Operations Research

Child Survival

Compliance, workload, and cost of IMCI in Niger
QAP studied the relationship between compliance with guidelines for the Integrated Management of Childhood Illness (IMCI), cost (drugs and provider time), and workload for 211 child cases of fever, cough, diarrhea, and earache in 26 health clinics in Niger. The study found rates of compliance with IMCI guidelines of 33 percent for assessment tasks, 81 percent for treatment, and 42 percent for counseling. No relationship was found between compliance and cost, even for particular diagnoses, nor between average clinic compliance and average clinic workload. While previously published studies have reported that increased compliance with IMCI guidelines has resulted in lower drug costs, this study suggests that such a relationship is not always present. The study also found that increased compliance did not lead to increased costs, either for drugs or for consultation time.

Download report:
Compliance, Workload, and the Cost of Using the Integrated Management of Childhood Illness Algorithm in Niger

Evaluation of computer-based training for IMCI in Uganda
This study compared the cost-effectiveness of a 9-day IMCI computer-based training course and an 11-day standard classroom IMCI training course on the knowledge, skills and performance of providers. The standard course was given to 55 providers, and 59 took the computer-based course. Tests of IMCI knowledge were given to all course participants before the training, immediately after the training, and 3-4 months after the training. Skill and performance in case management were observed by trained observers immediately after the training and again after 3-4 months. Both types of training led to led to significant and sustained improvements in participants' knowledge of IMCI, but there was no difference between the two training methods. No differences in skills were noted between the two types of training at the end of the course or after 3-4 months, although there was a substantial decay in skills over the 3-4 month period between observations. Because the computer course took less time and required fewer facilitators to administer, it cost 29% less than the standard course per trainee$335 per trainee for the computer course versus $472 per trainee for the standard course.

Download report:
A Comparison of Computer-Based and Standard Training in the Integrated Management of Childhood Illness in Uganda

Back to top

Impact of QA on IMCI compliance in Niger
This study examined the effect of performance feedback and feedback plus IMCI training on provider compliance with IMCI guidelines in three districts of Niger. Compliance with assessment, treatment, and counseling standards was measured by direct observation of IMCI cases at four different times over 18 months. The results varied from standard to standard and over time, in ways that are difficult to interpret. Nevertheless, there appears to be at least a short-term positive impact of IMCI training and, to a lesser extent, of performance feedback on assessment compliance. Training plus feedback had the most impact, increasing a 17-task composite index by 27 percentage points (from 21% to 48%) six months after the interventions. Indicator measurement and performance feedback cost $108 per health worker over the course of the study, and IMCI training cost $430 per worker.

Download report:
Impact of QA Methods on Compliance with the Integrated Management of Childhood Illness Algorithm in Niger

Impact of self-assessment and peer feedback on health worker IMCI performance in Mali
This study examined the effect of self-assessment and peer feedback on the quality of care provided to children with fever in a peri-urban area of Mali. Quality was defined as the percentage of assessment and counseling tasks performed according to nationally accepted standards. A sample of 36 providers was randomly assigned to a program group (12) and a control group (24), and then observed managing 103 cases of child fever (about 3 cases per provider). The program group received the self-assessment and peer feedback interventions, while the control group did not. In the program group, 54% of the tasks were performed according to standard, compared to only 44% in the control, a statistically significant difference. However, users found the self-assessment to be time-consuming and burdensome.

Download report:
The Impact of Self-Assessment with Peer Feedback on Health Provider Performance in Mali

Back to top

Job aids for IMCI in Zambia
This study investigated how a job aid could be used to increase compliance with IMCI guidelines in Zambia. Prior to the study, Zambia had trained many providers in IMCI, and several IMCI job aids were in use. The study included surveys of job aid usage and IMCI compliance in 1999 and in 2000, and the design and introduction of a new IMCI job aid between the two surveys. The 1999 survey observed 385 IMCI cases by 57 providers in 33 health centers. The 2000 survey observed 263 IMCI cases by 56 providers in 16 health centers, and reviewed a random sample of 157 completed IMCI records in the new job aid format. The surveys also interviewed providers and caretakers. Both surveys found high correlation between the use of job aids for IMCI case management and compliance with IMCI standards. This result does not demonstrate that job aids cause improved compliance, perhaps because the study methodology did not address whether individual providers who previously did not use a job aid improved their compliance when they started using job aids. There was no significant difference in compliance between users of the new job aid and the existing IMCI chartbook in 2000. Most providers (82%) said the new job aid was useful because it saves time, reduces errors, helps them remember the IMCI algorithm, and is easy to use, although they also used the existing IMCI chartbook frequently and for the same reasons. Nearly all caretakers said they preferred providers to refer to written material such as a job aid during the IMCI session, thus challenging the contention by some providers that using a job aid would make them look bad in the eyes of patients.

Download report:
Assessing the Functionality of Job Aids in Supporting the Performance of IMCI Providers in Zambia

Back to top

Job aids to improve adherence to cotrimoxazole treatment in Niger
This study tested the effect of a set of job aids and provider training on provider, caretaker, and patient adherence to cotrimoxazole for the treatment of childhood pneumonia in Niger. Data on 677 cases of childhood pneumonia were obtained from home and clinic observations and interviews in 4 experimental and 4 control clinics following the introduction of the job aids in the experimental clinics. The study found that caretaker adherence to the recommended regimen was much higher in the experimental than control clinics for cases treated by technical nurses (lower educational level), while little effect was observed on professional nurses (higher educational level). In fact, the performance of technical nurses in the experimental clinics rose to near the performance of the professional nurses, suggesting that the job aids may be a low-cost alternative to more expensive formal education. Another interesting result was that providers should prescribe and give caretakers the full course of pills at the initial visit. Partway through the study it was discovered that the clinics were giving a partial course of cotrimoxazole at the initial visit (1 to 3 days of pills rather than 5 days) for a variety of stated reasons (e.g., force caretaker to return for follow-up visit, misunderstood recommended practice, low inventory of pills). In fact, the study showed that children were far more likely to consume the full course if their caretaker received it at the initial visit than if not.

Download report:
Improving Adherence to Cotrimoxazole for the Treatment of Childhood Pneumonia in Niger

The Nicaragua Mother and Baby Friendly Health Units Initiative: Factors Influencing Its Success and Sustainability presents findings on that country’s efforts to support breastfeeding. The report cites data from earlier studies and national surveys showing expansion of breastfeeding practices in Nicaragua. The reports credits several factors for this continued growth and sustainability: national laws, leadership by the Ministry of Health, a growing cadre of health professionals who advocate for the principles of breastfeeding, expansion to all health programs, involvement of universities, publicity and educational activities, and quality assurance efforts. Appendices provide Nicaragua’s 11 criteria for certification as mother and baby friendly and a summary of self-assessment processes, problems uncovered, and corrective actions.

Download report:
The Nicaragua Mother and Baby Friendly Health Units Initiative: Factors Influencing Its Success and Sustainability
La Iniciativa de Unidades de Salud Amigas de la Niñez y la Madre en Nicaragua

QA teams and IMCI compliance in Kenya
This study tested whether facility-based QA teams, trained and coached to develop and implement solutions to IMCI problems, could improve IMCI case management after one year. The study looked at 21 QA teams that implemented a variety of improvements: procure more IMCI drugs, clocking-in register, on-the-job IMCI training, patient IMCI education, workload sharing by staff, reduce waiting time, and monthly meetings. Approximately 70 providers were observed attending about 10 IMCI cases each before the team interventions, and again after the interventions, in the 21 facilities with QA teams and in 14 facilities without QA teams. Case management was scored against a set of indicators for IMCI assessment, classification, treatment, and counseling, and change in performance was analyzed for the 59 providers observed both before and after. Quality of case management improved by 57 percentage points in the facilities with QA teams, compared to only 14 percentage point improvement in the control facilities.

Download report:
Using Problem-Solving Teams to Improve Compliance with IMCI Guidelines in Kenya