Institutional level
Phases of introduction of IMCI (Integrated Management of Child Health) into pre-service education at institutional level:
- Preparatory and orientation phase
- Planning phase
- Implementation and monitoring phase
- Review and re-planning phase
1. Preparatory and orientation phase
As seen for the same phase at national level, adequate preparatory work is necessary to establish the required conditions to introduce IMCI into pre-service education and institutionalize it for long-term sustainability.
This has been a major lesson learnt from the past, when other public health approaches were introduced into pre-service training but were not sustained over time, as preparatory and planning work had not addressed key issues effectively.
Identification of concerned departments within the teaching institution
Establishment of an IMCI working group
Training of key teaching staff in IMCI
Study tours and experience-sharing
Identification of concerned departments within the teaching institution
To define the target group for the initiative, first the departments to be involved within the academic institution should be identified.
This task requires a preliminary situation analysis and is usually carried out jointly by the national IMCI pre-service management structure and the institution concerned.
In this Region, the departments involved have usually included the paediatrics, community and family medicine departments, according to the organization of the school.
Orientation workshop
A workshop to orient academic institution decision makers and key teaching staff is then conducted.
In this Region, this activity has been well structured, based on the vast and rich experience acquired over the years in conducting it in many schools in different countries. It has in most cases been conducted together with the participation of WHO Regional Office CAH unit staff. It leads to key commitments and decisions.
This workshop plays a key role, since the following outcomes are expected:
official endorsement of the introduction of IMCI elements and approach in the teaching programme of the relevant departments by the university chancellor, faculty dean, and department head and council, or correspondent governing bodies;
decision on the establishment of an IMCI pre-service working group within the institution to coordinate all related activities, with designation of a focal point and definition of terms of reference.
identification of learning objectives of each of the departments involved, given their complementary role to ensure the coverage of all IMCI tasks within the existing teaching subjects and activities.
plan for training of key teaching staff in IMCI. A short, 5-day course has been used in the Region for senior professors, while the standard 11-day course has been used for all the other teaching staff.
Establishment of an IMCI working group
The establishment of an IMCI working group and a focal point in each concerned school helps coordinate and follow up all activities of the various departments concerned within the school in relation to IMCI pre-service education.
Training of key teaching staff in IMCI
A few, key teaching staff with decision-making responsibilities, including members of the school IMCI working group, undergo an IMCI training course to become more acquainted with the content and methodology. This provides them with background useful for planning.
Study tours and experience-sharing
The Regional Office has in selected cases organized and supported “study tours” to model medical schools and meetings—also at intercountry level—to share and review IMCI pre-service education experiences and expose new schools to them.
2. Planning phase
Placement of IMCI related elements in the teaching programme of relevant departments
Teaching process, indicators and resources
Monitoring, review and re-planning
Placement of IMCI related elements in the teaching programme of relevant departments
It should be stressed that “IMCI” is not a “subject” on its own. It should therefore be properly placed in the teaching programmes of the relevant departments and not be introduced as a “subject” in teaching.
While offered as a package in in-service training, the approach used in pre-service education differs, as it needs to take into consideration the existing certificate, diploma or degree programmes.
It is the IMCI elements and clinical approach—knowledge and especially skills—that should be placed in the existing teaching programme of departments such as paediatrics and community and family medicine, which cover subjects related to the areas addressed by IMCI.
It should also be emphasized that IMCI is in no way comprehensive paediatrics, as it focuses on the most important and common conditions in children under-five.
Learning objectives
Learning objectives need to be identified very clearly to guide any other decision.
This process, including the placement of IMCI related elements in the teaching programme of relevant departments, often requires re-distribution of time allocated to some existing topics and lessons.
The Regional office has included in the IMCI pre-service education package a guide on teaching sessions, including lessons plans with learning objectives, content and procedures of each session.
Teaching options
Several teaching options have been proposed for IMCI pre-service education:
“scattered” or “staggered” option, distributing its elements over the existing teaching programme;
“staggered with synthesis block” option, following the above “staggered” approach but adding a “synthesis block” at the end of the programme and/or as part of the paediatric rotation or specialty training, or house officer training;
“one block” option, delivering it as one “block”, i.e. one course—similarly to IMCI in-service training.
All teaching institutions which have introduced IMCI in their teaching programmes in the Region, except only for one country, have adopted the second option, that is the “staggered with synthesis block” option.
The delivery of an IMCI course (the “one block” option), as done in in-service training, has been largely discouraged. This option:
is a very intensive approach, unlikely to be sustainable over time;
requires additional time, overstretching the existing curriculum;
does not fit the existing teaching and remains unlinked with the content and methodology of what has been taught earlier.
A recent review of experience from schools in another Region has confirmed those concerns and come up with similar conclusions, recommending the other two approaches described above.
Teaching process, indicators and resources
As part of the teaching process, when planning decisions are made on:
definition of student learning objectives;
which teaching methods to be adopted for the different topics;
which resources to use for both teachers and students;
which steps to prepare the training sites for clinical practice and the teachers themselves (training on IMCI case management and facilitation skills);
which student-to-teacher ratio to choose according to the various sessions and methods employed
how to assess students; and
which teaching programme to use.
Decisions on these aspects are important as they relate to indicators on the quality of teaching which can be monitored and provide useful feedback.
Furthermore, any decision has to take into consideration the issue of long-term sustainability, as the pre-service initiative accomplishes its objective only if schools develop and implement approaches that the schools themselves can support over time.
The incorporation of questions in student examinations (“summative evaluation”) has proved to be very useful, as students “usually study what is in the exams”.
Budget
The additional costs involved in preparing the institution (e.g., training of teaching staff, preparation of clinical sites) and performing teaching (e.g., type and number of references for teachers and students) need to be calculated and be part of the plan.
The source of these financial requirements needs to be identified by each item in the plan.
Monitoring, review and re-planning
The plan needs to include also indicators and activities to monitor its implementation, including a review at the end of the process.
The findings of the review form the basis to develop a revised plan. Issues related to future sustainability of the approach followed need to be addressed very specifically.
Endorsement of the plan
The plan so developed needs to be formally endorsed in writing by the departments concerned and the school council.
This is a central and fundamental step, translating all the preparatory work and decisions made into “the” policy of the teaching institution and laying the foundation for the future sustainability of the IMCI pre-service initiative.
3. Implementation and monitoring phase
This is the phase when the plan is implemented.
First, preparations are made to prepare for teaching.
Faculty involved in teaching in the respective departments receive training in the IMCI guidelines and facilitation skills.
Resources for teaching and references for students are developed and reproduced.
Training sites for clinical practice are prepared.
Next, teaching starts.
Information to document the experience and monitor its progress is collected.
4. Review and re-planning phase
The whole process needs to be reviewed annually. The findings form the basis for re-planning, thus closing one teaching cycle and opening a new one.
All the various steps described for each phase should be reviewed critically to address key issues and “re-model” the approach.
Attitude and satisfaction of teaching staff and students towards the IMCI content and teaching methodology—including supervised clinical practice—should also be reviewed, as they are among the factors determining success and sustainability of the initiative in the long term.
A standard evaluation of teaching, both in terms of process and outcomes, provides further information to strengthen teaching. The Regional office has developed a guide to this type of evaluations as part of the IMCI pre-service education package.
Evaluations help understand to which extent IMCI pre-service education has succeeded in accomplishing its original objectives, i.e. student competency and health provider performance in the field. The latter aspect is usually coordinated by the ministry of health with involvement of academic institutions.
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IMCI pre-service education: guide to evaluation