attend various training courses, etc.
1. Health Centres in the Monkey Bay health zone
Four of the five health facilities in the Monkey Bay health zone function as
primary health centres. They are all equipped with an outpatient department, a
maternity ward, and an inpatient ward. These health centres are manned with
nurse/midwife technicians and medical assistants.
2. Monkey Bay Community Hospital
The Monkey Bay Community Hospital (MBCH), Figure 3-3, runs a level of
management above the health centres in the area but below the district hospital.
According to Malawian authorities, MBCH is the first of few planned community
hospitals in Malawi (51). The intention is that the hospital will serve as a first line of
referral for health centres in the Monkey Bay health zone and thus reduce the
24

workload at the Mangochi District
hospital. However, patients that
cannot be treated at MBCH must be
referred to Mangochi District
Hospital.
In contrast to the four health
centres in the area, MBCH is manned
Figure 3-3. Monkey Bay Community Hospital
with two clinical officers and more
nurses. It is more spacious than the
health centres and has better maintained physical structures. MBCH has a provisory
laboratory with a laboratory technician where simple laboratory investigations can
be made, e.g. Plasmodium parasite count, blood haemoglobin, microscopy of faeces,
etc. The ambulance service is administered from MBCH and it is the centre for
telecommunication in the area. Work is under way to construct a surgical ward at
the hospital.
The establishment of a community hospital in Monkey Bay has been challenging
in several ways (50). For instance, it has been difficult to adequately staff the hospital
according to national guidelines and the referral of patients from the four other
health centres in the area has not met expectations. The staff at MBCH currently
consists of two clinical officers, one medical assistant, three nurse technicians,
several nurse-midwife technicians, a lab technician, one environmental health
officer, cleaners and ward attendants. The hospital runs an outpatient department
(OPD), a maternity ward, a male ward, a female ward, a children′s ward, and a
nursery ward.
b. Collection of Data
i. Location
The data was collected from all five health facilities in the Monkey Bay health
zone, which are MBCH, Nankumba, Nkopé, Nankhwali and Malembo. The main
emphasis was, however, on collection of data at MBCH.
25

ii. Time
The research was conducted from March 16, 2005 to April 20, 2005. However,
depending on the type of data being collected, the time period varied among the
data sets described below.
iii. Interviews with Health Workers
In order to have the health workers′ perspective on IMCI, interviews were carried
out with all accessible health workers who consult children. A total of 14 health
workers were interviewed (Annex 1). Preliminary data from these interviews is
presented in this report.
iv. Children Attending the Outpatient Department
The Malawian health authorities supply each health facility in the country with
Outpatient Register books. Clinicians who consult patients in health centres or in the
outpatient departments of hospitals record the following information about each
patient in these books: monthly serial number, registration number, name, address,
age, sex, diagnosis, disease code, and a brief description of the treatment.
Data was collected on a specially designed form from each of the five health
facilities′ Outpatient Registers (Annex 2). Information was gathered about all
children attending the health facilities throughout March 2005. In the health
facilities, information was only available for days when the OPD was open. Opening
days varied among the health facilities (see Table 3-3). Patients attending outside
office hours were not recorded. Consequently, the number of days with data is
different. Since the IMCI does not guide health workers to reach diagnoses but
rather classifications, a child′s illness, as defined by a health worker, was regarded as
an IMCI classification.
Table 3-3: Children in OPD. (g) Government run, (c) CHAM-run.
Health Facility Time period Number of Days
MBCH (g) 1.3.2005 – 31.3.2005 21
Nankumba (g) 1.3.2005 – 31.3.2005 20
Malembo (c) 1.3.2005 – 31.3.2005 24
Nankhwali (c) 1.3.2005 – 31.3.2005 19
Nkopé (c) 1.3.2005 – 31.3.2005 23
26

The respiratory tract infections in the Outpatient Registers, other than
pneumonia, were grouped as an ORI classification (other respiratory infections). The
registers had diagnoses/classifications such as URTI (upper respiratory tract
infection), bronchitis, LRTI (lower respiratory tract infection other than pneumonia),
and ARI even though all are acute respiratory infections.
v. Interviews with Mothers
Interviews were taken with 11 mothers of children that attended the OPD. The
interviews were guided by a standard questionnaire used for IMCI-supervision and
follow-up assessment (Annex 3). The interviews were assisted with an interpreter.
Preliminary data from these interviews is presented in the present report.
vi. Drugs and Equipment at the Health Facility
During the study period, drug, vaccine, and equipment inventories were carried
out on a weekly basis at MBCH. The same inventories were also carried out once at
each of the health facilities when they were visited. The specially designed
inventories emphasised the availability of IMCI-recommended drugs and equipment
as well as vaccines (Annex 4). Extracted data on the availability of IMCIrecommended
drugs is presented in this report.
vii. Children admitted to MBCH
From March 16 to April 15, children′s admissions to the children´s ward in
MBCH were followed and examined. Data was collected from available records of
all children who stayed at MBCH. Data on the reason for admission, the kind and
quality of treatment, diagnosis, and outcome was recorded (Annex 5). This data is
not presented in the current report and awaits further analysis.
c. Data Processingg
The forms used in the research were generated in FileMaker Pro 5.5v2 for
Windows. The collected data was transformed to electronic form with the same
programme. The database was processed and statististical tests done in SPSS 13.0 for
Windows and JMP 3.2 for Mac OS. Student t-tests results were considered to show a
statistically significant difference when p

a 95% confidence interval. Official data on the population of the area was used for
health centre attendance calculations. Both SPSS and Microsoft® Excel 2000 were
used for the generation of charts and graphs.
d. Ethical Permissionn
The research was conducted under a contract between the University of Iceland
Medical Faculty and the Icelandic International Development Agency. It was
approved by the University of Iceland Research Committee and the Icelandic
International Development Agency.
Local permission was granted and the study was approved by the National
Health Sciences Research Committee and the Ministry of Health and Population in
Malawi.
28

4. Results
a. Health Care Workers
Interviews with health care workers revealed that children are attended by 10
health workers (15 if students during the research period are included) in the health
facilities (Table 4-1). Eight health workers are IMCI-trained (80% of employed
workers) but seven apply IMCI in their work. The health workers are generally very
satisfied with the IMCI guidelines. The most commonly observed complaint is that
applying IMCI is a time consuming process.
Table 4-1: Number of health workers who attended children in the five health centres by the type
of health worker and training in IMCI. (g) Government run, (c) CHAM-run.
Facility
Health workers Type of health worker Trained
attending children MA CO Midwife in IMCI
MBCH (g) 7 1 (6)* 1 0 2
Nankumba (g) 3 1 0 2 2
Malembo (c) 2 1 0 1 2
Nankhwali (c) 1 1 0 0 0
Nkope (c) 2 2 0 0 2
Total 15 6 (11)* 1 3 8
*In Monkey Bay there were 5 medical assistant students, who were not trained in IMCI
In addition, the interviews showed that out of the eight IMCI-trained health care
workers, four were supervised during the six months and two during the year
preceding the interviews, and that two were supervised more than three years
preceding the interviews. None other than IMCI-trained personnel at the five health
facilities have been supervised.
b. Health Facility Attendancee
The total number of attendees in each of the five health facilities in the Monkey
Bay health zone during the research period is shown in Table 4-2. The Outpatient
Department (OPD) at MBCH had the most numerous visits during the research
period, which accounted for almost half of the grand total of health facility
attendees.
29

Table 4-2. Total attendance to the five health facilities in the Monkey Bay health zone. (g)
Government run, (c) CHAM-run.
Health facility Males Females Total
MBCH (g) 1572 2286 3858 (43,8%)
Nankumba (g) 1046 1586 2632 (29,9%)
Malembo (c) 274 468 742 (8,4%)
Nankhwali (c) 192 210 402 (4,6%)
Nkope (c) 511 663 1174 (13,3%)
Grand total 3595 5213 8808 (100,0%)
Revisits during a disease episode were generally registered separately.
However, in Nankumba the Outpatient Register did not make any distinction as to
whether visits were primary or secondary. Nankhwali had the highest proportion of
revisits (Table 4-3).
Table 4-3: Revisits, total first-visit attendees, and total of all OPD visists to the five health facilities
in the Monkey Bay health zone. (g) Government run, (c) CHAM-run.
Health facility Revisits Total attendees
Total
(including revisits)
% revisits
MBCH (g) 424 3858 4282 10%
Nankumba (g) . 2632 . .
Malembo (c) 2 742 744 0.3%
Nankhwali (c) 84 402 486 17%
Nkope (c) 76 1174 1250 6%
Grand Total 586 8808 9394 6%
Monkey Bay Community Hospital, which was the most frequented health
facility, received on average 175 (median 180, range 53-261) attendees per day.
Nankhwali, the least frequented facility, received on average 21.2 (median 19, range
8-35) attendees. The government-run health facilities had on average 154 (median
150, range 53-261) visits while the CHAM health facilities had 35.1 (median 30.5,
range 8-81) attendees on average. Based on population data for each catchment area,
people living in a catchment area where there was a government run facility were
1.45 times more likely (RR, 95% CI 1.43-1.47) to visit their health centre than people
living in catchment areas where there was a CHAM run facility. Comparing the two
government-run facilities, the population in the MBCH catchment area was 1.26
more likely (RR, 95% CI 1.23-1.29) to attend the hospital than the Nankumba
catchment area population attending the Nankumba health centre.
30

In all health facilities there were more females than males. This was true for
both adults and children except in Nankhwali where there were more boys than
girls (Figure 4-1). Among adults, female attendance was significantly higher (p

A closer look at the children reveals that, in the government-run health facilities,
the proportion of 5-14 year-olds was greater than in the CHAM facilities (Figure 4-2).
The proportion of children aged 2-11 months was smaller in the same facilities.
100%
90%
80%
584
328
95
47
145
70%
60%
50%
40%
604
505
230
111
306
5-14 years
1-4 years
30%
20%
10%
0%
339
42
268
18
123
18
70
15
193
24
2-11 months

c. Diagnoses
Children could be classified with one
or two illnesses at the same time.
Therefore, the number of classifications is
higher than the number of children. The
diagnostic profile of children in the
Monkey Bay health zone during the
research period showed that malaria was
the most common problem and
respiratory infections the second most
common problem in under-fives (Figure
4-3).
Figure 4-4 shows that malaria and
respiratory infections were by far the
Ear
1%
Diarrhoea
4%
Other respiratory
tract infections
26%
Pneumonia
6%
most common diagnoses in all the health facilities. The proportions of patients
classified with other diseases that are dealt with in the IMCI, i.e. diarrhoea and ear
infection were below 10% in all cases. One case of malnutrition was recorded in a
child (1-4 years) in Nankumba during the research period and seven children aged
1-4 years and 6 children aged 5-14 years old were classified to have anaemia.
Eye
2%
Trauma
2%
Skin
7%
Other
classifications
9%
Malaria
43%
Figure 4-3: Disease classifications in U5s. Each
disease-classification as a proportion of the total
number of given classifications. Note: each child
may have up two classifications.
Percentage of children under 5
90%
80%
70%
60%
50%
40%
30%
20%
Malaria
Pneumonia
Other respiratory infections
Diarrhoea
Ear
Eye
Skin
Trauma
Other
10%
0%
MBCH (g) Nankumba (g) Malembo (c) Nankhwali (c) Nkope (c)
Figure 4-4: Percentage of under-fives classified with disease. (g) Government-run, (c) CHAM-run.
33

i. Malaria
More than half of under-fives were classified with malaria though the malaria
classification did not amount to more than 44% of all classifications (Figure 4-3). In
all health facilities, malaria was the most common classification (Figure 4-4). In
Nankhwali, over 80% of U5s (children under age of five years) were given a malaria
classification while MBCH around 40% of the under-fives were given such a
classification. The majority of malaria diagnoses fell within the 1-4 years-age group
(Table 4-5). In the less than 2 months age group there were few registered malaria
cases. However in Nankhwali 13/15 in this age group were diagnosed with malaria.
Table 4-5. Number of malaria cases and proportion of total children in each age group classified
with malaria by facility. (g) Government run, (c) CHAM-run.
HC
Total

Pro
ii.
Pneumonia
In total, about 7% of the children were classified with pneumonia and the highest
number was classified in the 1-4 years age group (Table 4-6). However, the 2-11
month group received proportionately most of the pneumonia classifications, as
attendees aged aged 2-11 months were roughly half as many as attendees aged 1-4
months (Table 4-4). In Nankhwali, almost 2/5 of all pneumonia classifications fell
within the 2-11 month age group.
The proportion of children who were classified with pneumonia varied from 1%
in Nkope to 22% in Nankhwali. In Nankhwali, where pneumonia classifications
were more common than other respiratory infections (Figure 4-4), 10 out of the 15
children less than two months were given a pneumonia classification.
Table 4-6: Number of pneumonia cases and proportion of total children in each age group
classified with pneumonia by facility. (g) Government run, (c) CHAM-run.
HC
Total < 2 months 2-11 months 1-4 years 5-14 years 0-14 years
children n (%) n (%) n (%) n (%) n (%)
MBCH (g) 1569 5 (0,3) 49 (3) 65 (4) 48 (3) 167 (11)
Nankumba (g) 1119 0 (0) 11 (1) 13 (1) 6 (1) 30 (3)
Malembo (c) 466 0 (0) 13 (3) 12 (3) 3 (1) 28 (6)
Nankhwali (c ) 243 10 (4) 20 (8) 12 (5) 11 (5) 53 (22)
Nkope (c) 668 2 (0,3) 3 (0,4) 3 (0,4) 1 (0,1) 9 (1)
Grand Total 4065 17 (0,4) 96 (2) 105 (3) 69 (2) 287 (7)
Figure 4-6 does not show
any trend in proportion of
Government
|
CHAM
tion of U5s with pneumonia p ay
por er d
children classified with
pneumonia in the govern-
0,600
ment-run facilities versus the
CHAM facilities. Comparing
0,400
the means of the CHAM
versus the government-run
facilities did not reveal a
significant difference.
0,200
Pneumonia was commonly
classified with malaria.
0,000
MBCH Nankumba Malembo Nankhwali Nkope
Health facility
Figure 4-6: Proportion of children under five (U5s) classified
with pneumonia per day
35

iii. Other Respiratory Tract Infections
The second most common classification was other respiratory infections (ORI),
almost exclusively upper respiratory tract infections or about one fourth of the
children (Figure 4-3). ORI includes classifications such as upper respiratory tract
infections (URTI), bronchitis, and acute respiratory infections or ARI (even though
the preceding classifications could all be grouped under ARI). ORI was classified in
almost 1/3 of all children (Table 4-7) but in 33% of U5s. The number of children with
an ORI classification in each age group shows a similar distribution as the total
number of children in each age group.
Table 4-7: Number of ORI cases and proportion of total children in each age group classified with
ORI by facility. (g) Government run, (c) CHAM-run.
HC
Total < 2 months 2-11 months 1-4 years 5-14 years 0-14 years
children n (%) n (%) n (%) n (%) n (%)
MBCH (g) 1569 11 (0,7) 109 (7) 165 (11) 120 (8) 405 (26)
Nankumba (g) 1119 12 (1) 152 (14) 217 (19) 90 (8) 471 (42)
Malembo (c) 466 9 (2) 30 (6) 40 (9) 17 (4) 96 (21)
Nankhwali (c ) 243 2 (1) 14 (6) 24 (10) 14 (6) 54 (22)
Nkope (c) 668 14 (2) 59 (9) 76 (11) 35 (5) 84 (13)
Grand Total 4065 48 (1) 364 (9) 522 (13) 276 (7) 1210 (30)
A box plot (Figure 4-7)
shows the health facilities′
distribution of the proportion
of U5s classified with ORI per
day. The government-run
facilities (that is MBCH and
Nankumba) had a significantly
higher proportion
(p

iv. Diarrhoea
As shown in Figure 4-3 (page 33), the diarrhoea classification accounted for 5% of
all the classifications. Only three cases of diarrhoea were reported in children less
than two months (Table 4-8). Although the total number of diarrhoea cases in the
age groups 2-11 months and 1-4 years was similar (around 80 cases), the proportion
of children in the former group classified with diarrhoea was 18% while 4.6% of
children in the latter group were classified with diarrhoea.
Table 4-8: Number of diarrhoea classifications and proportion of total children in each age group
classified with diarrhoea by facility. (g) Government run, (c) CHAM-run.
HC
Total < 2 months 2-11 months 1-4 years 5-14 years 0-14 years
children n (%) n (%) n (%) n (%) n (%)
MBCH (g) 1569 2 (0) 24 (2) 20 (1) 11 (1) 57 (4)
Nankumba (g) 1119 1 (0,1) 19 (2) 32 (3) 7 (1) 59 (5)
Malembo (c) 466 0 (0) 8 (2) 9 (2) 0 (0) 17 (4)
Nankhwali (c ) 243 0 (0) 2 (1) 7 (3) 2 (1) 11 (5)
Nkope (c) 668 0 (0) 32 (5) 13 (2) 2 (0,3) 47 (7)
Grand Total 4065 3 (0,1) 85 (2) 81 (2) 22 (1) 191 (5)
Figure 4-8 shows the
health facilities′ distribution
of the proportion of U5s
classified with diarrhoea per
0,500
Government
|
| CHAM
day. A significant difference
0,400
was not detected between the
means of the proportion of
under-fives with diarrhoea in
the government-run facilities
and the CHAM-run facilities.
0,300
0,200
0,100
Proportion of U5s with diarrhoea per day
0,000
MBCH Nankumba Malembo Nankhwali Nkope
Health facility
Figure 4-8: Proportion of children under five (U5s) classified
with diarrhoea per day
37

v. Ear Infection
Ear infection as a classification was given to 1.4% of all children attending the
five OPDs during the research period (Table 4-9). The classification was most
frequently given to children in the age group 1-4 years. Children aged less than a
year received few ear infection-classifications and none aged less than 2 months
were classified with that problem.
Table 4-9: Number of ear infections and proportion of total children in each age group classified
with an ear infection by facility. (g) Government run, (c) CHAM-run.
HC
Total < 2 months 2-11 months 1-4 years 5-14 years 0-14 years
children n (%) n (%) n (%) n (%) n (%)
MBCH (g) 1569 0 (0) 5 (0,3) 7 (0,4) 13 (1) 25 (2)
Nankumba (g) 1119 0 (0) 3 (0,3) 6 (1) 2 (0,2) 11 (1)
Malembo (c) 466 0 (0) 0 (0) 4 (1) 4 (1) 8 (2)
Nankhwali (c ) 243 0 (0) 1 (0,4) 2 (1) 1 (0,4) 4 (2)
Nkope (c) 668 0 (0) 1 (0,1) 2 (0,3) 4 (1) 7 (1)
Grand Total 4065 0 (0) 10 (0,2) 21 (1) 24 (1) 55 (1)
d. Drugss
Drug inventories taken 6 times in MBCH and once in each of the four health
centres. Table 4-10 shows the IMCI-recommended drugs and their availability. The
IMCI-recommended oral antibiotics were usually available: Co-trimoxazole was
available in all inventories and erythromycin was missing at the time of visit to
Malembo. Antimalarials were also usually available. Quinine was available in all
inventories and sulphadoxine-pyrimethamine (SP) was available in all inventories
except in the one that was carried out in Nankumba.
Intramuscular antibiotics were most often missing of the IMCI-recommended
drugs that were investigated. Benzyl penicillin was available in half of all the
inventories and in 2/6 of the inventories carried out at MBCH. Intramuscular
gentamycin was available in six out of the ten inventories carried out during the
research period.
MBCH was supplied with Oral Rehydration Salts (ORS) throughout the research
period. However, ORS was out of stock in the Nkope and Malembo inventories,
which are both CHAM facilities. Iron was available in all inspections. Vitamin A was
missing in one health centre.
38

Table 4-10: Availability of IMCI-recommended drugs for the major classifications. In MBCH, the
fraction indicates the number of times the drug was available out of the six times the drug inventories
were carried out. The HCs fraction tells how many health centres (HCs) out of all the four HCs had
the drug when the inventories were taken. (the font is coloured for clarity). SP, sulphadoxine
pyrimethamine; im, intramuscular antibiotic.
Age group IMCI classifications Recommended drugs
Available/inspection
MBCH HCs
Severe pneumonia or very benzyl-penicillin (im) 2/6 3/4
severe disease
Pneumonia co-trimoxazole 6/6 4/4
erythromycin (2 nd line) 6/6 3/4
Severe febrile disease quinine 6/6 4/4
benzyl penicillin (im) 6/6 3/4
paracetamol 6/6 4/4
Malaria SP 6/6 3/4
co-trimoxazole 6/6 4/4
Severe complicated measles vitamin A 6/6 3/4
2 months
benzyl penicillin (im) 6/6 3/4
to 5 years Measles vitamin A 6/6 3/4
Diarrhoea with dehydration Oral Rehydration Salts (ORS) 6/6 2/4
Anaemia iron 6/6 4/4
SP 6/6 3/4
albendazole 6/6 4/4
Severe malnutrition vitamin A 6/6 3/4
Mastoiditis benzyl penicillin (im) 2/6 3/4
paracetamol 6/6 4/4
Acute ear infection co-trimoxazole 6/6 4/4
erythromycin (2 nd line) 6/6 3/4
Less than
2 months
Diarrhoea with severe benzyl penicillin (im) 2/6 3/4
dehydration and possible gentamycin (im) 4/6 2/4
bacterial infection ORS 6/6 2/4
Diarrhoea with possible benzyl penicillin (im) 2/6 3/4
serious abdominal condition gentamycin (im) 4/6 2/4
e. Interviews with Motherss
Preliminary data from interviews with mothers of children attending the MBCH
OPD in Table 4-11 shows the satisfaction of 11 mothers with the care their children
had. Five mothers of children who received care from the IMCI-trained health care
worker were satisfied with the care while one was unsatisfied. Two mothers of
children who received care from the other health care worker (who had not taken a
training course in IMCI) were satisfied while three were unsatisfied.
39

Table 4-11: Mothers′ satisfaction with the care their children had at MBCH
Health care worker
Mothers′ satisfaction with care
Very satisfied Satisfied Unsatisfied Very unsatisfied
Total
Not IMCI-trained 0 2 3 0 5
IMCI-trained 2 3 1 0 6
The mothers complained most frequently about poor examination of the child,
and mothers whose children were attended by the health care worker who had not
received IMCI training made more negative remarks.
40

5. Discussion
The results of this study show that half of all attendees to the five health facilities
in the Monkey Bay health zone were children. The largest number of patients fell
within the 1-4 year age group. Around 84% of all classifications in under-fives are
directly dealt with in the IMCI guidelines indicating that the IMCI approach is
appropriate in these settings. The most common classification is malaria, which was
given to over half of attending under-fives. Respiratory tract infections accounted for
roughly a third of all classifications and diarrhoea was 5%. The drug inventories
revealed that IMCI-recommended oral drugs were mostly available while
intramuscular antibiotics were often out of stock.
a. Health Facility Attendancee
The total attendance to the five health facilities during the research period was
just less than nine thousand patients. Since patients were only recorded in the
Outpatient Registers during office hours, this is an underestimate of the total
number of attendees.
In 1987 the World Bank adverted the introduction of user fees for health care in
developing countries with the aim of improving efficiency, increase coverage and
quality and reduce frivolous demands in the health care system (52). On the
contrary, numerous studies have shown that user fees are not an efficient means of
raising revenues for the health care system, they have a much more devestating
impact on the poor than the rich, they do not improve the quality or coverage of
health care and they prolong the time which passes from the onset of disease until
health care is sought (52). In areas where user fees have been introduced, attendance
to health care facilities has decreased 30-50% (53, 54). Therefore, it was interesting to
examine whether there was a relative difference in attendance between CHAM
facilities, that charge user fees for their services, and the government facilities that
offer care free of charge. The results from outpatient departments in the Monkey Bay
41

area show that both children and adults are more prone to seek service at
government-run facilities than CHAM facilities. The difference is statistically
significant and is most dramatic in the age group of 5-14 year olds. Consequently,
Nankumba and MBCH are very important health facilities providing health care for
those who cannot afford paying user fees and buying drugs. The user fees at the
CHAM facilities are of concern as user fees in neighbouring countries have
predominantly affected the poor (55, 56). To illustrate, an interview with a mother
attending MBCH outpatient department with her sick child walked all the way from
Malembo (where there is a CHAM facility) in order not to pay for the health care.
The difference between attendance at the government facilities and CHAM
facilities leads to an increased burden on the workers of the government-run
facilities who are generally few and poorly paid. Hence, it is important that
authorities in Malawi stay firm on the policy of free health care services and it is
important that in the future a larger proportion of health facilities become free of
charge for the user.
The vast difference in revisits among the health centres (from 0.3% in Malembo to
17% in Nankhwali) raises the question whether the revisit count is accurate.
Inaccurate register of revisits alters the diagnostic profile in such a way that the
proportion of illnesses that need more follow-up increases.
Female attendants were more numerous than males in all health facilities. A
significant sex difference in attendance was detected for adults but not for children.
It may be speculated that adult males are more reluctant to seek medical care than
females or females may more frequently suffer from illness. A more likely
explanation is that females get acquainted with health services through birth
delivery and are thus more prone to seeking health care for other reasons.
In order to get a better picture of the patient flow in the area, the outpatient
registry needs to be improved in the five health facilities, for example in
distinguishing all revisits from primary visits, and patients that attend outside office
hours should be included. Up-to-date population data is required for a more
accurate analysis.
42

. Diagnoses
The fact that around 84% of all classifications given to children under five during
the research period are dealt with in the IMCI supports the pertinence of
implementing the programme in the Monkey Bay health zone. The rate is similar to
what has been reported elsewhere. In Kenya, IMCI was found to directly address
86% of all primary chief complaints that presented at the first-level facility studied
(18). In Gondar, Ethiopia, 87% of presenting complaints by patients or their mothers
were addressed by IMCI. These complaints were fever (more than half of all
complaints), cough (more than half), diarrhoea (almost half) and ear problems
(around 10%) (57).
i. Respiratory Infectionss
Respiratory infections range from mild diseases such as the common cold to life
threatening bacterial pneumonia. During the research period, respiratory infections
accounted for more than a third of all diagnosis. Pneumonia classifications varied
greatly among the health facilities. In addition, it is interesting that in health facilities
with a low proportion of pneumonia cases the number of ORI was high and vice
versa. The difference in the profiles of the health facilities suggests that the health
care workers in the health facilities assess the children differently. The differentiation
of pneumonia from other respiratory tract infections is indeed difficult in this setting
were health care workers rely fully on a few clinical signs. Results from studies in
remote villages in low-income countries where children are given a follow-up have
shown that 12.7 to 16.8 new respiratory tract infections occur in every 100 childrenweeks
and of these 0.2 to 3.4 are new cases of pneumonia (58). This shows that the
majority of new respiratory-disease episodes are because of other respiratory
infections than pneumonia. Hence, this stresses the importance that the health
workers in the Monkey Bay health zone differentiate between pneumonia and
relatively harmless upper respiratory tract infections to avoid unnecessary antibiotic
prescription.
43

ii. Malaria
More than a half of children U5 who attended the five health facilities in the
Monkey Bay health zone were classified with malaria. Malaria is clearly an immense
burden on the community in the area. It is therefore imperative that drugs for
malaria be sufficient and health workers be able to correctly identify malaria and
treat it.
Neonates have a significant degree of resistance to malaria by an unexplained
mechanism although maternal antibodies are believed to play a role (59, 60). Hence,
the proportion of children in the age group of less than two months classified with
malaria should be minimal. Consequently, the high proportion of children less than
two months (13/15) classified with malaria in Nankhwali is questionable and
presumably too high. In Nankhwali, a high proportion of the children in other age
groups were likewise classified with malaria. The Nankhwali health centre is
situated in the same area as the other four health facilities and should therefore have
similar transmission of malaria (61).
As the only clinical sign needed to classify malaria is fever, the classification is
obviously an overestimate of the number of children with clinical malaria. Fever in
children may be caused by many viral infections and bacterial infections such as
pneumonia (62). However, a laboratory to examine blood films and thus confirm the
malaria classification is not available in the four health centres (although it is
available at MBCH). Thus, the health workers need to rely on clinical signs alone.
There are concerns about the over-classification and the massive overtreatment of
malaria as malaria drugs are becoming more expensive and toxic as the years pass
by (18). On the other hand, even though the specificity of fever in the diagnosis of
malaria is very low (18), the risk of missing and not treating malaria cases cannot be
taken. In addition, blood films (that can be examined at MBCH) are not an absolute
indicator of the severity or presence of malaria (63). It is therefore necessary to
provide children who have fever with antimlarials and suspiciously high numbers of
malaria cases should be acceptable to some degree.
iii. Malaria versus Pneumoniaa
In the present study, pneumonia was commonly classified along with malaria.
44

This is interesting in the light of a previous study conducted in 1992 in Malawi. The
aim was to evaluate usefulness of clinical case definitions in managing pneumonia
and malaria in an outpatient department in Lilongwe, Malawi (64). The group found
that 95% of children meeting the WHO clinical definition of pneumonia also met the
clinical definition of malaria. Fever was not associated with malaria (while
splenomegaly was associated) and cough was not associated with pneumonia
(though crepitations were) in the study (64).
Recently, a study conducted in Uganda revealed that 32% of children seeking
care in the first two days of fever have overlapping symptoms with pneumonia
(cough or fast breathing) and 43% of children seeking care after two days of fever
have overlapping symptoms with pneumonia (62). With the resources available
today, children who have symptoms that, according to IMCI, indicate both
pneumonia and malaria need to receive treatments for both diseases. This example
highlights the importance of an integrated appraoch such as the IMCI where
children are treated on the basis of symptoms rather than diagnoses.
iv. Diarrhoeaa
Diarrhoea is the second most common cause of U5 death in the world (26) and
each child has on average three episodes of diarrhoea per year (65). Diarrhoea has
been a common problem for decades and probably will continue to be so. In the
Child Survival series that was published in Lancet in 2003, it is stated that diarrhoea
and pneumonia will continue to be considerable contributors to child mortality until
mortality rates become very low (7).
The proportion of diarrhoea classifications in the Monkey Bay area was very low
during the research period. Considering the mortality and morbidity of diarrhoea in
the world, the low proportion of children with diarrhoea is striking but difficult to
explain. It may be that caretakers are not bringing children with diarrhoea to health
facilities. It may also be that health care workers are not detecting the diarrhoea
cases. Finally, the incidence of diarrhoea may have been low during the research
period or may be generally low in the area.
45

v. Ear Infection
The ear infection-classification was quite low during the research period, or only
given to 1.4% of all attending children. Ear infections were most commonly reported
in children between 1-4 years. The reason for the low proportion of ear infectionclassifications
in children aged less than one year is likely to be a result of missed
cases.
Otitis media is a common problem in children younger than one year in
developed countries. In Ethiopia, a developing country, it was found that 10% of
presenting complaints of the children or mothers was ear problems (57). The fact that
the IMCI does not rely on otoscopy necessitates a very careful assessment of whether
the child has ear pain and whether pus is draining from the ear. It is difficult to
assess whether children less than 1 year old have ear pain or not and therefore many
of the cases may be missed. Diagnosis of otitis media has been reported poor in
countries implementing IMCI because of the lack of otoscopy (18). Improvements
need to be made in detection of otitis media, especially in younger children.
vi. Malnutrition and anaemiaa
Malnutrition and anaemia are common and serious problems in Africa. A study
in Malawi’s neighbouring country Tanzania, showed that 87% of under-fives had
some level of anaemia if haemoglobin levels were measured (66). In Kenya it was
found that 80% of the children attending the outpatient department met the WHO
criteria for anaemia (less than 11 g/dl) (18). A study in Southern Malawi showed
that the mean hemoglobin level in children aged 2-4 years was 83.8 g/L, standard
deviation 12.9 (67).
During the research period seven children were given the classification anaemia,
which is very low considering the statistics above. However, this is a comparision of
a measured haemoglobin level with a clinical assessment of anaemia. It may be
difficult for health workers to identify children with anaemia based on clinical signs
such as palmar pallor. In Tanzania it was found that anaemia often goes unnoticed
in children (66), which is probably the situation in the Monkey Bay area as well.
Also, since anaemia is usually a chronic state in children in Africa, it may not be
perceived as a disease.
46

In the present study, of the just less than three thousand U5s who attended the
five health facilities in the Monkey Bay area only one case of malnutrition was
recorded. It has been estimated that 56% of under-five deaths in Malawi are
compounded with malnutrition (68), in line with global figures. Therefore, since
treatment of malnutrition and anaemia is normally easy, it is important to improve
detection of the conditions and treat them immediately in order to decrease the great
number of deaths that result from these conditions.
c. Health Care Workerss
In the five health facilities in the Monkey Bay health zone, 8/10 health care
workers who attend to children are trained in IMCI. This is above the the proportion
of trained health care workers in Mangochi District. It is important that most if not
all health workers that consult children be trained in IMCI to maximise the
effectiveness of the programme.
Half of the IMCI-trained health care workers were supervised in the six months
preceding the interviews. Schellenberg et al. found that much emphasis was placed
on supervision in the two IMCI-implementing districts being studied in Tanzania
(35). One-fifth of IMCI-trained health workers had received supervisory visits in the
six months preceding the study. However, since the supervisors are under a heavy
workload, many of the visits did not include case-management (35). Supervisory
visits are an important component of the IMCI programme and serve to increase the
motivation of the health worker and improve his/her skills through continuous
learning.
The health workers most common complaint was that IMCI is time consuming. A
study in Ethiopia showed that while getting acquainted with the IMCI, a health
worker may spend 20 minutes with each child (57). After three months of applying
IMCI the consultation takes 5-10 minutes (57). Yet to a health worker in Malawi,
mere 10 minutes may seem a long time for a consultation. A health facility may
experience dozens of children in a single day which does not leave much time for
each consultation. In addition, the health facilities are undermanned and health
47

workers receive low salaries. Hopefully in coming years, the Malawian government
will continue and succeed in the endeavour of improving the working conditions in
health facilities in Malawi by increasing manforce and raise salaries. In the present
situation, it is important that health care workers are motivated in using the IMCI
guidelines despite time shortage because with constant use of the guidelines, they
become familiar and the consultation time shortens.
d. Drugs
Availability of oral and injectable drugs is one of the four indices with the highest
reliability and validity in measuring the quality of child health care at the primary
level (37). Therefore, drug shortages seriously impair the quality of service that can
be provided in the health facilities in the Monkey Bay health zone.
Drug shortage was existent in both government and CHAM-run facilities, which
indicates that increased drug availability does not accompany user fees in the
CHAM facilities. Iron was available in all inspections, which is a positive result.
However, inferring from the low number of anaemia classifications, iron is not used
sufficiently to treat anaemia. The same holds for vitamin A and the necessity to use it
in treatment of malnutrition.
The most commonly missing drugs during the research period were
intramuscular antibiotics. With conservative prescription of intramuscular
antibiotics the consignments may be used more effectively. This may be achieved to
a certain extent by following the IMCI guidelines closely so that antibiotics are not
prescribed unnecessarily, e.g. for mild viral infections of the respiratory tract.
However, conservative prescription of drugs will not eliminate drug shortages. It is
important that health care workers are provided with the proper drugs and
equipment to maximise the IMCI system of classification, treatment, and counselling
that has been integrated into the health care system of Malawi.
e. Interviews with Motherss
Few interviews were taken with mothers of children who attended MBCH and
only two health workers consulted the mothers’ children. Therefore, data from the
interviews must be interpreted with care. Regardless, mothers whose children
48

eceived care from the trained health care worker were generally more satisfied with
the care than those mothers who had their children examined by a non-IMCI-trained
worker. Interestingly, the mothers in the interviews were mostly concerned about
how their children were examined rather than the treatment. This gives room for
improvement.
A study in Brazil compared the quality and satisfaction with nutritional
counseling provided by IMCI-trained and non-trained medical doctors. It showed
that significantly more numerous mothers (65%) of sick children were satisfied with
the care from an IMCI-trained doctor than mothers whose children received care
from non-trained doctors (53%) (69). They were complimented more often and the
mothers who took their child to an IMCI-trained doctor did better in recollecting
nutritional recommendations than mothers in the control group (69). Recent findings
from the Multi-Country Evaluation of IMCI in Brazil shows that health worker’s
communication with caretaker significantly improves after IMCI-training (70). The
findings that communication with caretakers improves with IMCI-training and the
speculations that the IMCI assists the health worker in making a more thorough
examination of children than previous approaches may explain why more mothers
were satisfied with care provided by the IMCI-trained health care worker.
Conclusion
The higher attendance to the government-run facilities than CHAM-run facilities
in the Monkey Bay health zone shows that patients prefer facilities that do not
charge for services despite patient overload and drug shortages that occur more
frequently at the government-run facilities. In the light of the current economic
situation Malawi shares with many low-income countries, it is important that health
structures be supported to improve service delivery, as ICEIDA is currently doing in
Monkey Bay. Further, Malawian authorities should be encouraged to continue with
the desirable policy of providing health care free of charge to reach those most in
need.
The present study shows that the implementation of IMCI is both appropriate
and managable in the Monkey Bay health zone. The algorithm encompasses more
49

than four-fifths of all disease classifications for children under five. However,
examination routines need to be revised and can probably be improved. Prescription
of drugs can be improved as well as accessibility to IMCI-recommended drugs.
Properly implemented IMCI is a great asset to primary health care workers working
in Malawi and elsewere in sub-Saharan Africa and can contribute to reduce the
disturbingly high child mortality in the world, in line with the Millennium
Developmental Goals.
50

Acknowledgments
This project is a collaboration of the Icelandic International Development Agency
(ICEIDA) and the Faculty of Medicine at the University of Iceland. ICEIDA, through
its director Sighvatur Björgvinsson, granted funds for the research. I am grateful for
the opportunity of dwelling and working in Malawi that I was provided with by
these parties.
Thanks go to the ICEIDA personnel in Lilongwe: Þórdís Sigurðardóttir, Margrét
Einarsdóttir, and Stella Samúelsdóttir for a warm welcome and much assistance. I
also want to thank the ICEIDA technical advisors in Monkey Bay, Lovísa Leifsdóttir
and Ragnhildur Rós Indriðadóttir for all their help and hospitality.
I thank the staff at Monkey Bay Community Hospital for all the valuble lessons and
their friendliness. Mr. Kapinga was very welcoming and helped considerably in the
first phases of study preparation and data collection. In addition, the Medical
Assistant students Mr. Kafwafwa and Mr. Kadzuwa eased my data collection and
were of valuble help throughout the research period. Medical Assistant Mr.
Masonde in MBCH and other responsible health workers in the Monkey Bay health
zone facilities are also gratefully acknowledged.
I thank medical student Eyþór Jónsson for good company and memorable times
during the six weeks of our research in Malawi.
Finally, I thank my supervisor, Geir Gunnlaugsson, for all the efforts in the
preparation of this project, assistance in data processing and the guidance in my
writing of this report.
51

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Annexes
57

Annex 1
58

Annex 2
59

Annex 3
60

Annex 4
61

Annex 5
62