Effect of Integrated Management of Childhood Illness (IMCI) on health worker performance in Northeast-Brazil O efeito da Atenção Integrada às Doenças Prevalentes na Infância (AIDPI) sobre o desempenho de profissionais de saúde no Nordeste do Brasil

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. Health Services; Quality of Health Care; Evaluation Introduction Despite recent advances in reducing childhood mortality in the world, over ten million children under five years of age still die every year, with the majority of these deaths occurring in developing countries 1. Globally, almost 50% of all childhood deaths are due to pneumonia, diarrhea, measles or malaria, in combination with malnutrition 2,3,4, all of which are preventable or treatable. Integrated Management of Childhood Illness (IMCI) is a strategy developed by the World Health Organization (WHO), Pan-American Health Organization (PAHO), and the United Nations Children’s Fund (UNICEF) with the aim of improving the health status of the world’s children 5,6. The strategy includes three components: improving case-management skills of health workers, improving health systems support, and improving family and community practices. The IMCI strategy is a priority in the Brazilian Ministry of Health (MoH) child health policies, giving special emphasis to first-level health care 7. IMCI implementation started in Brazil in 1996 and is moving ahead strongly in several States, particularly in the Northeast and Northern regions that currently present with country’s worst socioeconomic and health indicators 8. IMCI in Brazil is being implemented in the context of a Family Health Program (FHP), supAmaral J et al. S210 Cad. Saúde Pública, Rio de Janeiro, 20 Sup 2:S209-S219, 2004 ported by the World Bank and by the MoH. The FHP, integrated with the Community Health Worker’s Program (CHWP), is included among the public policies of the MoH with a special emphasis on first-level care. Health care is provided to families in low-income municipalities, or neighborhoods in larger cities, by FHP teams which include a family doctor, a registered nurse, two health auxiliaries, and 4-6 community health workers (CHW). The FHP teams are based in first-level government facilities (known as Family Health Program facilities), and a given facility may have one or more teams depending on the size of its catchment area. In addition to providing comprehensive care, the FHP teams are responsible for developing activities in health promotion, prevention, early diagnosis, treatment, and rehabilitation, while patients requiring higher-level care are referred to regional centers of reference (http://www. paho.org/portuguese/gov/cd/cd41_11.pdf ). Each FHP team covers about 600-1,000 families, and each CHW is responsible for visiting about 100-200 families at least once a month. Over 110,000 CHWs are currently operational in the country. CHW training guidelines to ensure full compatibility with IMCI have been completed (Ministry of Health. Integrated Management of Childhood Illness; 1999). The wide coverage reached by CHWs means that the community component of IMCI, which addresses key family behaviors that are essential for child health, has the potential to be implemented strongly. By January 2001, the FHP had been implemented in 1,933 municipalities with as many as 5,139 FHP teams. FHP team members have been the primary target for IMCI case management training in Brazil. Most municipalities in which IMCI has been implemented therefore also have FHPs. However, IMCI training coverage is increasing at a much slower rate than FHP coverage, so that there are still many FHP municipalities without implementation of IMCI. The Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE), coordinated by the Department of Child and Adolescent Health and Development (CAH) of the WHO, was designed as a global evaluation to determine whether the IMCI strategy has a measurable impact on child health outcomes and to better assess its associated costs 9. The MCE is currently under way in five countries, including Bangladesh, Brazil, Tanzania, Uganda, and Peru. The general objective of the MCE in Brazil is to evaluate the impact of the IMCI strategy on child health by comparing municipalities with and without IMCI implementation. More specifically, the objectives include the comparison of health care provided to sick children in first-level health facilities with and without IMCI implementation, in terms of health worker performance, health systems support structure, and intensity of community activities; the comparison of health-related behaviors, intervention coverage, and impact indicators (mortality and nutrition) in municipalities with and without IMCI; the documentation of IMCI implementation at the health facility and community levels in a selected number of municipalities with strong implementation; and the assessment of costs and cost-effectiveness associated with IMCI implementation. In this paper we report on the MCE – Brazil health facility survey conducted in 2002. The objective was to assess the effect of IMCI case management training on the quality of care provided to sick children under the age of five visiting first-level health facilities, and to compare health systems support structures in facilities in which IMCI had been implemented to those in which IMCI implementation had not yet started.