The IMCI Health Facility Assessment is designed to assess the quality of care delivered to sick children at an outpatient facility. The Integrated Management of Childhood Illness is a strategy developed by UNICEF/WHO to reduce child illness and mortality from the most common childhood diseases. IMCI components include health worker skills development, health system strengthening, and community level support to prevent and treat illness at home and to promote careseeking.
MTI supports health facilities to adopt or improve integrated child health, and the first step in that support is to assess the current status of care. The quantitative R-HFA survey created by MCHIP 1 (and endorsed in the MTI M&E Manual 2 )
is preferred, but may not be feasible in all circumstances. The IMCI health facility assessment checklist below is based on a qualitative tool developed by WHO 3 , and can be done without requiring a clinician on the assessment team to confirm correct diagnoses or treatment. The tool primarily evaluates health worker practices and facility supplies and services. In analyzing the data gathered, it is very important to recognize that this tool is qualitative in nature; it does not use random sampling and is not designed to give statistically representative information about the quality of care at all times in the facilities where the tool is applied. The results should be interpreted with caution, and used only as a clue to potential gaps in skills and supplies which might warrant intervention.
The assessment team should divide responsibilities, if possible. Two team members should observe six consecutive clinical cases from the time of arrival to the time of departure, including an interview with the caregiver after she exits the clinic.
Other team members should complete the equipment/supply observation checklist, and interview the clinic director about facility services. The results of the assessment should be shared with the clinic staff at the end.
1
ICF Macro (2006). Rapid health facility assessment: A tool to enhance quality and access at the primary health care level. Available at http://www.mchipngo.net/lib/components/documents/R-HFA.zip
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2 MTI (2009). Monitoring and Evaluation Manual. Available at: http://www.medicalteams.org/docs/learningzone/ME_Manual_April_2009.pdf
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3
WHO (2003). Health facility survey : tool to evaluate the quality of care delivered to sick children attending outpatient facilities.
Available at: http://whqlibdoc.who.int/publications/2003/9241545860.pdf
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Date of interview:
Name of interviewer:
Name and location of facility:
Individuals interviewed:
MODULE 1: OBSERVE THE HEALTH WORKER
Observe six consecutive eligible clinical cases. Eligible cases are those that are sick children, 1-59 months of age.
They should be seen for any one (or a combination) of the three following reasons:
Malaria or fever; rapid or difficult breathing; diarrhea.
1.
Does the health worker weigh the child?
2.
Does the health worker check the temperature of the child?
3.
Why did the mother bring the child to the health facility?
(Diarrhea, fever, cough/fast breathing, ear problem, well-child check, other)
4.
Does the health worker ask if the child can drink or breastfeed?
5.
Does the health worker ask if the child vomits everything?
6.
Does the health worker ask if the child had convulsions?
7.
Is the child awake?
8.
If the child is not awake, does the health worker check for consciousness/lethargy (try to wake)?
9.
Does the health worker ask about cough or difficult breathing?
10.
If the child has cough or difficulty breathing, does the health worker count breaths, look for chest indrawing, and
listen for stridor or wheezing?
11.
Does the health worker ask about diarrhea?
12.
If the child has diarrhea, does the health worker look for sunken eyes, pinch the skin, and offer the child water?
13.
Does the health worker ask about fever (or feel for temperature, or check temperature)?
14.
If the child has fever, does the health worker feel the neck for rigidity?
15.
Does the health worker check for visible emaciation (marasmus or kwashiorkor)?
16.
Does the health worker look for pale palms (anemia)?
17.
Does the health worker look for edema of the feet?
18.
Does the health worker check the child’s weight on a growth chart?
19.
Does the health worker look at the child’s vaccination card?
20.
If the child does not have a vaccination card, does the health worker ask if the child has ever been given: BCG, polio,
DTP, measles, vitamin A?
21.
Does the health worker ask about breastfeeding?
22.
Does the health worker ask if the child eats any other food or fluids?
23.
Does the health worker ask about “other problems”?
24.
Does the health worker classify the child? a.
Any general danger signs b.
Severe pneumonia / pneumonia / no pneumonia (“Ira”) c.
Severe dehydration / Some dehydration / no dehydration d.
Severe persistent diarrhea / Persistent diarrhea e.
Dysentery f.
Severe febrile disease/ Malaria / Fever g.
Mastoiditis / acute ear infection / chronic ear infection h.
Severe malnutrition / very low weight for age i.
Anemia / severe anemia j.
Other
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25.
Does the health worker give injections? ____________________________
26.
Does the health worker prescribe or give ORS?
If yes, does the health worker give ORS at this facility?
27.
Does the health worker immediately refer the child for any reason?
If yes, does the mother accept the referral?
28.
Does the health worker give or prescribe any oral medicine?
If yes: ___________________________________________________________
If antibiotic, does the health worker explain the prescription:
Name, tablet or suspension, dose, # times per day, # days: ____________________________________________
29.
Does the health worker explain how to give oral medicine?
30.
Does the health worker demonstrate how to take the oral medicine?
31.
Does the health worker ask the mother how she will give the medicine?
32.
Does the health worker give the first dose of oral medicine at the facility?
33.
Does the health worker counsel the mother to give more breastmilk or liquids at home?
Does the health worker give advice on the frequency of feeding or breastfeeding?
If yes, how many times per day: _____________________________
34.
If the child has very low weight for age, does the health worker give nutrition counseling and make a return appointment for 30 days?
35.
Does the health worker tell the mother to bring the child back for any of the following:
Unable to drink or breastfeed, or drinks poorly
Becomes sicker
Develops a fever
Develops fast breathing or difficulty breathing
Develops blood in stools
Other ______________
36.
Does the health worker ask at least one question about the mother’s own health (FP, vaccinations, other health issues)?
37.
Did the health worker use the IMCI chart booklet or wall chart at any time during the visit?
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MODULE 2: INTERVIEW THE MOTHER
After the caregiver leaves the clinic, ask her if she would be willing to be interviewed about her experience at the health facility. Explain that the information will be kept confidential and will be used to help improve the quality of services.
1. What do you think about the services for sick children at this facility?
A) Good as they are
B) Need to improve (how:__________________)
C) Don’t know
2. How do you feel about how long you had to wait before your child was seen by the health worker?
A) Too long
B) OK
C) Very quick
D) Don’t know
3. Did the health worker prescribe any oral medicines for your child today?
4. Any antibiotics? If yes, give name: ___________________________________________
How much do you give each time? ___________________________________________
How many times do you give it each day? ______________________________________
How many days will you give it? _____________________________________________
6. Was ORS prescribed?
If yes: how much water do you mix with one packet? ____________________________
How many times will you give ORS each day? _____________________________
How much will you give each time? _____________________________________
8. Did the health worker give you a specific day to come back to the facility? If yes: _____________days
9. Sometimes children get worse and need to go to a health facility right away. What symptoms would cause you to take your child back to a health facility right away?
At the end of the interview, make sure the mother knows how to prepare ORS, when to return, how to give the medicine, and what to do if the child becomes worse at home.
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MODULE 3: EQUIPMENT/SUPPLY CHECKLIST
Check whether each of the items below is either in the child consultation room where the service is given, or in an adjacent room. Mark each with “Y” for yes or “N” for no.
A working adult scale?
A working baby scale?
A working watch or timer for every health worker?
Supplies to mix and give ORS?
Source of clean water?
Drug logbook?
Child health cards?
Pregnant mother health cards?
IMCI chart book?
Accessible transportation for patients requiring referral?
Ask to see the following drugs and supplies. If the item is located in a different part of the facility, go there to observe it.
If you are unable to see an item, ask if it is available and the expiration dates have not passed. Mark each with “Y” for yes or “N” for no.
Needles and syringes for vaccination
(Single or multiple use)
ORS Injectable antibiotic for children
Functional sterilizer, cooker, or stove
Functional refrigerator
Ice packs and cold box for vaccines
Vaccines in stock: BCG, polio, DPT, measles, tetanus
Antibiotic #1 for pneumonia
Antibiotic #2 for pneumonia
Antibiotic #1 for dysentery
Antibiotic #2 for dysentery
Oral antimalarial #1
Injectable penicillin
Injectable gentamycin
Sterile water for injection
IV fluid for severe dehydration
Vitamin A
Iron
IV administration sets
MODULE 4: FACILITY SERVICES
Speak to the most experienced health worker involved in management of curative child health services.
It is best to ask these questions after patient sessions have finished.
1.
How many health workers are assigned to the facility? a.
Describe type of health workers (MD, Nurse, Assistant, etc.):
2.
How many are IMCI trained?
3.
How many are present today?
4.
How many days per week is the facility open?
5.
How many days per week are child health services provided?
6.
How many days per week are vaccinations provided?
7.
How many times in the last 6 months did the facility receive a supervisory visit?
8.
Did the supervisor observe case management of a sick child during the last visit?
9.
Where do you refer very sick children?
10.
How long does it usually take a patient to get to the referral facility?
11.
Have you ever wanted to refer a very sick child but were unable to do so?
12.
If you had to refer 10 very sick children to a hospital, how many of them do you think will actually go to the hospital?
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