‫بسم اهلل الرحمن الرحيم‬

Nile University

Faculty of Medicine

Community Medicine Department

Fifth year, Semester 1X

Research project in public health proposal

Batch 9 , Group 3

Assessment of the implementation of IMCI Strategy

in Three primary Health Care Center, Sharg AlneeL
Locality, Khartoum, Sudan, March-April 2020

By:

1. Alaa Yousif Dafalla

2. Reham Hamad Mohamed

3. Abubaker Mahmoud Mohamed

Supervisor:

Prof. Sumaia M. Alfadil

MB.BS, DPH, MD Community medicine and Diploma of Health Education
 Dedication:

I dedicate my thesis work to my family and many

friends .A special felling of gratitude to my loving
parents , whose words of encouragement and push for tenacity
ring in my ears . My sisters and brothers have never left my
side and are very special .

I also dedicate this thesis to my friends who have supported

me throughout the process .I will always appreciate all they
have done .
 Acknowledgment:

This thesis is made possible through the help and support

from supervisor Prof: Sumaia Alfadel

Thanks for her most support and encouragement.

Table of contents:

Content Page number

Dedication

Acknowledgement

Abstract in English

Abstract in Arabic

CHAPTER ONE :INTRODUCTION 1-4

1.1 Background

1.2 Problem statement

1.3 Rationale

CHAPTER TWO : LITERATURE REVIEW

2.1 Global level

2.2 Regional level

2.3 Local level

CHAPTER THREE : OBJECTIVES

3.1General objectives

3.2 Specific objectives

3.3 Variables

CHATER FOUR : METHOD AND MATERIALS

4.1 Study design

4.2 Study population

4.3 Study area

4.4 Sampling

4.4.1 Sample size

4.4.2 Sample technique

List of abbreviation:
FMOH Federal ministry of health

HCP Health care professionals

MNCI Integrated management of childhood illness

MD Medical doctor

MA Medical assistance

ORS Oral rehydration solution

SCM Standard case management

Vit Vitamins
CHAPTER ONE
1.Chapter 1 : Introduction

1-1-Bacground :

Integrated management of Newborn and childhood illness (IMNCI)

is a systematic approach to children’s health which focuses on
the well being to the whole child. The IMNCI strategy includes
three main components: improving case management skills of
healthcare staff, the health systems and family and community
health practices .It aims to reduce death and frequency and
severity of illness and disability, and contributes to
improved growth and development. Integrated management of
childhood illness is successfully introduced in more than 75
countries around the globe.[1]

Skills of health care providers (HCP)are improved through a

training protocol on standard case management (SCM).The
training package of this strategy was meant to enable HCP at
primary health care level to acquire or strengthen the
clinical and communication skills. Physicians and especially
medical assistants at PHC facilities are the main target for
IMCI training. Nurses and nutritionists have also been trained
in IMCI to provide assistance in the cases [1]. They can take
temperature, weigh the child , manage triage and counsel the
mother or care taker of the child according to recommendations
of HCP.The IMNCI is meant to move along the two tracks of the
health system and community respectively while promoting the
establishment of strong links between the two , then IMNCI
presented as strategy which has three components aiming to:[1]
 Improve health workers skills
It is clinical and communication skills and covers
both pre service educating and in service training
 Improve health systems
It concerns with policy ,planning, management
,financing ,organization of work and distribution of
tasks at health facilities ,human resource
,availability of drugs and supplies, referral
monitoring and health information systems
,supervision ,evaluation and research.
 Improving family and community practices
 It refers to twelve key family and community
practices related to child health and development which
include :
 Exclusive breastfeeding
 Complementary feeding
 Micronutrients supplementation
 Hygiene including dispose faeces of children’s
safely
 And hands washing after defecation, and before
preparing meals .
 Use of insecticides treated bed nets to prevent
malaria
 Psychosocial care and development
 Home care for illness
 Home treatment for infections
 Care seeking
 Compliance with advice of HCP
 Checking antenatal care of the child’s mother .[1]
Integrated management of childhood illnesses in Sudan is
moving forward including the community component
interventions to promote selected key family practice on child
care ,Sudan has adopted nine key family practice interventions
which include :[2]
 Exclusive breast feeding for six months
 Continued breast feeding and complementary feeding from
six months
 Prevention and case management of childhood malaria
 Vitamin A supplementation from six months of age
 Comprehensive care of children infected with or exposed
to HIV
 Routine immunization and H.influenzae , meningococcal,
pneumococcal and rotavirus vaccines
 Management of sever acute malnutrition
 Case management of childhood pneumonia
 Case management of diarrhea.[2]

The IMCI strategy has been introduced in Sudan by the

Federal Ministry of Health (FMOH) in 1996, in four districts:
two in Khartoum State and two in Gezira State as an early
implementation phase to test whether the strategy will suit
the background of HCP and fits within the health system in
Sudan or not [3].
Integrated management of childhood illness was introduced
to the preservice of medical schools in Sudan 2001 and later
into the medical assistants schools . To date 29 medical
[1].
schools have introduced IMNCI. Integrated management of
childhood illness is an important strategy to know as a health
extension practitioner because it will enable to help reduce
the numbers of babies and children in community who become ill
or die, to promote the healthy growth and development of
them ,will also improve awareness on reduction of morbidity
and mortality rates of under five children through IMCI
implementation [4].
Implementation of IMCI:
Implementing and introducing the IMCI strategy in a
country is a phased process that requires a great deal of
coordination among existing health programs and service it
involves working closely with local governments and ministries
to plan and adapt the principle of the approach to local
circumstances.
There are six main steps to the process:

 Inclusion of an approach to improve overall health of

children in national health policy.
 Improving standard IMCI clinical guidelines to adapt to
the needs, availability of the culture and the local
language of the population.
 Improving care in local health centers to qualify the
local health workers and practitioner in new ways to
improve examination and treatment, and to counseling
parents effectively .
 Lowering the cost of essential care and providing
medicines reasonable price and simple equipment
 Improving care of hospitals for those who are bedridden.
 Developing support mechanism within the community for
preventing disease and helping the locals to care for
sick infants and getting them to clinics or hospitals
when necessary.[5]

The IMNCI cases management training targets medical doctors

and medical assistants working in PHC facilities. The training
is based on seven modules each covers a step in the protocol
of managing sick children. This is as well called IMNCI
clinical guidelines. The guidelines are presented for easy
reference of HCP into chart-booklet and wall charts as well
as recording forms. The clinical guidelines covers two age
groups of children under five years: children aged 0- < 2
months and children aged 2-59 months.[6]

They meant to guide HCP through the following key steps,

while each step includes several tasks to be performed by HCP
in order to manage the sick child which are :

.Assess and classify the sick child, age two month up to five
years:

1. Assess the child by checking first for danger sings ,

asking question about common conditions, examining the child ,
checking nutrition and immunization status and checking child
for other health problem .

2.Classification of childs follows a color coded algorithm

indicating actions to be taken by the HCP. These are:
Red which means that the child have sever classification and
need urgent attention and referral or admission for inpatient
care or given pre-referral treatment and refer urgently
 Yellow – means the child needs specific medical treatment
at home and follow up in certain duration
 Green – means the child is fine and shall not be given
medical treatment but will advised on home care. (5)
1. Identify treatment.
This step provides guidance to HCP on what treatment
including home care and counseling shall the sick child
receive based on the classification
2. Treat the child
In this step the protocol includes essential medicines and
supplies required for SCM. In a table it guides HCP to
provide the specific medications according to age and
weight of the child.
3. Counsel the mother
This part of the guidelines helps the HCP with steps for
counseling the mother/care taker on the condition related
to the child. It includes providing medications,
breastfeeding, feeding during illness (providing food and
fluids for children above 6 months), treating local
infections, seeking care etc..
4. Follow up the sick child
Using this guidance HCP will be able to advise sick children
based on their classification to return back for follow on
certain days according to the case and also advise them when
to return immediately in case of complications.[5]

Assess and classify the sick young infant , age 0-< 2

months :

These guidelines as well assist HCP to classify the sick

young infant, identify treatment and treating him/her etc..
as in above steps.[5]

B-Problem statement:
The under five child mortality rate in Sudan is 82 death
per 1000 live births. Most of them die because of preventable
causes that can be managed probably in PHC level. Integrated
management of newborn and childhood illnesses strategy can
reduce a lot of these deaths if well implemented at PHC
level.[7]

C-Rational:
We are not aware about a recent assessment of the
implementation of the IMNCI strategy in Sudan at PHC centers
with focus on the SCM and health system support . Our
research is bound to explore some of the strengths and
weaknesses in the implementation of the IMNCI strategy to
identify the gaps that will assist local health authorities in
Shareg Elneel and state ministry of health in improving the
IMNCI implementation. .
Chapter two
2. Chapter two: literature review

2.1 At global level:

A research done in Mwanza, Tanzania 2014 about factors

influencing the implementation of IMNCI by health care workers
at public health centers and dispensaries. The result of it ;
are The main challenge identified in the implementation of
IMNCI are low initial training coverage among the health care
workers , lack of essential drugs and supplies ,lack of onsite
mentoring and lack of refresher .[8]

A research done in west java province, Indonesia 2014 ,

about challenges to the implementation of the integrated
management of childhood illness (IMNCI) at community health
centers . The result of it ;only 64% applied it to all
visiting children , several barriers to IMNCI implementation
were identified , including shortage of health workers trained
in IMNCI , only 19% of health centers had all essential drugs
and equipment for IMNCI .[9]

A research done in Indian 2012 about integrated management of

neonatal and childhood illness (IMNCI): skill assessment of
health and integrated child development scheme (ICDS) workers
to classify sick under five 2014, the result of it ,all
symptoms were asked only in 15%. Danger sings were checked in
<40% observations , immunization card was asked for in 20%
observations. [10]

2.2 At regional level:

A research done in Ethiopia 2019 to assess the factors

affecting the implementation of integrated management of
childhood illness treatment of under five children by health
professionals in health care facilities in yifat cluster in
north shewa zone , amhara region. The result of it , revealed
that proportion of IMNCI implementation in the study setting
was law (58%) . Only 57.7% oh health care workers –
professionals have reported to attend IMNCI training as
compared to WHO recommendation (60&). This study identified
barriers by health care workers which include : shortage of
essential drugs and supplies , inadequate training staff ,
time consuming nature of protocol , lack of supervision , lack
of knowledge about strategy and lack of good attitude of
health care workers –professionals towered the IMNCI strategy.
[11]

A research done in south Africa 2017 about health system

factors affecting implementation of integrated management of
childhood illness (IMCI):qualitative insights , the result of
it ;key barriers for implementation ;stock outs of growth
monitoring equipment , vitamin A and deworming drugs ,
generalized drug dispensing system , key enablers promoting
implementation ; using of standardized child health files with
IMNCI recording forms , availability of a national essential
drug list .[12]

A research done in Nekemte town Ethiopia about Knowledge ,

perception and practice of mothers/caretakers and family’s
regarding child nutrition (under 5 years of age ),2013 ; the
result of it about 84.2% of mother practiced exclusive
breastfeeding for the first 4-6 months ,highest proportions
(92.4%) of women have knowledge that breastfeeding should
continue up to 2 years or older , 55.4% of mothers practiced
complementary food starting from 6 months.[13]

2.3 At local level:

 A research done in Sudan about knowledge, attitude and
practice of mother of under 5 years children regarding
integrated management of childhood illness in Salamat health
center Omdurman Sudan 2016, the result of which showed
that , the mothers under study were found to have several
misconceptions regarding breast feeding (49%) were exclusively
breastfeed their last child, (82.3%) introduced complementary
feeding between 4-6 months , children who were immunized up to
date (93.4%) , (54%) of mothers using ORS .(42.4%) were
increased the amount of food during illness ,( 31.3%) stop
breast feeding during illness ,( 57.6%) of mothers adhered to
medical advice , (38.9%) of the mother getting health
information from the health workers .(14)

A research done in rufa, gezira state , sudan 2015 about;

awareness of mother of under five children towards home care
of sick children in malik alaagid health center ; the result
of it was ;(61.0%)of mothe decrese fluid taken ,(79.5%)
decrease food taken , (58.0%)decrease breast feeding , 80.5%
of mother knew the meaning of exclusive breast feeding , 71.5%
of mothers used to start supplementary feeding at 4-6 months ,
88.5%of the children were fully vaccinated , 9.5% partially
vaccinated and 2%not vaccinated ,82% of mothers have mother’s
card , vitamin A supplementation was 60.5%.[15]
Chapter three
3.Chapter three : objective

1-3-Study objective:

1-3-1-General objectives:
To assess the implementation of IMCI strategy including
standard case management (SCM) MD and MAs in primary health
care centers in sharg alneel locality in order to identify
gaps in implementation and propose possible solution.

1-3-2-Specific objectives:
1-To identify the proportion of MD and MAs who follow the
IMCI SCM skills.

2-To identify the health system enabling and disabling

factors that might affect implementation of IMNCI.

3-To identify the proportion of care takers who are aware

about the key family and community practices adopted by FMOH

1-3-3-Variables:
1. MD and MAs
a. Categories of HCP
b. Date of graduation
c. Working experience at PHC center in months (this one
or before this )
d. Exposure to IMNCI in the pre-service training
e. Exposure to IMNCI in-service training
f. Following Tasks of SCM
 Asking about child complaint (mandatory for all
children)
 Recording weight(mandatory)
 Recording tempaterture (mandatory)
 Asking and checking about general danger signs
(mandatory)
 Asking about the main symptoms (mandatory)

 Asking about cough or difficult breathing

  Asking about diarrhea
 Asking about fever
 Ear problem
 Checking nutritional status (mandatory)
 Checking vaccination and vit A supplementation
(mandatory)
 Asking and assessing about other problems
(mandatory)
Chapter four
 4-chapter four : Method and materials

4-1-Study design:
This is an Observational descriptive cross sectional study .

4-2-Study population:
The study will focus on qualitative assessment of the strategy
implementation which will include assessment of adherence of
HCP to SCM tasks, assessment of logistic supply at the pHC
centers and we will take a sub-sample of an exit interview
with care takers to assess their knowledge and practice
regarding the key family practices.

Therefore the study will comprise different elements

2-3-Study area:
Three primary health care centers in sharg alneel
locality the total primary health care centers in sharg alneel
locality are 46 in which 6 are referential centers and 3 of
them are currently out of service.

2-4-Sampling design:

2-4-1-Sample size:

 T hree PHC centers will be chosen by convenient

sampling because of logistic issues and time
constraints
 All HCP (MD &MA) in the three PHC centers will be
included
 Cases managed by HCP


2-4-3-Sampling technique:
Total coverage of HCP will be taken while a convenient
sampling of care takers will be used by using observational
list .
The list of available medicines and supplies will be assessed

In exit interview an interviewers questioner will be used.

2-5-Data management:

2-5-1-Data collection:
Assessment of the implementation of the IMNCI strategy is an
extensive process compared to time allowed for investigators

The group was advised by the supervisor to take proxy

indicators that can confirm whether IMNCI protocol /strategy
is implemented or not regardless the quality level of doing
the tasks under SCM.

1/ Health care providers (MD and MAs) will be observed while

they are managing under five children and a check list will be
used by investigators to check whether tasks of the SCM are
followed or not. Some tasks will not be fully checked by
observation such as “checking for chest indrawing”. So the
check list will include only tasks that can be checked by
observation only.

2/ Another check list will be used to assess available

equipment and supplies necessary to perform the SCM.

3/ A short structured interviewer administered questionnaire

will be used to collect data from care takers of children
under five years

2-5-2-Data Analysis:
The answers from questionnaires will be coded, and data
will be interred in the statistical package of social science
(SPSS), software version 19.0 and analyzed. The percentage of
various variables will be calculated and computed. Then the
result will be presented using text, charts, graphs, or
tables.

2-6-Ethical considerations:
Research participants should not be subjected to harm in
any ways whatsoever. Respect of the dignity of the
research participants should be prioritized. Full consent
should be obtained from the participant prior to the
 study protection of the privacy of research participants
has to be insured. Adequate level of confidentiality of
the research data should be insured. Ananounimity of
individuals and organizations participating in the
research has to be insured. Any deception or Exaggeration
about the aims of the objectives of the research must be
avoided. Affiliations in any forms, sources of findings,
as well as any possible conflicts of interests has to be
declared. Any type of communication in relation to the
research should be done with honesty and transparency.
Any type of misleading information as well as
representation of primary data finding in a biased way
must be avoided.

2-7-Work plan:

Activity Time Month Date

Obtaining Day1 February February
approvals of 2020
concerned
institute

Training of Day2 February February

data of 2020
collectors

Field testing Day3 March march of

of 2020
questionnaire
Data Day4 April April of
collection 2020

First draft Day5 April April of

of the report 2020

Amendments Day6 April April of

2020

Submission of Day7 April April of

final report 2020

Dissemination Day8 June June of

of results 2020

Reference:
[1] WHO: Integrated Management of Childhood Illness (IMCI)
[Internet] World Health Organization. 2019 [cited 10 December
2019]. Available from: http://www.who.int

[2]WHO: the partnership of maternal, newborn and child Health:

A global review of the key interventions related to
reproductive, maternal ,newborn and child health
(RMNCH).Geneva, Switzerland.2011:p11.

[3] Sumaia Mohammed Al Fadil, Samira Hamid Abd Alrahman, Simon

Cousens, et al. Integrated management of childhood illness
strategy: compliance with referral and follow-up
recommendations in Gezira State, Sudan. Bulletin of the world
Health Organization.2003:81(10):708-1.

[4] Omobobolanle Elizabeth Adekanye, DO Titilayo. Awareness

and Implementation of Integrated Management of Childhood
Illness (IMCI) among nurses in pediatric settings of selected
hospitals in Ibadan, Nigeria.ISOR Journal of Nursing and
Health Science.2014: 3(5):29-34.

[5]WHO. Assess and classify the sick child. In: WHO. Handbook
(IMCI) Integrated Management of Childhood Illness. Swizerland:
WHO Library Cataloguing-in-Puplication data: 2005. P11-56.

[6]world health organization; UNICEF: integrated management of

childhood illness: The sick child age2 month up to 5 years:
Assess and classify.2005:p13-43.WHO/FCH/CAH/00.12

[7]

[8]Augustine kiplagat ,Richard Musto,Damas Mwizamholya and

Domenica Morona ,Factor influencing the implementation of
integrated management of childhood illness (IMCI) ,BMC public
health 2014, available from :http://www.biomedcentral.com
/1471-2458/14/277

[9] CR Titaley , H jusril, I Ariawan , N Soeharno , T Setiawan

, MW Weber , Challenges to the implementation of the
integrated management of childhood illness (IMCI),April-June
2014, vol 3,no 4,dio: 10.4103/2224-3151.206732-pmid:28607302.

[10] Hemant D, Shewade, Arun K, Aggarwal Bhavneet Bharti,

Integrated masnagment of neonatal and childhood illness
(IMNCI): skill assessment of health and integrated child
development scheme (ICDS) workers to classify sick under five-
children .22/ 3/ 2012.doi10.1007/s12089-012-0835-4.

[11]Ayele Mamo Abebe m Mesfin Wudu kassaw and Fikir Alebachew

Mengistu ,Assessment of factors affecting the implementation
of integrated management of neonatal and childhood illness for
treatment of under five children by health professionals in
health care facilities in yifat Cluster in North Shewa Zone ,
Amhara Region ,Ethiopia .2019,available from
:https://doi.orgl10.1155/2019/9474612.

[12]Himani pandya, Wiedaad slemming , Haroon saloojee ,Health

system factor affecting implementation of integrated
management of childhood illness(IMCI), 17/11/2017,
33,2018,171-182 .doi:1093/heapol/czx154.

[13] Wondu garoma berra , Knowledge , perception and practice

of mother / caretakers and family’s regarding child nutrition
( under 5 years od age ), 2013 ,2(4)78-86.

[14]Alrayan Mohammed Almubarak Abdalrazeq , Knowledge,

attitude and practice of mother of under 5 years children
regarding integrated management if childhood illness in
salamat health center, Omdurman , Sudan .2016, available
from :http://repro.uofg.edu.sd/handle/123456789/1240.

[15]Rehab imam mukhtar elsharief , awareness of mother of

under five towards home care of sick children, 12/2015 .corpus
d 150561945.
 ‫إستمارة اإلقرار المستنير‬

‫نحن الباحثون ريهام حمد محمد عثمان الملك‪ ,‬ابوبكر محمود محمد علي‪ ,‬اكرم عبد الرحمن احم د عثم ان‪ ,‬اروى عب اس‪,‬‬
‫االء يوسف دفع هللا محمد طالب بالسنة الخامسة طب‪ ،‬جامع ة الني ل نق وم بدراس ة عن تق ييم تنفي ذ اس تراتيجية المعالج ة‬
‫المتكاملة المراض الطفولة والتى تتبناها وزارة الصحة ‪ .‬الهدف األول من هذه الدراسة ه و تط بيق ط رق البحث العلمى‬
‫كما درسنا والثانى هو معرفة تطبيق إستراجية العالج المتكامل ألمراض الطفولة والتى تتبناها وزارة الصحة ‪.‬‬

‫‪ .‬لقد تم اختيارك لتشارك في هذا البحث ومعك‪ 20‬مبحوث اخرين لجمع معلومات عن تق ييم تنفي ذ االطب اء والمس اعدين‬
‫الطبيين لالستراتيجية نتوقع بمشاركتك انت والمشاركين االخرين ان نتحصل علي نت ائج تفي د المجتم ع وت وفر معلوم ات‬
‫كافية ودقيقة عن طريقة تنفيذاإلستراتيجية ‪.‬‬

‫خالل هذه الدراسة ساقوم باخذ معلومات منك وس نمأل اس تمارة توض ح معلوم ات شخص ية عن ك ‪ .‬كم ا سنس تخدم قائم ة‬
‫الضبط للحصول على بعض المعلومات الهامة لدراستنا‪ ,.‬هذه المعلومات س تحفظ بطريق ه س رية وب دون كتاب ة اس مك في‬
‫االستمارة‪ .‬ونود ان نشير لك ان المشاركة في البحث طوعي ة تمام ا وبمش اركتك س تكون اح د المتط وعين ال ذين يش ملهم‬
‫البحث وعددهم متطوع من االطباء كما ناكد لك‪.‬‬

‫لك كامل الحرية فى المشاركة أو عدمها أو عدم اإلجابة عن ألى سؤال ترى أنه غير مقبول لك‬