Increasingly, a number of parents are reported to be seeking children healthcare provision in hospitals, healthcare centers, traditional healers, and doctors just to mention but a few. However, research report affirms that many children are insufficiently attended to by the aforementioned providers and their parents are not well educated in the process (WHO 1).
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This is more compounded in the developing world like Kenya where some healthcare systems are dysfunctional or not existing, and drugs are sometimes unavailable.
Broadly speaking, most of the services provided do not offer comprehensive services, and oftentimes, rely on history and obvious systems in their course of treatment (WHO 4). Because of these factors, the World Health Organization (WHO) and UNICEF are seeking to mitigate these dilemmas by introducing the Integrated Management of Childhood Illness (IMCI) Strategy (WHO 6).
Simply defined, ICM refers to an ’integrated approach to child health that focuses on the well-being of the whole child’ (WHO 6).
The objective of this system strategy is the elimination and maintenance of diseases and conditions leading to reduced child mortality and disability within a child’s first five years. It encompasses both ‘preventive and curative’ methodologies of disease prevention, treatment, and management incorporated in families and communities (WHO 9).
Components of IMCI Strategy
Generally, the components are three as follows:
- Improving Case Management Skills of Health-Care Staff;
- Improving Overall health Systems;
- Improving Family and Community Health Practices (WHO 8).
IMCI in Kenya
In Kenya, good steps in implementation and evaluation of the progress of IMCI strategy have been made. Regardless, full implementation of it remains largely narrow (Goodman and Mullei 2). Government priority in IMCI implementation is key in reduction of deaths.
However, regardless of this implementation details and attempts, child mortality has not been fully tackled and remains high, indeed, statistically, 115 of every 1000 children born die before they are five years of age (Goodman and Mullei 9). The causes of the child mortality have been identified as mainly associated with pneumonia, malaria, measles, malnutrition, and diarrhea. These have remained largely problematic killers for children due to lack of proper primary healthcare in the country (Goodman and Mullei 9).
In the year 2007, most districts in the country were already executing IMCI, with a saturated bias towards enhancing skills in Case Management and ‘Health Care Delivery Systems’ (Goodman and Mullei 8). The good news to this has largely been that a number of developmental organizations working in the country have training anchored and facilitated to main healthcare workers and managers in most marginalized parts of the country (Goodman and Mullei 8).
Basically, the Components of IMCI, which are being implemented, are as identified the World Health Organization as follows.
Improvement of Case Management Skills
This entails attendance by health workers training course that lasts 11 days. The training usually encompasses illumination into the common diseases and conditions that affect children. In the process, assignments related to the training are given and followed up within a period of 6 to 8 Weeks (Goodman and Mullei 7).
Improvement of Healthcare delivery systems
This is done through the enhancement of quality facilities in terms of quality and appropriateness of drugs and health care equipments. Beyond this, health care providers are sufficiently supervised.
This is about Community and Family education, as well as their participation in health matters. It involves among others, awareness creation and campaigns against practices that facilitate some disease acquisition or inhibition of seeking health care when some diseases are discovered. Moreover, it fights both cultural and religious impediments towards better health practices and promotion.
Challenges of Implementing IMCI in Kenya
Claeson & Wagstaff (88) note that a number of developing countries trying to implement IMCI program face some challenges; regardless of some of the facts that some insurmountable steps have been made, full implementation has been identified as the main challenge in relation IMCI in Kenya. The challenges can be summarized as low training coverage, in absolute obedience to guidelines by workers, and barriers associated with communities in the access of services provided in IMCI.
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Low training coverage can be seen in a number of ways in Kenya. These include the expense of training, which is largely high, as well as insufficient resources that would fully support the system. Beyond this, there are widespread lethargy by the government and other stakeholders to finance IMCI programs, besides lowly detailed pre-service course training to healthcare providers (Goodman and Mullei 10).
The other challenge is lack of obedience to protocol by the taught workers in health. This is seen in a number of areas including in the evaluation of time-period that a child is sick. Other than this, job aids are largely inadequate and indifferent set of attitude of medical practitioners especially nurses and doctors, as compounded by insufficient supervision (Goodman and Mullei 11).
The barriers are also largely seen to be concentrating in the community aspect of the whole programme. Overall, households are exposed to fundamental barriers in right of entry to services of primary healthcare. Therefore, the immediate impact in relation to this is that the intentions of IMCI are then not fully realized. The cause of this can be broadly categorized as high cost of ‘user fees’ in the health facilities namely dispensaries, clinics and hospitals, as well as high fees that comes with referrals.
On the former, the conceptualization is the twenty shillings charged to take care of outpatient services in the health facilities. This is regardless of the fact that children under the age of five should be medically taken care of free of charge. The rationalization of this practice is pegged on laboratory tests, unavailable or high cost drugs, and the government intention of raiding revenue to deal with some expenses (Goodman and Mullei 14).
The latter is a fundamental aspect of IMCI programme in regard to children who suffer serious illnesses and conditions. Regardless of the fact that it is recognized as weighty component, oftentimes, parents and other caregivers have notably been reluctant in stringently keeping with the demands of referrals designated to district hospitals.
This is mainly due to associated expenses such as transport fee (Goodman and Mullei 15), given the fact that such district hospitals are always far apart while transport system is as efficient as it would be expected to be.
The Underlying causes
On examining the causes aforementioned, it is imperative that we illuminate of the underlying initial causes leading to this point in IMCI. These include the following. One is that the there were gaps right at the process of policy introduction. Being at WHO strategy in a holistic sense, it lacked the fundamental specificity in terms of fitting into the Kenyan situation.
This can be conceptualized in a number of dimensions such as the countries budget system and the structure of health services provision, which have traditionally not taken proper care of training, and other bureaucratic tendencies tailored on staffing. This was clearly more of directive approach hinged on top-down strategy, and pushed by international development agencies who stressed the need to keep their defined standards. This has largely led to a gap in implementation.
No wonder today most of these international stakeholders are supporting ‘flexibity’ in IMCI implementation which Kenya is increasingly reluctant to formulate and implement. Instead, the Kenyan Government has remained steadfast in applying the set guidelines by WHO and the phobia associated with bending the rules.
Secondly, it must be seen with the context of local leadership at the grassroots level. At the inception of this strategy and up until now, many districts do not have fully trained leadership to take care of IMCI implementation.
Way Forward for Kenya in its implementation of IMCI
A number measures have been identified to improve IMCI implementation. These include the following
Building support and securing resources for IMCI Strategy
This is viewed by many health practitioners as a way forward to ensure holistic approach. The argument is that, support in terms of awareness creation will help to further build a child’s health issues and anchor IMCI in our psyche. Ondimo (40) reasons that the target groups here should be policy makers/politicians to influence the legislative framework in pushing for budget consideration for child health, doctors, as well as other opinion leaders who would be instrumental in shaping full adoption of IMCI.
Scaling up in service training coverage
This means that alternative training structure should be established to soften the cost associated with training. Here, the options should include reducing course duration or incorporating training and supervision while on job. Beyond this, a comprehensive budget plan running for a long period of time should be considered by stakeholders in the field of health (Goodman and Mullei, 2008).
Comprehensive Appraisal of `pre-service training’
This implies that the government should take the lead role in advocating for the integration of IMCI into the medical syllabus so that students have prior knowledge before getting into the practice (Goodman and Mullei 16).
Improvement of Supervision
Supervision has been identified as one of the bottlenecks in the implementation of IMCI. Addressing it will certainly improve the adoption and execution of the program (Evans 19).
According to Evans (19), the way to do it should include among others including it in “routine integrated supervision visits, based on the routine supervision checklist.” The intended checklist should be comprehensive in scope and its development should be finalized by the government for implementation. The other tailing to this is that, the case management should be done by district managers annually.
Addressing facility-level implementation Challenges
According to Goodman and Mullei (2008), this implies addressing a number of areas that hinder facility implementation. This includes increasing the number of employees in the health sector as far as IMCI is concerned. In addition, drug supplies must be beefed to sufficiently respond to the increasing demands of IMCI. Additionally, giving health workers both moral and incentive support to fully embrace IMCI would be instrumental.
Other strategies in this would be enforcement of establishment of rehydration corners, and facilitation of observation of patients in terms of dosage take, with the direct concern for children aged five years and below (Evans 19).
Further, provision of guidance and counseling to trainees, patients and other stakeholders should be part and parcel of the programme. This should be done by the directors when trainees are undergoing training, at the phase of supervision by the district managers of the programme. This strategy can also be anchored by peer reviews by stakeholders during formal meetings in health facilities.
Certainly, some strides have been made in the implementation of IMCI system in Kenya. Much as it has rolled out the plan, its full execution largely remains a challenge; so, a number of issues must be ironed out because this is tenet (implementation remains largely insufficient) to facilitate the full realization of the benefits that IMCI portends in health management.
Broadly speaking, the main challenges as far as the full implementation package go include “low training coverage, lack of framework for health workers to follow a template guideline, and the fact community members meet impediments to the accessing IMCI Services” (Goodman and Mullei, 2008).
In summery, these bottlenecks are indicative of both specific and general problems in the Kenyan healthcare system. Thus, they necessitate a well crafted plan of action in evaluating a number of dimensions of medical training in the medical colleges and universities, upgrading internship, and seeking to explore facilities in the execution of IMCI and enhancement of monitoring and evaluation strategies in the programme (Amin et al 44).
Amin, Samia et al. Are you being Served?: New Tools for Measuring Service Delivery. Washington DC: World Bank, 2008.
Claeson, Miriam and Wagstaff, Adam. The Millennium Development Goals for Health: Rising to the Challenges. Washington DC: World Bank, 2004.
Evans, Judith, et al. Africa’s Future, Africa’s Challenge: Early Childhood Care and Development. Washington DC: World Bank. 2008.
Goodman, Catherine and Mullei, Kethi. Implementing IMCI in Kenya. DFID. 2008. 11 April 2011. http://www.crehs.lshtm.ac.uk/downloads/publications/IMCIbrief_2009.pdf
Ondimo, Kennedy. Child Exclusion Among Internally Displaced Populations in Rift Valley and Nyanza Provinces of Kenya. Addis Ababa: OSSREA, 2010.
WHO. Integrated Management of Childhood Illness. 2011. 11 April 2011. https://www.who.int/maternal_child_adolescent/en/