Integrated Management of Childhood Illness: efficiency of primary health in Northeast Brazil.

OBJECTIVE: The Integrated Management of Childhood Illness is a strategy designed to address major causes of child mortality. The aim of this study was to assess the impact of the strategy on the quality of child health care provided at primary facilities. METHODS: Child health quality of care and costs were compared in four states in Northeastern Brazil, in 2001. There were studied 48 health facilities considered to have had stable strategy implementation at least two years before the start of study, with 48 matched comparison facilities in the same states. A single measure of correct management of sick children was used to assess care provided to all sick children. Costs included all resources at the national, state, local and facility levels associated with child health care. RESULTS: Facilities providing strategy-based care had significantly better management of sick children at no additional cost to municipalities relative to the comparison municipalities. At strategy facilities 72% of children were correctly managed compared with 56% in comparison facilities (p=0.001). The cost per child managed correctly was US$13.20 versus US$21.05 in the strategy and comparison municipalities, respectively, after standardization for population size. CONCLUSIONS: The strategy improves the efficiency of primary facilities in Northeastern Brazil. It leads to better health outcomes at no extra cost.

Integrated Management of Childhood Illness: efficiency of primary health in Northeast Brazil

OBJECTIVE: The Integrated Management of Childhood Illness is a strategy designed to address major causes of child mortality. The aim of this study was to assess the impact of the strategy on the quality of child health care provided at primary facilities. METHODS: Child health quality of care and costs were compared in four states in Northeastern Brazil, in 2001. There were studied 48 health facilities considered to have had stable strategy implementation at least two years before the start of study, with 48 matched comparison facilities in the same states. A single measure of correct management of sick children was used to assess care provided to all sick children. Costs included all resources at the national, state, local and facility levels associated with child health care. RESULTS: Facilities providing strategy-based care had significantly better management of sick children at no additional cost to municipalities relative to the comparison municipalities. At strategy facilities 72 percent of children were correctly managed compared with 56 percent in comparison facilities (p=0.001). The cost per child managed correctly was US$13.20 versus US$21.05 in the strategy and comparison municipalities, respectively, after standardization for population size. CONCLUSIONS: The strategy improves the efficiency of primary facilities in Northeastern Brazil. It leads to better health outcomes at no extra cost.

OBJETIVO: A atenção integrada às doenças prevalentes da infância é uma estratégia desenvolvida para contribuir na redução das principais causas de mortalidade infantil. O objetivo do estudo foi avaliar o impacto da estratégia sobre a saúde infantil. MÉTODOS: Compararam-se a qualidade do atendimento à saúde infantil e os custos associados em quatro estados da região Nordeste do Brasil, em 2001. Foram estudadas 48 unidades de saúde onde havia implementação estável da estratégia por pelo menos dois anos antes do início do estudo e 48 unidades sem (controle) nos mesmos estados. O percentual de crianças doentes atendidas corretamente foi utilizado para avaliar a qualidade da atenção oferecida a crianças doentes. O custo total da atenção à saúde infantil foi avaliado a partir de dados coletados nos níveis nacional, estadual, municipal e de unidade de saúde. RESULTADOS: As unidades que adotam a estratégia obtiveram desempenho significantemente melhor no atendimento de crianças doentes, sem custos adicionais em relação aos municípios sem. Nas unidades com a estratégia, 72 por cento das crianças avaliadas foram atendidas corretamente, comparado com 56 por cento nas unidades controle. O custo por criança atendida corretamente foi de US$13.20 versus US$21.05 nos municípios com e sem a estratégia respectivamente, após os ajustes para o tamanho das populações municipais. CONCLUSÕES: A estratégia melhorou a eficiência das unidades de atenção primária de saúde da região estudada. Em unidades de atenção primária com a estratégia, a qualidade do tratamento foi melhor, sem aumento de custos.

Measuring the quality of child health care at first-level facilities.

Sound policy and program decisions require timely information based on valid and relevant measures. Recent findings suggest that despite the availability of effective and affordable guidelines for the management of sick children in first-level health facilities in developing countries, the quality and coverage of these services remains low. We report on the development and evaluation of a set of summary indices reflecting the quality of care received by sick children in first-level facilities. The indices were first developed through a consultative process to achieve face validity by involving technical experts and policymakers. The definition of evaluation measures for many public health programs stops at this point. We added a second phase in which standard statistical techniques were used to evaluate the content and construct validity of the indices and their reliability, drawing on data sets from the multi-country evaluation of integrated management of childhood illness (MCE) in Brazil, Tanzania and Uganda. The statistical evaluation identified important conceptual errors in the indices arising from the theory-driven expert review. The experts had combined items into inappropriate indicators resulting in summary indices that were difficult to interpret and had limited validity for program decision making. We propose a revised set of summary indices for the measurement of child health care in developing countries that is supported by both expert and statistical reviews and that led to similar programmatic insights across the three countries. We advocate increased cross-disciplinary research within public health to improve measurement approaches. Child survival policymakers, program planners and implementers can use these tools to improve their monitoring and so increase the health impact of investments in health facility care.

Effect of Integrated Management of Childhood Illness (IMCI) on health worker performance in Northeast-Brazil.

A multi-country evaluation is being carried out in Brazil and four other countries to determine the effectiveness, cost, and impact of the Integrated Management of Childhood Illness (IMCI). We examine the effect of IMCI on the quality of health care provided to children under five visiting health facilities. A health facility survey was conducted at 24 facilities (12 with IMCI) in each of four States in the Northeast. We assessed the quality of care provided to children between 2 months and 5 years attending the facilities. Health workers trained in IMCI provided significantly better care than those not trained. Significant differences between health workers who were trained or not trained in IMCI were found in the assessment of the child, disease classification, treatment, and caretaker communication. Nurses trained in IMCI performed as well as, and sometimes better than, medical officers trained in IMCI. We conclude that while there is room for further improvement, IMCI case management training significantly improves health worker performance, and that parts of Brazil that have not yet introduced IMCI should be encouraged to do so.

Improving antimicrobial use among health workers in first-level facilities: results from the multi-country evaluation of the Integrated Management of Childhood Illness strategy.

OBJECTIVE: The objective of this study was to assess the effect of Integrated Management of Childhood Illness (IMCI) case management training on the use of antimicrobial drugs among health-care workers treating young children at first-level facilities. Antimicrobial drugs are an essential child-survival intervention. Ensuring that children younger than five who need these drugs receive them promptly and correctly can save their lives. Prescribing these drugs only when necessary and ensuring that those who receive them complete the full course can slow the development of antimicrobial resistance. METHODS: Data collected through observation-based surveys in randomly selected first-level health facilities in Brazil, Uganda and the United Republic of Tanzania were statistically analysed. The surveys were carried out as part of the multi-country evaluation of IMCI effectiveness, cost and impact (MCE). FINDINGS: Results from three MCE sites show that children receiving care from health workers trained in IMCI are significantly more likely to receive correct prescriptions for antimicrobial drugs than those receiving care from workers not trained in IMCI. They are also more likely to receive the first dose of the drug before leaving the health facility, to have their caregiver advised how to administer the drug, and to have caregivers who are able to describe correctly how to give the drug at home as they leave the health facility. CONCLUSIONS: IMCI case management training is an effective intervention to improve the rational use of antimicrobial drugs for sick children visiting first-level health facilities in low-income and middle-income countries.

Effect of Integrated Management of Childhood Illness (IMCI) on health worker performance in Northeast-Brazil

Uma avaliação está sendo realizada entre cinco países, inclusive o Brasil, para determinar a efetividade, custo e impacto da Atenção Integrada às Doenças Prevalentes na Infância (AIDPI). Os autores examinam o efeito da AIDPI sobre a qualidade da assistência prestada a crianças abaixo de cinco anos em consultas realizadas em serviços de saúde. Foi feito um inquérito em 24 serviços de saúde (12 com AIDPI) em cada um de quatro estados do nordeste. Avaliou-se a qualidade da assistência prestada às crianças entre 2 meses e 5 anos de idade que freqüentavam os serviços. Profissionais de saúde treinados em AIDPI prestavam assistência significativamente melhor, comparada com aqueles sem treinamento em AIDPI. Foram observadas diferenças significativas entre profissionais com e sem treinamento em AIDPI, na avaliação da criança, classificação da doença, tratamento e comunicação com os pais ou cuidadores. Enfermeiros treinados em AIDPI mostravam desempenho tão bom quanto, e às vezes melhor do que médicos treinados em AIDPI. Os autores concluem que, embora ainda exista espaço para melhoria, o treinamento em AIDPI melhora o desempenho dos profissionais de saúde no tratamento de crianças, e que as regiões brasileiras que ainda não implementaram a AIDPI devem ser incentivadas com o intuito de adotá-lo.