A Case Study of Integrated Management of Childhood Illness (IMCI) Implementation in Kenya K Mullei, F Wafula, C Goodman October 2008 This paper is an output of the Consortium for Research on Equitable Health Systems. The authors are based at the Kenya Medical Research Institute (KEMRI), Kenya. Kenya Medical Research Institute, PO Box 43640, 00100 GP, Nairobi, Kenya. 1 ABOUT CREHS The Consortium for Research on Equitable Health Systems (CREHS) is a five year DFID funded Research Programme Consortium that is made up of eight organisations based in Kenya, India, Nigeria, South Africa, Tanzania, Thailand and the United Kingdom. It aims to generate knowledge about how to strengthen health systems, policies and interventions in ways which preferentially benefit the poorest. The research is organised in four themes: health sector reform, financial risk protection, health workforce performance and scaling up. The consortium will achieve its aim by: • working in partnership to develop research • strengthening the capacity of partners to undertake relevant research and of policymakers to use research effectively • communicating findings in a timely, accessible and appropriate manner so as to influence local and global policy development For more information about CREHS please contact: Consortium for Research on Equitable Health Systems (CREHS) London School of Hygiene and Tropical Medicine, Keppel Street, London, UK WC1E 7HT Email: [email protected] Website: www.crehs.lshtm.ac.uk ACKNOWLEDGEMENTS We would like to thank the following organisations and individuals for their valuable contributions and support in preparing this report: the members of the Division of Child Health; representatives of national and local development partners; and the District Health Management Teams and health workers in Malindi and Homa Bay. We are also grateful to Mike English for his input on earlier drafts, and to Lucy Gilson for her expertise and advice throughout the research. 2 TABLE OF CONTENTS List of Acronyms…………………………………………………………………………………………….. 5 Executive Summary………………………………………………………………………………………… 7 Section I: Introduction…………………………………………………………………………………......... 10 Section II: IMCI in Kenya i General overview……………………………………………………………………....... 12 ii Key actors……………………………………………………………………………....... 14 iii Coverage of IMCI implementation in Kenya…………………………………………... 16 iv Health systems context……………………………………………………………........ 18 Section III: Methodology i General approach…………………………………………………………………......... 20 ii District selection……………………………………………………………………........ 20 iii Context of study sites………………………………………………………………....... 21 iv Stages of data collection………………………………………………………………… 23 v Data analysis……………………………………………………………………………... 24 Section IV: IMCI in Homa Bay & Malindi i Training coverage…………………………………………………………………......... 27 ii Equity of coverage of IMCI trained staff……………………..…………………........ 29 iii Follow-up supervision…………………………………………………………………… 32 iv On-Job-Training (OJT)………………………………………………………………….. 32 v Health worker compliance to IMCI guidelines……………………………………...... 33 vi Managerial perceptions of IMCI implementation…………………………………...... 34 vii Fees charged for under 5s…………………………………………………………....... 35 viii Care giver compliance to referrals…………………………………………………...… 36 Section V: Factors leading to low levels of implementation at health facilities i Factors affecting health worker compliance with guidelines a. Health worker perceptions of IMCI…………………………………………… 37 b. Time constraints……………………………………………………………….. 42 c. Facility support…………………………………………………………………. 45 ii Supervision & OJT a. Inadequate support supervision……………………………………………… 50 b. Ineffectiveness of OJT………………………………………………………… 52 iii Factors affecting community uptake & compliance to referrals a. User fees & Poverty………………………………………………………........ 53 b. Non-compliance of care givers to referrals……………………………........ 56 Section VI: Factors affecting training coverage Training coverage differences in Malindi and Homa Bay………………………………......... 58 i Financing of IMCI training a. District level financing……………………………………………………........ 58 3 b. National level financing…………………………………………………......... 59 ii Reasons for reluctance to fund IMCI training a. High cost of training……………………………………………………………. 60 b. Failure to adopt alternative training options……………………………....... 61 c. Difficulties in demonstrating impact of IMCI……………………………….. 65 d. Increased interest in c-IMCI…………………………………………………... 66 e. The low profile of child health………………………………………………… 67 Section VII: Discussion: IMCI effectiveness and implementation…………………………………………………………. 69 Identifying the root causes of poor implementation i Process of policy introduction………………………………………………………..... 72 ii Context……………………………………………………………………………........... 74 iii Nature of target behaviours…………………………………………………………….. 75 iv Role of power in implementation………………………………………………………. 77 Policy Recommendations i Recommendations concerning IMCI policy content and practice…………………. 79 ii Recommendations concerning broader health systems issues……………………. 81 References…………………………………………………………………………..………………………. 83 Appendices: Appendix I. IMCI Implementation Timeline…………………………………………………….. 86 4 LIST OF ACRONYMNS AIDS Acquired Immuno Deficiency FBO Faith-based Organisation Syndrome GAVI Global AIDS Vaccine Initiative AL Artemether Lumefantrine (Co-artem) GFATM/ GF Global Fund for AIDS TB & Malaria AMREF African Medical Research Foundation GOK Government of Kenya AOP Annual Operational Plan HPPH Head of Promotive & Preventive Health BDMI Bungoma District Malaria Initiative HFC Health Facility Committee CDC Centres for Disease Control HIV Human Immuno Deficiency Virus CDF Constituency Development Fund HMIS Health Management Information Systems CHAK Christian Health Association of Kenya IMCI Integrated Management of Childhood Illness CHWs Community Health Workers KEMSA Kenya Medical Supply Agency CO Clinical Officer KEPH Kenya Essential Package for CRS Catholic Relief Services Health DANIDA Danish International KEPI Kenya Expanded Programme of Development Agency Immunization DASCO District AIDS / STI Coordinating MCH Maternal & Child Health Officer MEDS Mission for Essential Drugs & DOCH Division of Child Health Supplies DOT Directly Observed Therapy MOH Ministry of Health DHMT District Health Management NGO Non-Governmental Agency Team NHSSP National Health Sector Strategic DMOH District Medical Officer of Health Plan DMS Director of Medical Services NCK Nursing Council of Kenya ECN Enrolled Community Nurse OJT On Job Training C-IMCI Community IMCI ORT Oral Rehydration Therapy F-IMCI Facility IMCI 5 PEPFAR Presidential Emergency Plan for AIDS Relief PHMT Provincial Health Management Team PI Poverty Incidence PMTCT Prevention of Mother-to-Child Transmission RN Registered Nurse UoN University of Nairobi UNICEF United Nation‟s Children‟s Fund USAID United States Agency for International Development USPMI United States Presidential Malaria Initiative VCT Voluntary Counselling & Testing WHO World Health Organisation 6 EXECUTIVE SUMMARY The major gaps between health policies on paper and the reality on the ground have been documented, especially in relation to policies with the potential to benefit the poor. We have investigated these issues through a study of the implementation of the Integrated Management of Childhood Illness (IMCI) in Kenya. IMCI was developed by WHO as a holistic approach to improving management of sick children. It consists of a facility component (f-IMCI), which aims to improve health workers‟ skills and facility supports, and a community component (c-IMCI). The main focus of this study is f-IMCI, which has been official Government policy in Kenya since 1999, and introduced in 64% of districts. The study was based on case studies of 2 relatively poor rural districts, Homa Bay and Malindi, and relies mainly on qualitative methods. After an initial document review, in-depth interviews were conducted with health workers, district managers and other stakeholders at the district level, followed by additional interviews at the provincial and national levels. This was supplemented by observations of health workers in rural facilities and the collation of nationwide quantitative data on IMCI coverage. Kenya has made some important progress with IMCI implementation, which could be observed in both Malindi and Homa Bay. Financial and logistical support for training had been secured at national and district levels, from a range of development partners such as AMKENI, DANIDA, CHAK, CRS, Global Fund and PLAN International. DHMT staff in both districts had undergone IMCI case management training and facilitator training, which had improved district capacity to support trainings and follow up supervision. While training had mainly covered public health workers, some private and faith based institutions were also included, and trained health workers were distributed throughout the districts and across all facility types (hospitals, health centres and dispensaries). Moreover, at a national level, training coverage was relatively equitably distributed across the country, targeting a high proportion of the poorest districts. There is strong support for the technical content of the strategy at all levels of the health system, and it is seen as fitting well with other programmes, such as immunization. Compliance by trained health workers with some aspects of the protocol, such as checking weight and immunization status and counselling the care giver on how to administer drugs, appeared to be adequate,.