Rationale
Situation analysis is essential to introduce a quality care intervention in a health facility and to plan for all its key supporting elements. The time taken to adhere to the IMCI protocol may be a constraint in a busy facility with a high case-load if carried out just by one health provider without shared responsibilities with others at the same facility.
One approach used in the Region has been the reorganization of work at a health facility where more than one health provider works — including physicians, medical assistants, nurses, midwives, health volunteers — redistributing tasks in order to deliver quality care efficiently within available resources.
3 key steps have been identified for this purpose: triage, clinical management and counselling.
Triage
When sick children are taken to a health facility, they should be quickly assessed to identify those who are severely ill and who need to be seen by the physician or medical assistant without delay. For example, a child who is lethargic or unconscious, unable to drink or breastfeed, is having convulsions or vomiting needs urgent attention.
The basic skills to perform these tasks can be taught in a training course for paramedical staff which specifically focuses on triage.
Other tasks can also be carried out before the child is seen by the clinician, such as weighing, taking the temperature, checking the immunization status, etc. Children who are (very) low weight-for-age and require feeding counselling are in this way identified in advance, as are those who are febrile and require assessment of specific signs and symptoms.
Selected categories of health providers have been trained in newly assigned tasks in shorter and competency-based courses in some countries of the Region.
The pre-screening of sick children, achieved through training and redistribution of tasks, saves time and may have a positive effect on the overall management of the child.
Clinical management
It is helpful to integrate clinical protocols as much as possible. The health provider who delivers services at primary health care level is usually the same person, irrespective of whether the guidelines come from one programme or another.
This effort towards integration of clinical management guidelines has been a characteristic of IMCI. IMCI uses a holistic approach to the management of the child and the guidelines guide the health provider through the key steps of the clinical process, from assessment to classification, treatment and counselling.
If triage of children is performed, the physician or medical assistant can then use his or her time to concentrate on clinically examining the sick child and prescribe treatment.
Country-adapted IMCI protocols are currently followed as the standard for the management of under-5 children in countries and areas in which IMCI is being implemented.
To emphasize the importance of counselling as a key task in case management, many countries in the Region request the physician or medical assistant to carry out this task as part of the IMCI approach, while in others this is delegated to paramedical staff. The decision as to who should carry out this task depends also on the staffing situation at the health facility.
Counselling
Counselling caretakers of children is a key aspect of the overall management. Most child care is delegated to child caretakers at home, whether it is related to the administration of medicines (antibiotics, antimalarials, oral rehydration salts, etc.), feeding, administration of fluids, or timely care-seeking. Thus, caretakers need to be properly counselled.
Counselling requires interpersonal communication skills that are often inadequately taught at medical and allied health professional schools. It is often perceived by health providers as a time-consuming and less important task.
The result is that caretakers are often poorly advised on how to care for their children at home and unlikely to care for them properly.
Despite the consultation with the health provider, the child may not receive proper care, the outcome may be poor, more consultations may be required if the child's condition does not improve, and family and health system resources wasted.
IMCI training and follow-up emphasize the importance of counselling. Counselling can be performed by the physician or medical assistant or by other staff available at the facility, such as nurses, nutrition educators, health volunteers after proper training.