IMCI and ETAT integration at a primary healthcare facility in Malawi: a human factors approach

Abstract

BackgroundIntegrated Management of Childhood Illness (IMCI) and Emergency Triage, Assessment and Treatment (ETAT) are guidelines developed by the World Health Organization to reach targets for reducing under-5 mortality. They were set out in the Millennium Development Goals. Each guideline was established separately so the purpose of this study was to understand how these systems have been integrated in a primary care setting and identify barriers and facilitators to this integration using a systems approach.MethodInterviews were carried out with members of staff of different levels within a primary healthcare clinic in Malawi. Along with observations from the clinic this provided a well-rounded view of the running of the clinic. This data was then analysed using the SEIPS 2.0 work systems framework. The work system elements specified in this model were used to identify and categorise themes that influenced the clinic’s efficiency.ResultsA process map of the flow of patients through the clinic was created, showing the tasks undertaken and the interactions between staff and patients. In their interviews, staff identified several organisational elements that served as barriers to the implementation of care. They included workload, available resources, ineffective time management, delegation of roles and adaptation of care. In terms of the external environment there was a lack of clarity over the two sets of guidelines and how they were to be integrated which was a key barrier to the process. Under the heading of tools and technology a lack of guideline copies was identified as a barrier. However, the health passport system and other forms of recording were highlighted as being important facilitators. Other issues highlighted were the lack of transport provided, challenges regarding teamwork and attitudes of members of staff, patient factors such as their beliefs and regard for the care and education provided by the clinic.ConclusionsThis study provides the first information on the challenges and issues involved in combining IMCI and ETAT and identified a number of barriers. These barriers included a lack of resources, staff training and heavy workload. This provided areas to work on in order to improve implementation.

Key challenges of health care workers in implementing the integrated management of childhood illnesses (IMCI) program: a scoping review

“…Our work also highlights the magnitude of the poor supervision and monitoring after the early phases of implementation of IMCI in LMICs, reflecting larger problems relating to scale-up, such as lack of political commitment, human resources issues, fragmented program management and ineffective decentralization [24,25,30,32,40,[44][45][46]. It appears that IMCI programs are also not harmonized to other vertical programs, creating linkage issues for HCWs [25,26,47]. HCWs lack clear roles around the IMCI program and often received no clear directives from higher authorities, resulting in fragmentation of services.…”

Clinical diagnosis in paediatric patients at urban primary health care facilities in southern Malawi: a longitudinal observational study

“…However, clinicians at PHC often face challenges in correctly differentiating malaria, sepsis, meningitis and pneumonia leading to underdiagnosis and misdiagnosis due to similar disease presentations. The similar disease presentation challenges clinicians to correctly diagnose and treat especially if resources are stretched as is often the case at PHC level in low-resource settings [23]. For example, in this study, PHC diagnosis of sepsis, meningitis and pneumonia were correct in only 58.5%,44.4% and 39.6% respectively (Table 2).…”

Clinical diagnosis in paediatric patients at urban primary health care facilities in southern Malawi: a longitudinal observational study

“…In contrast, clinicians at PHC often face challenges to correctly diagnose malaria, sepsis, meningitis and pneumonia commonly leading to under or misdiagnosis due to similar disease presentations. These often challenge clinicians to correctly diagnose and treat especially if diagnostic resources are stretched as is often the case at PHC level in LMICs [ 29 ]. Furthermore, due to limited resources, clinical technicians and medical assistants are often trained to manage symptoms.…”

“…The numerators for each set of columns are the samethe number of times a condition was diagnoses both at PHC and at the secondary level The total number of case records exceed 233 in this analysis as patients can be diagnosed with more than one condition at both PHC and secondary level facility leading to under or misdiagnosis due to similar disease presentations. These often challenge clinicians to correctly diagnose and treat especially if diagnostic resources are stretched as is often the case at PHC level in LMICs [29]. Furthermore, due to limited resources, clinical technicians and medical assistants are often trained to manage symptoms.…”