The Implementation of Integrated Management of Childhood Illness ...

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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
Page 1 and 2: The Implementation of Integrated Ma
Page 3 and 4: . Diagnoses .......................
Page 5 and 6: List of Abbreviations ARI………
Page 7 and 8: Since 1970 there has been a conside
Page 9 and 10: over half of all deaths associated
Page 11 and 12: (16). The vertical programmes were
Page 13 and 14: The case-management guidelines are
Page 15 and 16: The childhood deaths resulting from
Page 17 and 18: though ear infection is not one of
Page 19 and 20: guidelines after training seems unn
Page 21 and 22: 3. Material and Methods a. The Sett
Page 23 and 24: perform surgical procedures. Illnes
Page 25 and 26: workload at the Mangochi District h
Page 27 and 28: The respiratory tract infections in
Page 29 and 30: 4. Results a. Health Care Workers I
Page 31 and 32: In all health facilities there were
Page 33 and 34: c. Diagnoses Children could be clas
Page 35 and 36: Pro ii. Pneumonia In total, about 7
Page 37 and 38: iv. Diarrhoea As shown in Figure 4-
Page 39 and 40: Table 4-10: Availability of IMCI-re
Page 41: 5. Discussion The results of this s
Page 45 and 46: This is interesting in the light of
Page 47 and 48: In the present study, of the just l
Page 49 and 50: eceived care from the trained healt
Page 51 and 52: Acknowledgments This project is a c
Page 53 and 54: area of Kenya with high malaria tra
Page 55 and 56: 53. Creese A, Kutzin J. Lessons fro
Page 57 and 58: Annexes 57
Page 59 and 60: Annex 2 59
Page 61 and 62: Annex 4 61

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