The challenges of managing childhood illness in Kenya and Tanzania

Of every 1,000 children born in Kenya and Tanzania, an average of 115 die before the age of five. In response to this high rate of mortality, Integrated Management of Childhood Illness was rolled out nationally in 1998 in Tanzania, and in 2002 in Kenya. However, research finds that training coverage is low and implementation is poor in both countries.

Two reports from theConsortium for Research on Equitable Health Systems (CREHS, UK) identify thechallenges in implementing the Integrated Management of Childhood Illness(IMCI) strategy in Kenya and Tanzania. CREHS’ findings are based on research bythe KEMRI-Wellcome Trust Research Programme in Kenya’s Coast and Nyanza Provinces,and the Ifakara Health Institute in Mara Region, Tanzania.

The five main causes ofunder-five deaths – diarrhoea, pneumonia, malaria, measles and malnutrition –can all be managed in primary health care facilities. The IMCI strategy aims toimprove treatment of these conditions by building case management skillsthrough health worker training, better health care delivery systems and improvedcommunity practices related to child health.

By2007, IMCI had reached almost two thirds of Kenyan districts and over 80percent of Tanzanian districts. Well over half the districts had conducted IMCItrainings. Districts were more likely to achieve high levels of IMCI trainingif key individuals were committed to it and were able to access external fundsand help adapt national policies to local circumstances.

Yet there was significant variation in levels of IMCI training coverageacross districts. National trainingcoverage remained low in both countries at less than 20 percent, far short ofthe 60 percent recommended by the World Health Organization. Even trained healthworkers often do not follow IMCI protocols (e.g. checking for symptoms ofsevere disease, monitoring growth, making appropriate referrals). Keychallenges include:

• IMCI training costs US$1,000 per health worker, as it is aresidential course over 11 days that employs high numbers of facilitators(trainers). 
• Lower-cost training options such as pre-service and on-the-jobtraining are not well implemented.
• Kenya has limited funds available, as donors are prioritisingother sectors; Tanzanian district health budgets set limits to what can bespent on training.
• Staff are under pressure, lack resources and often feel IMCI procedures toassess each child are too time-consuming in the face of long patientqueues.
• Some staff have negative attitudes towardsIMCI, especially those at higher levels such as clinical officers anddoctors.
• Supervision is infrequent and of inadequate quality.

Further, community members findit hard to access IMCI services as they are often charged unofficial fees andreferrals are expensive.

Policymakers wishing toimprove IMCI implementation in Kenya and Tanzania should:

• rapidly expand IMCI training by encouraging lower-cost trainingoptions such as shorter, non-residential courses with fewer facilitators
• improve implementation of pre-service and on-the-job training
• improve IMCI supervision and conduct IMCI case managementobservations at least once a year for all trained staff
• address under-staffing, infrastructure constraints and drug shortagesat health facility level
• secureadditional IMCI funding by raising child health awareness among doctorsand local politicians, advocating the benefits of an integrated approachin Kenya, and encouraging greater district flexibility in financialmanagement decisions in Tanzania.