HUMAN DEVELOPMENT SECTOR UNIT Central Asia Country Unit | Europe and Central Asia Region Republic of Tajikistan Quality of Child Health Services in Tajikistan THE WORLD BANK World Bank Report Number 62870-TJ ON THE COVER Family Medicine Doctor and under-five patient in Tajikistan HUMAN DEVELOPMENT SECTOR UNIT Central Asia Country Unit Europe and Central Asia Region June, 2011 Republic of Tajikistan Quality of Child Health Services in Tajikistan THE WORLD BANK Table of Contents Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Acronyms, Abbreviations and Tajik Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Chapter 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Chapter 2. Key Survey Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Quality of Clinical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Health Systems Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Chapter 3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Chapter 4. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK iii Annexes Annex 1: Objectives of the Study and Survey Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Annex 2: Descriptive Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Annex 3: List of Surveyed PHC Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Annex 4: IMCI Priority Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Table of Figures Figure 1: Trends in Tajikistan’s Infant Mortality Rate 1990-2006 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Figure 2: Leading Causes of Post-Neonatal Mortality in Tajikistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Figure 3: Tuberculosis and Measles Vaccine Coverage for Children Aged 12-23 Months . . . . . . . . . . 5 Figure 4: Assessment of Danger Signs by Regions (N=300 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Figure 5: Assessment of Weight against Growth Chart by Regions (N=300) . . . . . . . . . . . . . . . . . . . . . 9 Figure 6: Integrated Assessment: Main Tasks and the WHO Index (N=300) . . . . . . . . . . . . . . . . . . . 10 Figure 7: Rational use of Antibiotics by Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Figure 8: Vaccines Availability in Primary Health Care Facilities (N=70) . . . . . . . . . . . . . . . . . . . . . 14 Figure 9: Availability of Basic Equipment and Supplies in the Facilities (N=70) . . . . . . . . . . . . . . . 15 Figure A1: Cases Seen by Health Care Providers’ IMCI Training Status . . . . . . . . . . . . . . . . . . . . . . . 22 List of Tables Table 1: Leading Causes of Child Mortality in Tajikistan by Region (2001-2002) . . . . . . . . . . . . . . . 4 Table 2: Comparison of Selected Indicators by Family Doctors Previous Specialization . . . . . . . . . . 13 Table A1: Sampling Frame and Survey Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Table A2: PHC Facilities Visited . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Table A3: Health Care Provider Type and IMCI Training Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Table A4: Characteristics of the Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Table A5: Study PHC Facilities by Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 iv Quality of Child Health Services in Tajikistan Acknowledgments This report was prepared by a World Bank team with support M. Atoev (Director, Center of Pediatrics and Pediatric from the Global Alliance for Vaccines Initiative (GAVI) Trust Surgery, Tajikistan), Dr. Z. Nabiev, Dr. Vakhidov (Center Fund. Wezi Msisha (Task Team Leader, Health Specialist, of Paediatrics & Pediatric Surgery, Tajikistan), and Dr. Z. ECSH1) led the preparation of the report. The team mem- Kasimova (CBHP Project Implementing Unit). bers from the World Bank included Sarvinoz Barfieva (Operations Officer, ECSH1), Gabriel Francis (Program The report has benefited greatly from the peer reviewer Assistant, ECSHD), Gulnora Kamilova (Program Assistant, comments (on both the concept note and the draft report) ECCUZ), Shoira Zukhurova (Team Assistant, ECCTJ), provided by Aparnaa Somanathan (Economist, EASHD), Ivdity Chikovani, Maya Kherkheulidze, Natia Rukhadze, and Mariam Claeson (Program Coordinator, SASHN), Salima Ketevan Chkhatarashvili (Curatio International Foundation). Kasymova (National Program Officer, WHO Tajikistan), and Editorial services were provided by Rosemarie Esber. Son Nam Nguyen (Senior Health Specialist, ECSHD). The comments and guidance received from Charles Griffin (Sr. This report would not have been possible without techni- Advisor, ECAVP) were also very useful. cal support from the WHO and UNICEF Tajikistan. We especially would like to acknowledge the support we received This task was undertaken under the guidance of Tamar from, Salima Kasymova (National Program Officer, WHO Manuelyan Atinc (former Sector Director, ECSHD), Tajikistan) and Dr. S. Kurbanov (UNICEF, Tajikistan). Mamta Murthi (Acting Sector Director, ECSHD ), Abdo Yazbeck (former Sector Manager, ECSH1), Daniel Dulitzky We also extend our thanks to Dr. S. Rhakmatuloev (Head (Sector Manager, ECSH1), Motoo Konishi (Country of Maternal & Child Health Department [MCH], Ministry Director, ECCU8), Chiara Bronchi (former Country of Health, Tajikistan), Dr. S. Rakhmatullaeva (Deputy Head Manager, ECCUTJ), and Marsha Olive (Country Manager, of MCH Department, Ministry of Health, Tajikistan), Dr. ECCUTJ). Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK v Acronyms, Abbreviations and Tajik Terms ADB Asian Development Bank NNS National Nutrition Survey ARI Acute Respiratory Illness Oblast A province CPD Continuous Professional Development ORT Oral Rehydration Therapy DPT Diphtheria Polio Tetanus PHC Primary Health Care FM Family Medicine Rayon A rural district GBAO Gorno-Badakhshan Autonomous Oblast RRP Rayons of Republican Subordination IMCI Integrated Management of Childhood Illness TLSS Tajikistan Living Standards Survey IMR Infant Mortality Rate U5MR Under Five Mortality Rate Jamoat A local self-government unit, usually a UNDP United Nations Development Program rural sub district UNICEF United Nations Children’s Fund MCH Maternal and Child Health USAID United Sates Agency for International MDG Millennium Development Goals Development MICS Multiple Indicator Cluster Survey WHO World Health Organization MOH Ministry of Health vi Quality of Child Health Services in Tajikistan Executive Summary 1. The Government of Tajikistan has identified Primary though most children were weighed at the clinic, in only 27 Heath Care (PHC), and Maternal and Child Health (MCH) percent of the cases did providers check the child’s weight as top priorities in its first Comprehensive National Health against standard growth charts. This simple step is essential to Sector Strategy (2010-2020). Poor child health outcomes reveal long-standing health problems, particularly malnutri- in Tajikistan are related to systemic health sector issues, tion. Ten tasks should routinely be performed on every child including the financing and quality of health services, as presenting at a clinic, according to the IMCI guidelines. Our well as poverty, rural residence, and access to clean water. findings show that overall, on average, only 6.9 tasks were Tajikistan’s Millennium Development Goal (MDG) target for performed, and the RRP facilities had the worst performance a two-thirds reduction in child mortality requires an infant in most instances. mortality rate (IMR) of 29.6 and the under-five mortality rate (U5MR) of 39.3 by 2015.1 The most recent estimates place 4. On accuracy of diagnosis, the findings were equally the IMR at 52 per 1,000 live births and the U5MR at 61 per troublesome. Providers appropriately referred ten sick chil- 1,000 live births.2 dren to a higher-level facility for treatment. Of the remaining 290 in the sample, only 49 percent were correctly diagnosed. 2. To reduce its high infant and child mortality rates as well Only 42 percent of children needing an antibiotic left the as develop PHC, the Government of Tajikistan introduced facility with one. While 24 percent of children not needing the Family Medicine model of practice in 2001, and the an antibiotic left the facility with one, or a prescription for Integrated Management of Childhood Diseases (IMCI) an antibiotic. Only 8 percent of children who should have strategy in 2000. This World Bank study was undertaken in received a first dose of an antibiotic at the facility during the 2010 to assess the quality of outpatient health care services visit actually received it. The treatment of children with diar- for sick children aged two months to five years at primary rhea was better. Of the children needing oral rehydration salts, health care (PHC) facilities in Tajikistan. The specific focus 84 percent of them received a first treatment at the facility, of this study is on the quality of care delivered by PHC pro- but only 22 percent with anemia received an iron supplement viders who were retrained over the last several years as Family at the facility. Medicine practitioners. The team employed the standardized WHO/UNICEF IMCI survey methodology to evaluate the 5. The study also finds that supervision of PHC workers is quality of care delivered to sick children attending outpatient irregular, and training does not seem to be performed system- facilities. The study was conducted in 19 districts in Khatlon atically to improve children’s health outcomes. For example, region, Sogd region, the Rayons of Republican Subordination in the Sogd region, no IMCI-trained nurse worked in any of (RRP), and Dushanbe City. the 20 PHC facilities surveyed, even though they play a key role in the provision of child health services. For the majority 3. The study findings which closely mirror those of the 2009 of indicators examined, no statistically significant differences WHO/UNICEF IMCI survey will be of great concern to the were found between providers retrained in the six-month Ministry of Health and should provide the impetus to take Family Medicine program and those who were not. The cur- immediate remedial actions. Of the sample 300 sick children rent Family Medicine retraining program does not seem to brought to the PHC facilities by a caretaker, only 46 percent improve the use of the IMCI guidelines for acute child health were assessed for the basic three danger signs: inability to care services. These findings indicate the need to improve the drink, vomiting, and convulsions. Providers should have overall training of Family Medicine practitioners in the basic screened 100 percent of these sick children for these seri- management of sick children following the IMCI clinical ous symptoms, according to the IMCI guidelines. Only 4 guidelines, particularly because Family Medicine practitioners percent of sick children were appropriately screened at the are often the first point of contact between sick children and RRP’s primary health centers. This shocking finding sharply the health care system. decreased the overall average. Nonetheless, the other regions scores ranged from 46 to 64 percent, still a poor showing for 6. Two main issues are highlighted by this study. Firstly, the an indicator that should be consistently 100 percent. Even quality of primary health care services provided to children is lacking in many areas, irrespective of the PHC provider’s type of training. Second, is that the family medicine and IMCI 1 UNDP (2005) Investing in Sustainable Development: Tajikistan MDG Needs Assessment. training programs and methods require further enhancement to ensure that the service quality for children improves. Some 2 UNICEF State of the World’s Children Report 2011. Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 1 of the findings of this survey may be due to the staff facing the system of routine supervision and support of primary constraints that could be relieved with additional resources in health care providers to identify problems and reinforce their all PHC facilities to ensure the availability of essential drugs, adherence to recommended clinical practice guidelines. antibiotics and vaccines in all PHC facilities. However, train- ing and incentives to provide appropriate care to sick children 8. Medium-term actions to implement include: (i) under- should be revisited urgently. The existing approach is not take an independent and external evaluation of the Family serving children or their parents well. While many determi- Medicine re-training programs to ensure adequate and rel- nants of infant and child mortality lie outside the health care evant content and training methods, with special attention system, it is vital that when a sick child comes in contact with to MCH; (ii) provide continuous skills improvement training the medical care system that it should perform well on behalf for the trainers of Family Medicine providers at the four of the child. main post-graduate training centers; (iii) improve methods of paying primary health care providers through further develop- 7. In light of these findings, several actions must be taken ment of the current per capita system, including exploring the by the Ministry of Health and its development partners to use of incentive payments to Family Medicine practitioners improve the current state of affairs. Of immediate concern are to improve quality of services, and (iv) improvement of the the following: (i) ensure the availability of essential antibiotics current system of quality assurance in primary health care and vaccine stocks in all first-level primary health care facili- facilities. ties, with a special focus on PHC facilities in the RRP; (ii) undertake a closer assessment of factors contributing to poor 9. Improving the country’s system of PHC is within the reach performance in PHC facilities in the RRP and other poor per- of the Tajikistan Ministry of Health. With careful planning forming rayons and implementing the appropriate solutions; and coordination, the MoH can successfully implement these (iii) provide intensive on the job training on correct child recommendations, which will result in much needed service growth monitoring and nutrition to reinforce the skills and improvements for sick children and their health outcomes. knowledge of primary health care workers; and (iv) improve 2 Quality of Child Health Services in Tajikistan Chapter 1. Introduction CHILD MORBIDITy & MORTALITy 1.3 Other countries with GDP levels similar to Tajikistan are making better progress towards reaching their MDG targets. 1.1 Globally, the majority of under-five mortality is attributed In the Lao People’s Democratic Republic, for example, the to a few commonly occurring and preventable childhood ill- IMR is 46 per 1,000 and in the Kyrgyz Republic and neigh- nesses. These diseases, which often occur concurrently, are boring Uzbekistan; the IMR is 32 per 1,000 live births. For pneumonia, diarrhea, malaria, measles and HIV. In many under-five mortality rates, Lao and the Kyrgyz Republic are cases, childhood diseases are worsened by under-nutrition, respectively at 59 and 37 per 1,000 live births (UNICEF, which contributes to approximately 35 percent of child 2011). Understanding the factors that promote or hinder deaths, and 11 percent of the total global disease burden.3 progress towards achieving the MDGs critical and some of 1.2 Tajikistan’s infant and child mortality rates are still quite these are discussed below. high. Current estimates place the infant mortality rate (IMR) at 52 per 1,000 live births and the under-five mortality rate TAjIKISTAN DEMOgRAPHIC (U5MR) at 61 per 1,000 live births,4 compared to an IMR of SITUATION 65 per 1,000 live births and an U5MR of 79 per 1,000 live births in 2005.5 Despite Tajikistan’s significant improvements 1.4 Poverty rates in Tajikistan have declined significantly from in MCH outcomes, to achieve its Millennium Development 72.1 percent in 2003 to 53.1 in 2007 and even further to Goal (MDG) goal of a two-thirds reduction in child mortality 47.2 percent in 2009. Even so, it remains the poorest country by 2015, Tajikistan’s task is to attain an IMR of 29.6 and an in Central Asia. Poverty is mainly a rural phenomenon, with U5MR of 39.3 by 2015.6 the rural poor accounting for 75 percent of all poor and 72 percent of the extreme poor (World Bank, 2010). Out of 3 Black et al (2008). Maternal & Child Undernutrition: Global & an estimated population of 7 million people, approximately Regional Exposures and Health Consequences. The Lancet, 371 (9068), 3 million (42%) are aged 18 and under, with the median 243-260. age of the population at just 20.7. Life expectancy at birth 4 UNICEF State of the World’s Children Report 2011. is 67.3 years. Although fertility has fallen in recent years, 5 Goskomstat. (2007). Tajikistan Multiple Indicator Cluster Survey the total fertility rate is still greater than 3 and the annual 2005 Final Report. average population growth rate is approximately 1.9 percent 6 UNDP (2005). Investing in Sustainable Development: Tajikistan MDG Needs Assessment. per year (UNICEF, 2011, UNDP, 2010). To advance overall Figure 1: Trends in Tajikistan’s Infant Mortality Rate 1990-2006 100 WHO WHOSIS: 91 90 MICS 2000: IMR = 89 80 LSMS 1999: 79 WHO WHOSIS: IMR = 75 70 MICS 2005: 65 60 50 40 WHO WHOSIS: 38 30 20 10 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 MOH Estimates HFA WHO WHOSIS MICS 2000-2005 LSMS 1999/2003/2007 Source: Multisectoral Determinants of Child Health in Tajikistan (2009). Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 3 Figure 2: Leading Causes of Post-Neonatal Mortality in Tajikistan7 2009 2010 ARI, 20% ARI, 18% Other, 36% Other, 35% Pneumonia, 19% Pneumonia, 21% Congenital Congenital Malformations, 7% Acute Diarrhea, 18% Malformations, 7% Acute Diarrhea, 19% Total Cumulative Reported Deaths = 1,535 Total Cumulative Reported Deaths = 1,604 population health, policies focused on improving child health (ARI), pneumonia, and acute diarrhea still account for more outcomes are critical. than 50 percent of reported child deaths within the first year of life, a pattern that has remained persistent over the last eight years until the present (Figure 2). CAUSES Of CHILD MORBIDITy & MORTALITy 1.6 Child morbidity and mortality patterns in Tajikistan also vary significantly by geographic area. The lowest U5MR 1.5 Preventable illnesses contribute to a considerable propor- and IMR are in the Gorno-Badakhshan Autonomous Oblast tion of all child deaths in Tajikistan. A significant proportion of neonatal deaths are due to prematurity and low birth weight, while acute infections are the leading cause of deaths 7 Data are from official medical statistics and reflect only reported child in the post-neonatal period (Table 1). Acute respiratory illness deaths. Table 1: Leading Causes of Child Mortality in Tajikistan by Region (2001-2002) Khatlon Region & Dushanbe City Sogd Region & RRP Premature birth (32%) Prematurity/low birth weight (43%) Pneumonia (21%) Birth asphyxia (33%) Congenital malformations (12%) Acute diarrhea (12%) Birth asphyxia (8.6%) Pneumonia (6%) Post-neonatal Deaths Post-neonatal Deaths Meningitis/encephalitis (20%) Acute diarrhoea (25%) Acute diarrhea (17%) Severe/moderate malnutrition (24%) Severe malnutrition (16%) Meningitis/encephalitis (16%) Pneumonia (14%) Pneumonia (16%) Severe anemia (12.6%) Severe anemia (15%) Source: UNICEF Tajikistan, 2004. *Rayons of Republican Subordination (RRP). 4 Quality of Child Health Services in Tajikistan Figure 3: Tuberculosis and Measles Vaccine Coverage for Children Aged 12-23 Months 100 90 80 70 60 50 BCG Measles 40 30 20 Total Dushanbe Other Urban Rural Sogd Khalton RRP GBAO None Primary Basic Secondary general Sec special Higher Poorest 2 Quinitile 3 Quintile 4 Quintile Richest Source: TLSS 2007. (GBAO) region (54 and 46 per 1,000 respectively), as well as age of five was 29 percent nationwide, and highest in the Dushanbe City, while the highest rates are in Khatlon region Khatlon region at 36.9 percent, 27.9 percent the in Sogd (102 and 81 per 1,000 respectively), according to the 2005 region, 22.8 percent in the RRP, 25.4 percent in GBAO, and Multiple Indicator Cluster Survey (MICS). Several factors lowest in Dushanbe at 21.8 percent (UNICEF, 2010). which vary by region, are known to increase the risk of poor 1.9 Variation in these critical factors contributes to the child health outcomes in the country including short breast- increased risk for poorer child health outcomes within the feeding duration, late vaccinations, low use of oral rehydration country. Of course, these factors alone do not entirely account therapy (ORT) for diarrheal diseases, micronutrient deficien- for all observed child morbidity and mortality, but they are cies, and low antenatal care visits. For instance, contraceptive exacerbated or indirectly caused by other broader environ- use among married women is highest in GBAO region (55%) mental factors, such as region of residence, maternal educa- and lowest in the Khatlon region (33%). Similarly, immuniza- tion and household poverty levels. tion coverage rates were lowest in the Khatlon region and the Rayons of Republican Subordination (RRP) and highest in 1.10 While child health outcomes are affected by multiple the Sogd region. factors, this study chose to assess a very specific health systems aspect, namely the quality of health services in the primary 1.7 Notably, only 41 percent of children in the RRP had been health care setting. Service quality is affected by several fac- vaccinated against measles compared to 77 percent in Sogd tors including information, infrastructure, materials, drugs, (Figure 3). In addition, the proportion of exclusively breastfed human resources, what activities are done as well as how they infants aged 0 to 3 months was 23 percent in Dushanbe and are done.8 Quality assessment is a way to measure the differ- 33 percent in Khatlon compared to 61 percent in GBAO ence between expected and actual performance to identify (TLSS 2007). The practice of early weaning combined with opportunities for improvement.9 the chronic food shortages faced by many households, par- ticularly the poorest, contribute to the relatively high levels of stunting observed in Tajik children and is also reflected in the high incidence of low birth weight babies. 8 Massoud et al (2001). A modern paradigm for improving health care quality. Quality Assurance Project. 1.8 According to the most recent National Nutrition Survey 9 Lin & Tavrow (2000). Assessing health worker performance of IMCI (NNS), the prevalence of stunting among children under the in Kenya. Quality Assurance Project Case Study. Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 5 PRIMARy HEALTH CARE IN Management of Childhood Diseases (IMCI) strategy, initially on a pilot basis in 2000. The strategy, developed by the WHO TAjIKISTAN and UNICEF, aims to improve child health and reduce child 1.11 Over the last decade, Tajikistan has been reforming its mortality due to pneumonia, diarrhea, malaria, measles and health care system, which was based on the Soviet model of under-nutrition.11 The strategy has three main components: health service provision. The Soviet system was centralized (i) in-service training of PHC workers in the delivery of effec- and focused largely on curative inpatient services provided tive and efficient preventive and curative care for the cited by highly specialized doctors, with little emphasis on pri- problems; (ii) improving family and community practices on mary health care (PHC) and preventive services. As such, the child health; and, (iii) strengthening health systems support, strengthening of PHC services, including improvements in including the supply of drugs and vaccines.12,13 The WHO financial and human resource allocation to the primary care and UNICEF recommend an eleven day in-service training level, has become the basis for the ongoing health system program for health workers on the IMCI case management reforms in the country. Key reform directions for strengthen- guidelines. This consists of seven modules that combine class- ing the management and delivery of primary health care ser- room work with hands on clinical experience.14 vices include the introduction of per capita financing mecha- nisms, building management capacity, and the introduction 1.15 In Tajikistan training of health personnel on the IMCI of the Family Medicine (FM) model of practice.10 The guidelines has been done through continuous professional Ministry of Health has introduced these reforms in selected development (CPD) workshops ranging from three to nine districts of the country on a pilot basis with the support of day duration. The guidelines are also included in the six- various international donors. Family Medicine is seen as the month FM postgraduate training program, with two days most important pillar of the PHC reform as it is expected to (16 hours) specifically dedicated to them. This training is lead to better health outcomes through efficiency gains and intended to result in improvements in the quality of care improved population health service coverage. provided to sick children in PHC facilities. 1.12 It is recognized that building an adequate cadre of FM 1.16 The IMCI Strategy components encompass the main practitioners in Tajikistan will take several years. Thus a two programmatic directions that the MOH identified in several pronged approach is being pursued to meet the country needs policy and strategic documents as critical to improving the for FM providers; (i) retraining of health personnel specialized health of children aged five and under. These documents in another area (internists, pediatricians, obstetricians and include the National Strategy on Child and Adolescent Health nurses) as Family doctors and family nurses; and (ii) prepara- (2008-2015); Action Plan on Child and Maternal Nutrition tion of new FM specialists at the undergraduate level. (2009); and more recently, Tajikistan’s first Comprehensive National Health Strategy (2010-2020), in which maternal 1.13 The FM retraining is a six month long full time post and child health and primary health care are central features. graduate program that was initiated in 2001. The program includes theoretical and clinical training covering cardiology, 1.17 The Government implemented its IMCI strategy nation- obstetrics and pediatrics among other topics. In the last few wide in 2003. Its impressive support structure included the years, the Ministry of Health and its international develop- establishment of a National IMCI Center, three regional and ment partners have undertaken various small-scale assess- more than 65 district IMCI Centers to coordinate the pro- ments of the FM retraining process and to a lesser degree gram. Yet high morbidity and mortality rates among children the practices. However, no overall assessment exists for the under the age of five due to diarrheal diseases, malnutrition, performance of Family Medicine providers in the provision of critical primary health care services, particularly those related to maternal and child health care. 11 Arifeen, Bryce, Gouws et al (2005). Quality of care for under-fives in first level health facilities in one district of Bangladesh. Bulletin of the World Health Organization; 83 (4):260-267. 1.14 The Government’s concern over the high infant and 12 Gouws, Bryce, Pariyo et al (2005). Measuring the quality of child child mortality rates prompted it to introduce the Integrated health care at first-level facilities. Social Science & Medicine; 61:613-625. 13 Bryce, Victora & the MCE-IMCI Technical Advisors (2005). Ten methodological lessons from the multi-country evaluation of integrated 10 Family medicine is the medical specialty that provides continuing, management of childhood illness. Journal of Health Policy and Planning, comprehensive health care for the individual and family. It is a specialty 20 (supplement 1): i94-i105. in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ 14 WHO and UNICEF (1997). IMCI in service training guide. system and every disease entity. American Academy of Family Physicians Available online: http://www.who.int/child_adolescent_health/docu- (2010). ments/9241595650/en/index.html 6 Quality of Child Health Services in Tajikistan and pneumonia persist. With appropriate case management, assess how FM and other PHC practitioners use the IMCI correct clinical assessment, provision of appropriate treatment guidelines. The WHO/Unicef IMCI Health Facility survey and counseling on continued home management, and care therefore provided a systematic and well tested approach to of the child at home the majority of these deaths can be pre- examine the quality of child care using the IMCI guidelines vented. The IMCI strategy provides comprehensive guidelines are a basis for assessing the performance of FM practitioners to treat common childhood illnesses at first level facilities. As through the collection of primary data. To assist in this assess- such if these guidelines are properly followed, they should ment, the team studied the nature and quality of services result in the provision of basic quality care for sick children. received by 300 sick children who visited 70 primary health care centers in three regions of Tajikistan and Dushanbe city. 1.18 To improve the quality of health services, and ultimately Details on the study methodology and descriptive statistics are child health outcomes, policy makers, PHC managers, prac- provided in Annexes 1 to 3. titioners, training institutions, and organizations need to Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 7 Chapter 2. Key Survey Results 2.1 The main findings of the survey are presented in the assessed children for all three danger signs as IMCI guidelines subsequent sections following the main areas of focus of the require. IMCI guidelines, with particular attention paid to the perfor- 2.4 There were large variations in the distribution of the indi- mance of FM doctors. cator by regions (see Figure 4). In the RRP, only 4.3 percent of children were checked for the danger signs. QUALITy Of CLINICAL CARE 2.5 Even when family doctors and pediatricians saw the chil- 2.2 This section presents the findings of case assessment, dren, no statistically significant difference was found. Danger classification, treatment and counseling, which are organized signs were assessed by these specialists in respectively only according to the IMCI priority indicators (shown in Annex 44.0 percent and 49.3 percent of cases. When analyzed by 4). length of IMCI training, the providers trained in the longer nine-day IMCI training performed better.15 Assessment Child checked for three danger Child’s weight checked against a growth chart signs (PI.1) – 45.7% (PI.3) – 26.7% 2.3 Assessing each child for three key danger signs: inability to 2.6 Most of the children were weighed (86.7%) on the day drink, vomiting everything after each feeding and convulsions of the assessment. However, only in a very small proportion is critical to detect cases of very severe disease requiring urgent of cases (26.7%) did health providers check the child’s weight referral. The IMCI guidelines require that these key assess- against the growth chart or standard tables or formulas to ment tasks be performed on every sick child, irrespective of determine the weight-for-age, which would indicate whether the specific complaint. Health care provider should assess all the child was within appropriate guidelines. Monitoring of the three danger signs in each case of a sick child visit. This children’s weight is critical in Tajikistan because chronic assessment is the first step for early identification of patients underweight is a problem in nearly a third of the children who need urgent treatment. When assessing each danger sign aged five and under. Because malnutrition is an underlying independently, researchers found that providers assessed only cause of childhood diseases, early identification and proper 66.3 percent of children for inability to drink, 65.0 percent management are imperative. The WHO growth charts are for vomiting everything after each feeding, and 52 percent for convulsions. In less than half of all cases (45.7%), providers 15 p value < 0.05. Figure 4: Assessment of Danger Signs by Regions (N=300 ) 80 63.8 % of children observed 60 56.9 53.5 45.7 40 20 4.3 0 Dushanbe Khatlon Sogd RRP Total 8 Quality of Child Health Services in Tajikistan Figure 5: Assessment of Weight against Growth Chart by Regions (N=30016) 100 94.2 93.8 83.1 % of observed children 80 72.5 86.7 60 42.5 40 27.9 23.1 20 10.1 26.7 0 Dushanbe Khatlon Sogd RRP Total child weighted weighted assessed against growth chart part of the physical exam in pediatrics and a powerful tool two years of age be assessed for feeding practices (including that can sensitively detect a child’s nutritional status. In the breastfeeding for children under two years old, complemen- majority of cases, providers only weighed a child but did not tary feeding, and feeding changes during acute episodes of ill- assess whether the child’s weight was age and height appropri- ness). Such assessment is very important to establish adequate ate. Weighing a child without proper assessment has no value. feeding practices and prevent development of nutritional A regional comparison shows that the lowest proportion of problems. This study shows that of the 232 children under children assessed for weight-for-age was in the RRP (Figure two years of age who were not referred to a higher level of 5). care, less than half (45.3%) were assessed for feeding practices. Children with low weight-for-age were not more likely to 2.7 Children seen by family doctors were twice as likely to receive feeding assessment than those without this condition. be weighed and have their weight checked against the growth From 40 children with low weight and not requiring referral, chart compared to children seen by pediatricians (30.2% 45.0% were assessed for feeding problems (SI.3). vs. 14.9%17 ). No difference was found in this indicator for cases seen by current and former pediatricians when con- 2.9 No statistically significant difference in adherence to pro- sidering the provider’s specialization before retraining into tocols was found between cases observed by family doctors Family Medicine). When cases were analyzed according to and those observed by pediatricians (a finding similar to other the health workers training in IMCI, it was found that no indicators). However, providers trained in IMCI were more single child was assessed weight-for-age when a health worker likely to assess children for feeding practices, and the rate was was not trained in IMCI (25). Among cases seen by IMCI- higher among cases managed by providers who attended the trained health worker (275), a third of children received seven-day IMCI course. weight-for-age assessment, with a higher proportion observed among children whose providers attended the nine-day IMCI 2.10 Assessment of respiratory rate in children with cough course. or difficulty breathing . A child’s breathing rate is one of the most sensitive and specific indicators of pneumonia. Child under two years of age assessed for feeding The IMCI guidelines recommend assessing breathing rate practices (PI.6) – 45.3% and chest retractions in every case with a cough and diffi- culty breathing. In 147 cases, caregivers complained of their 2.8 The IMCI guidelines recommend that children under children suffering from respiratory problems. Nonetheless, providers only counted the breathing rate in half of the 16 Sample sizes for regions are Dushanbe: N=65, Khatlon: N=86, Sogd: cases (53.1%). Failure to assess for this important indicator N=80, RRP: N=69; Total: N=300. can easily lead to misdiagnosis, especially in infants. IMCI- 17 p value < 0.05. Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 9 trained health workers were more likely assess the respiratory 2.12 The index of integrated assessment for Tajikistan was rate of children than those examined by non-trained staff. 6.9, indicating that on average for every child, providers Assessment of respiratory rate was positively associated with performed a mean 6.9 assessment tasks of the WHO recom- the IMCI training duration, with a statistically significant mended 10 tasks. difference.18 2.13 Of the 10 main assessment tasks, health care providers most frequently perform child weighing, assessment of vac- Index of integrated assessment (mean) cination status, and the check for the three main symptoms, (PI.5) – 6.9 while assessment of weight-for-age is the most neglected 2.11 In any sick child visit, and despite the problem and task, as shown in Figure 7 below. complaints for the visit, the provider should perform several key assessments, according to IMCI guidelines. A thorough 2.14 The highest index was found in the Khatlon region (8.0) and systematic assessment helps to identify conditions that are and the lowest in the RRP (4.5). No difference was found not reported by the caretaker. To measure the completeness of between cases observed by family doctors and those observed the assessment received by each child, an index of integrated by pediatricians. The IMCI trainings had a positive influence assessment was used. The index consists of key tasks and gives on the integrated assessment. The index was higher for equal weight to each task done (score per task done = 1). It children observed by providers trained in a nine-day IMCI is expressed as the mean of the number of tasks performed in course (7.8 out of 10 tasks) than those seen by untrained each child (out of those that should have been performed). providers or those trained for three to five or seven days (6.1, This was based on the generic index proposed by the WHO, 6.3 and 5.8 tasks out of 10 respectively). which includes ten assessment tasks. These are child checked for three danger signs (1, 2, 3); checked for the three main Classification and Treatment symptoms (4, 5, 6); child weighed (7); and weight checked Child is correctly classified (SI.5) – 49.3% against a growth chart (8); child checked for palmar pallor (9); and, for vaccination status (10). The index of integrated 2.16 Of the 290 children not requiring referral to a higher- assessment enables follow-up of improvements in care and level facility, almost half were correctly classified according to progress over time. Taking into account each of the tasks of the main symptoms of childhood illnesses. The term “correct the generic index, the higher the number of tasks performed, classificationâ€? was used when the health providers’ classifica- the higher the index. It also allows comparisons with other tion agreed with that of the surveyors (“gold standardâ€?). The surveys in different countries. following classifications were analyzed: very severe disease or severe pneumonia or pneumonia; diarrhea with severe dehy- 18 p value < 0.05. dration or some dehydration, severe persistent diarrhea or Figure 6: Integrated Assessment: Main Tasks and the WHO Index (N=300) % of children observed 0 20 40 60 80 100 Child checked for 3 general danger signs 45.7 Child checked for 3 main symptoms 71.3 Child weighted 86.7 Child’s weight checked against growth chart 26.7 Child vaccination status checked 82.0 Child checked for palmar pallor 44.0 Index of integrated assessment (mean) 6.9 (mean) 10 Quality of Child Health Services in Tajikistan persistent diarrhea and/or dysentery; very severe febrile disease Non-severe pneumonia was classified in 12 children, and only or fever-possible bacterial infection; measles with or without in 33.3 percent of cases were antibiotics prescribed correctly complications. (SI- 6). Only five children were classified as having dysentery and were prescribed oral antibiotics, although in one case, the 2.17 Children seen in the RRP were classified correctly in prescription was incorrect. A higher rate of correct oral anti- 34.8 percent of cases (lowest rate) with the highest rate found biotic prescription was found among the cases managed by in Khatlon (57.8%). Children seen by IMCI trained health family doctors (48.1%) compared to pediatricians (23.1%); workers were classified correctly in half of the cases and in however, the difference did not reach the level of statistical one-third of cases if the health worker was not trained in significance. Analyses by providers’ with IMCI training status IMCI. did not show any statistically significant difference. 2.18 In addition to the above standard indicator, the provid- Child not needing antibiotics and left the facility without ers’ classification was matched against the “gold standardâ€? for antibiotics (PI.8)-55.9% all IMCI problems (Streptococcal or non-Streptococcal sour throat; mastoiditis; acute or chronic ear infection, pharyngeal 2.23 In approximately half of the cases (55.9 %), health care abscess; severe malnutrition or low weight; anemia or severe providers did not prescribe antibiotics to patients who did not anemia in addition to the above mentioned key IMCI condi- need antibiotic treatment, according to the IMCI classifica- tions). The study revealed that 44.7 percent of all observed tion. In 24.3 percent of cases (54 out of 222), providers pre- children (N=300) were correctly classified by the providers. scribed antibiotics even though there was no need. Common reasons for irrational antibiotic prescription (among 54 2.19 No statistically significant difference between provider children) were classifications not requiring antibiotic treat- specialties was found (family doctors versus pediatricians). ment such as “no pneumonia, cough or coldâ€? (61.1%), non- However, IMCI training had a positive influence on the pro- Streptococcal pharyngitis (20.4%), or misclassification of viders’ classification skills.19 health conditions by providers. 2.24 Regional analysis demonstrated that in Dushanbe and Rational Use of Antibiotics the RRP, the rational use of antibiotics was better than in Child needing an oral antibiotic and were cor- other regions (Figure 7). rectly prescribed an oral drug (PI.7) – 42.0% 2.25 An equal proportion of cases (not needing antibiotic 2.20 Only 42.0 percent of the 69 children with an IMCI treatment and left without antibiotic) managed by family doc- condition who did not require urgent referral and or need oral tors and pediatricians left the facility without being prescribed antibiotics were prescribed antibiotics correctly. Antibiotics antibiotics.20 were prescribed as recommended by the national IMCI guide- lines (first choice medications) and the national list of essen- Oral rehydration salt (ORS) tial medicines. For the antibiotic to be prescribed correctly, the provider had to state the dose, frequency and duration of Child with dehydration treated correctly treatment clearly in the prescription. (SI.7) – 84.0% 2.26 Twenty-five children were classified as having diarrhea 2.21 In the majority of cases, prescribed antibiotic dosage and with some dehydration but not in severe condition. Of them, the routine of administration were correct, but the treatment the majority (84%) received ORS at the facility. All children duration was wrong. Duration of dosage is considered a weak in Dushanbe and the RRP were started on oral rehydration area in other countries as well. For example, when providers therapy at the facility, as recommended by the IMCI guide- classified Streptococcal pharyngitis, they prescribed antibiot- lines. The availability of ORS at more than 80 percent of the ics for three or five days instead of the recommended duration facilities ensured that this important action was taken. (10 days) as advised by the IMCI guidelines. 2.22 The Sogd region showed the lowest rate of correctly Child with anemia treated correctly administered oral antibiotics to children who needed oral (SI.9) –21.6% antibiotic treatment (14.8%) compared to other regions. 2.27 Fifty-one children were classified as having anemia but 19 9 days – 57.7%, 7 days – 34.5, 3-5 days – 32.5%, non-trained in 20 57.6% vs. 56.9%; p value < 0.05. IMCI – 24.9%; p value < 0.05. Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 11 Figure 7: Rational use of Antibiotics by Region 100 % of children observed 80 69.2 68.8 62.5 64.2 60 53.6 55.9 46.2 42.0 40 38.5 20 14.8 0 Dushanbe Khatlon Sogd RRP Total needing oral antibiotic & correctly prescribed (N=69) not needing oral antibiotic leaves facility without it (N=222) not in severe condition. Correct treatment was administered effective strategies in preventing complications from disease. in about one-fifth of the children. None of children seen Providers should give caretakers three basic messages on by non-IMCI trained health workers were prescribed iron home care of children during illness. The ‘home care rules’ supplements in the case of anemia, compared to children seen for caretakers of all sick children are (i) giving extra fluids, (ii) by IMCI-trained medical staff (27.5%). continuing feeding and (iii) knowing the danger signs of the diseases and when to urgently return to the health provider. Child received first dose of treatment at facility In this survey, health care providers advised caretakers of 45.5 (SI.10) – 7.6% percent of children not needing urgent referral to give the child extra fluid and continue feeding during the illness. 2.28 In total, 66 children were identified as needing the first antibiotic dose at the facility. Out of these, only 7.6 percent 2.31 Providers retrained in family medicine (49.3%) advised received the medication at the facility. These children were caretakers more frequently than non-retrained doctors managed at four of the 70 surveyed PHC facilities. One-third (33.3%), although the difference was not statistically signifi- of the facilities of the 66 facilities where antibiotics were cant. IMCI trained health workers were more likely to advise not administered did not have injectable antibiotics, as caregivers to give extra fluid and continue feeding during the recommended by the IMCI guidelines. illness.21 A higher rate was found among cases managed by seven-day IMCI course attendees. 2.29 Although health providers may know the correct treat- ment, the lack of the basic essential antibiotics prevents Failure to receive vaccination (PI.10) – 69.6% them from effectively managing sick children who come to their facilities. Therefore, the responsible district and local 2.32 Of all the observed children, 69 needed to receive a vac- health authorities must ensure that adequate drug stocks are cination on the consultation day, as identified by the surveyors provided and maintained for all PHC facilities to prevent the based on the child’s vaccination card. However, 69.6 percent occurrence of child deaths from easily treatable conditions. of the children left the facility without receiving the required vaccination during the visit. Nevertheless, more than half of the facilities visited did have at least four of the five main vac- Vaccination and Caregiver Counseling cines (Polio, DPT, Measles and Hepatitis B) in stock during Advise to use extra fluid and continue feeding the time of the survey. The smallest proportion of children (PI.9) – 45.5% who did not receive vaccinations during their consultation were found in the Sogd region. 2.30 Counseling caretakers on home treatment of illnesses is a key step in the management of children and one of the 21 p value < 0.05. 12 Quality of Child Health Services in Tajikistan 2.33 While this finding may be due in part to some rural pri- weight (n=40) received correct counseling and age-appropri- mary health care facilities only offering vaccinations on spe- ate feeding messages. This indicator is very low, indicating cific days, the issue requires close follow up to avoid declines that providers do not pay sufficient attention to the problem in immunization coverage and completion rates. of underweight, even though this is a concern for many Tajik children. The survey also showed that feeding problems are Caretakers’ knowledge on antibiotic and ORS assessed more frequently than counseling on feeding practices administration (PI.11) – 71.6% is done. Therefore, providers are failing to follow through with the most important and main goal of the assessment: 2.34 Caretakers of children who were administered antibiotics identifying the problem and correctly managing it. and/or ORS by providers were interviewed before they left the facility. The caretaker was asked to describe how to give 2.37 Most family doctors were trained in various medical correct antibiotic treatment to the child, including amount, specialties prior to being retrained as FD’s (mainly pediatrics number of times per day and number of days. Of the 183 and internal medicine). To ascertain whether prior training interviewed caregivers, 71.6 percent were able to correctly had any bearing on patient care, a comparison of FD’s by describe how to prepare and administer antibiotic / ORS to their previous specialty was done on some selected IMCI the child. performance indicators, which are summarized in Table 2. The findings indicate that the specialization of family doc- 2.35 Comparison by providers’ specialization showed that tors has some impact on their current daily practice. Those caretakers’ knowledge was higher when children were man- family doctors who previously practiced as pediatricians aged by family doctors (74.8%) than those managed by pedia- demonstrated slightly better assessment, classification and tricians (57.5%), with borderline statistical significance.22 proper management skills compared to other family doctors. Analyses by the IMCI status also showed higher rates among However, the only statistically significant difference was on IMCI-trained doctors versus non-IMCI-trained staff; how- the administration of antibiotics. Former pediatricians did not ever, the difference was not statistically significant. prescribe unnecessary antibiotics to sick children. Caretaker received correct counseling for child with very low weight (SI.15) – 35.0% HEALTH SySTEMS ISSUES 2.36 Very low weight in children is a significant problem 2.38 The survey included various aspects of health systems that worsens the condition of a sick child. Only 35 percent support that are needed for quality implementation of child of caretakers whose children were classified as having low health care services. These include training of health workers, supervision and support for health workers clinical practice, 22 p value - 0.061. availability of essential drugs, vaccines, equipment and sup- Table 2: Comparison of Selected Indicators by Family Doctors Previous Specialization Indicator Pediatricians (%) Other (%) PI. 1 Child checked for three danger signs 44.7 41.8 PI. 5 Index of integrated assessment (mean) 6.3 5.9 PI. 8 Child not needing antibiotic and who leaves the facility without antibiotic* 61.5 35.6 PI. 11a Caretaker of a child who is prescribed ORS, and/or an oral antibiotic, who knows how to give the treatment 76.8 69.4 SI.3 Child with very low weight is assessed for feeding problems 44.0 41.7 SI.7 Child with dehydration treated correctly 88.2 83.3 SI.9 Child with anemia correctly treated 36.0 22.2 SI.10 Child receives first dose of treatment at facility 10.8 0 * Difference statistically significant Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 13 plies necessary for full immunization. This information was found in the 20 PHC facilities surveyed. Because nurses play a collected by interviewing the PHC manager and direct obser- critical role in providing primary and community health care vation. The findings on each of these aspects are discussed in in Tajikistan, they too require the necessary basic skills and the following section. knowledge to provide appropriate care to children. Training and Supervision Supervision (PI.13) – 27.1% IMCI training (PI.18) 2.41 Routine supervisory visits to the health care facilities by IMCI program supervisors are critical to assess health workers’ 2.39 A key factor in the successful implementation of the performance, identify shortcomings and provide on-the-job IMCI strategy is the training the maximum number of health training when needed. One main task for supervisory visits care providers in the strategy. According to WHO recommen- is observing case management. Of the 70 surveyed facilities, dations, at least 60 percent of health workers must be trained only 27.1 percent of the PHC care facilities reported having in IMCI to achieve a significant impact on child health out- received at least one supervisory visit in the past six months. comes. Based on this, a coverage analysis of the proportion of Among the regions, the lowest rate of supervisory visits was in health workers trained was done separately by doctors only Dushanbe facilities (16.7%), and the region with the highest and both nurses and doctors. Under the IMCI trainings three, number of visits was Khatlon (44.4%). five, seven and nine-day duration courses were analyzed. Among the surveyed facilities more than half (52.9%) had at least 60 percent of doctors trained in IMCI. The level of train- Availability of Drugs ing coverage was higher in Dushanbe (58.3%) and lower in 2.42 The surveyed primary health care facilities were checked Sogd (45.0%). In total, eight facilities (11.4%) had no doctor for the availability of basic medical supplies and medications trained in IMCI. that are required to manage cases according to the national IMCI guidelines. The presence of the following key medica- 2.40 For nurses, the findings were quite disappointing. Of the tions was assessed: surveyed faculties, only 17.1 percent met the recommended 60 percent IMCI training coverage for both nurses and doc- • Essential oral treatments – These are oral drugs tors. In the Sogd region, not a single IMCI trained nurse was recommended for home treatment of pneumonia, dys- Figure 8: Vaccines Availability in Primary Health Care Facilities (N=70) Index of availability of four vaccines 2,94 (excluding BCG) (mean) Index of availability of ve vaccines 3,24 (excluding BCG) (mean) HepB 61.4 Measles 67.1 DPT/Pentavalent 80 OPV 85.7 BCG 30 0 20 40 60 80 100 % of PHC facilities 14 Quality of Child Health Services in Tajikistan 2,94 Figure 9: Availability of Basic Equipment and Supplies in the Facilities (N=70) Child scale Baby scale Watch/timing device Supplies to mix OBS Source of clean water Child vaccination cards Mother’s counseling card IMCI chart booklet 0 20 40 60 80 100 % of PHC facilities entery, diarrhea, anemia and fever. The list of essential Vaccines oral medications include: ORS, amoxicillin, ciprofloxa- cin, iron, and paracetamol. The index score found was Availability of vaccines (PI.17a; PI.17b) 3.16, indicating that a mean of three out of five drugs – 90.0% was available at the facility on the day of assessment 2.43 The PHC facilities were assessed for the availability (PI.14). Only six facilities (three in Dushanbe and one of vaccines and supplies. The index score of the availability in each region) had all five drugs in their stock. of five vaccines (BCG, OPV, DPT or Pentavalent vaccine, Measles, Hepatitis B) was 3.24 ranging from 2.7 in the Sogd • According to the national IMCI guidelines, the list of region to 4.6 in Dushanbe. Out of four vaccines (excluding injectable drugs for one-dose pre-referral treatment BCG), a mean of 2.9 was found in every facility. In seven for children with severe classifications needing urgent facilities (10%), vaccine stocks were not available at all. This referral include Chloramphenicol, Benzylpenicillin and may be explained partially by the fact that in some facili- Gentamycin. An index score of 1.17 was found, mean- ties, immunization sessions are held on specific days of the ing that from three main drugs, a mean of one drug week when facilities receive vaccines from the district level. was available in the facilities (PI.15). Only two facili- Nevertheless, this is a worrisome finding. ties had all required injectable antibiotics available, and 21 had no single injectable antibiotic in stock (nine in 2.44 The availability of vaccines was found to be lowest Khatlon, nine in RRP and three in Sogd). for the BCG, followed by Hepatitis B. The Polio vaccine This means that 30 percent of these facilities would was available in the majority of facilities, and that could be have been unable to provide pre-referral treatment as explained by the polio immunization campaigns, which were recommended by the IMCI guidelines. This was con- recently carried out. The lack of BCG vaccine in most facili- firmed by the survey (described previously). A third of ties is possibly because BCG is in most cases provided at the facilities that failed to administer the initial antibiotic maternity facilities within three days of the birth of a child. dose to a sick child did not have the necessary drug in 2.45 However, the importance of ensuring that all PHC facili- stock. ties are provided with an adequate stock of all the five basic • RRP PHC facilities showed the lowest index for vaccines, to ensure that all children have completed the basic both oral and injectable drugs compared to other immunization schedule before the first year of life, cannot be regions. emphasized enough. This is essential to avoid vaccine prevent- able disease outbreaks. Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 15 Availability of immunization equipment and Availability of Supplies and Equipment supplies (PI.16) 2.47 Basic supplies and equipment needed for IMCI include 2.46 The list of essential equipment for provision of immuni- scales, timing devices, supplies to mix ORS, pure water sup- zation includes self-destructing needles/syringes, safety boxes, ply, vaccination cards, mother’s counseling cards and IMCI functioning refrigerator with correct temperature inside, and chart booklet. All these equipment was available in only cold box with frozen ice packs. The study found the avail- 38.6 percent of the 70 surveyed facilities. In the RRP, only ability of immunization equipment and supplies to be at a 10 percent of facilities had all the above listed equipment in satisfactory level. The majority of facilities (90%) had all possession (SI.17). the above equipment available. Self-destructing syringes and safety boxes were available in almost all facilities (98.6%), cold boxes were found in all facilities, and a functioning refrigera- tor with thermometer inside was respectively in 94.3 percent and 91.4 percent of facilities. 16 Quality of Child Health Services in Tajikistan Chapter 3. Conclusions 3.1 The study findings which closely mirror those of the 2009 retraining program does not seem to improve the use of the WHO/UNICEF IMCI survey will be of great concern to the IMCI guidelines for acute child health care services. These Ministry of Health and should provide the impetus to take findings indicate there is an urgent need to improve the immediate remedial actions. Much remains to be done to overall training of Family Medicine practitioners in the basic improve the overall quality of primary health care services for management of sick children following the IMCI clinical under-five children. The quality of services varies across the guidelines, particularly because Family Medicine practitioners regions, with Dushanbe City generally performing better in are often the first point of contact between sick children and many areas of care provision than Khatlon, Sogd and RRP. the health care system. 3.2 The RRP PHC facilities’ performance on many indicators 3.6 The findings on the duration of IMCI training offered of child health is of particular concern and warrants immedi- to health personnel are unequivocal. There is a positive cor- ate attention. For instance, only 4 percent of sick children in relation between the length of primary health care provider’s RRP were appropriately screened for the three basic danger IMCI training and the quality of care they give to children. signs: inability to drink, vomiting, and convulsions. Another Participating in a seven- to nine-day IMCI training program worrying finding in view of the persistent problem of child- produces better practice results than a three- to five-day train- hood stunting in Tajikistan, is the low proportion of providers ing program. who checked the children’s weight against standard growth charts even though most of them did weigh the children. 3.7 Two main issues are highlighted by this study. Firstly, the quality of primary health care services provided to children is 3.3 On accuracy of diagnosis, the findings were equally lacking in many areas, irrespective of the PHC provider’s type troublesome. Providers appropriately referred ten sick chil- of training. Second, is that the family medicine and IMCI dren to a higher-level facility for treatment. Of the remaining training programs and methods require further enhancement 290 in the sample, only 49 percent were correctly diagnosed. to ensure that the service quality for children improves. While 24 percent of children not needing an antibiotic left the facility with one, or a prescription for an antibiotic. Only 3.8 Some of the findings of this survey may be due to the 8 percent of children who should have received a first dose of staff facing constraints that could be relieved with additional an antibiotic at the facility during the visit actually received resources in all PHC facilities to ensure the availability of it. The treatment of children with diarrhea was better. Of the essential drugs, antibiotics and vaccines in all PHC facili- children needing oral rehydration salts, 84 percent of them ties. However, training and incentives to provide appropriate received a first treatment at the facility, but only 22 percent care to sick children also need to be revisited urgently, as with anemia received an iron supplement at the facility. the existing approach is not serving children or their parents well. Training needs to be further accompanied by consistent, 3.4 The study also finds that supervision of PHC workers is regular and supportive supervision, as it is well known that irregular, and training does not seem to be performed system- on its own does not necessarily lead to better performance of atically to improve children’s health outcomes. For example, health personnel. in the Sogd region, no IMCI-trained nurse worked in any of the 20 PHC facilities surveyed, even though they play a key 3.9 While many determinants of infant and child mortality role in the provision of child health services. For the majority lie outside the health care system, it is vital that when a sick of indicators examined, no statistically significant differences child comes in contact with the medical care system that it were found between providers retrained in the six-month should perform well on behalf of the child. Improving the Family Medicine program and those who were not. country’s system of PHC is within the reach of the Tajikistan Ministry of Health. With careful planning and coordination, 3.5 While family doctors previously trained as pediatricians the MoH can successfully implement the recommendations performed slightly better on some indicators than those outlined in the following section, which will result in much trained in other specialties (ORS prescription and administra- needed service improvements for sick children and their tion of first treatment dose at the facility), these differences health outcomes. were not statistically significant. The current Family Medicine Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 17 Chapter 4. Recommendations 4.1 In light of the study findings, several actions must be 4.7 Expand coverage of IMCI training activities for PHC taken by the Ministry of Health and its development partners health workers (especially nurses), to ensure that all children to improve the current state of affairs. Of immediate concern under five receive equally high quality services, starting with are the following: the identified facilities in the Sogd region. (i) ensure the availability of essential antibiotics and vac- 4.8 Conduct standardized IMCI training course (11 day dura- cine stocks in all first-level primary health care facilities, tion), as recommended by the WHO guidelines. Standardized with a special focus on PHC facilities in the RRP; courses enable providers to focus more on practical sessions essential for skill development. As shown by the survey short (ii) undertake a closer assessment of factors contributing courses (3-5 day) had limited effect on practices of health to poor performance in PHC facilities in the RRP and workers. Recent evidence suggests that short duration com- other poor performing rayons and implementing the puter-based IMCI courses can be as effective as standard appropriate solutions; training, yet considerably less expensive. (iii) provide intensive on the job training on correct child growth monitoring and nutrition to reinforce the skills 4.9 Strengthen the training on basic pediatric following the and knowledge of primary health care workers; and IMCI guidelines in the Family Medicine retraining courses, as the study revealed no difference between family doctors and (iv) improve the system of routine supervision and support non-Family Medicine trained heath workers on the majority of primary health care providers to identify problems of IMCI practices. and reinforce their adherence to recommended clinical practice guidelines. 4.10 Although this study did not focus on the quality of ser- vices provided by newly graduated FM practitioners, it is very Additional recommendations based on the study findings are important to ensure that the IMCI guidelines are included highlighted below. in the undergraduate medical and nursing curriculums. This will ensure consistency in the approach to management of Policies sick children. 4.2 The MOH must ensure that the clinical protocols cur- rently in use for managing sick children are consistent with Training and Supervision the IMCI guidelines to avoid conflicting messages to primary 4.11 The IMCI trainers/supervisors should conduct small health care providers and to ensure unified a unified treatment scale qualitative assessments in each of the study districts with approach. the providers to find out the factors that diminish their ability to provide care as recommended in the IMCI guidelines. 4.3 The MOH should commit to undertaking periodic assessments of PHC services for children, using this study as a 4.12 Greater efforts should be made to ensure that PHC baseline reference point to evaluate the impact of the correc- nurses (and other mid-level providers, e.g., feldshers23) are tive actions to be taken. systematically targeted to receive training not only on IMCI but also basic management of the sick child within the com- 4.4 Develop an incentive provision program for PHC provid- munity setting, since most nurses maintain close contact with ers when certain targets for preventive and curative service caregivers through home visits, etc. provision to children have been met, to encourage better qual- ity of child health care and improve outcomes. 4.13 IMCI training courses should focus more on main weak- nesses identified by the survey, such as assessment of danger 4.5 Conduct a thorough review of the current family medi- signs in every case, weight-for-age assessment, assessment cine training programs (undergraduate and post-graduate) and classification of anemia and feeding practices, rational to identify areas for improvement in general and in pediatric antibiotic therapy. care specifically. 4.6 Ensure consistency of IMCI training, follow-up and sup- 23 Feldshers are auxiliary medical personnel, introduced during the portive supervision activities across the country. Soviet era to provide medical assistance to the population, particularly in rural areas. 18 Quality of Child Health Services in Tajikistan 4.14 During the training courses / supervision special atten- (i) Supporting an independent and external evaluation of tion should be paid to increasing PHC providers’ practical the Family Medicine retraining programs by mid-2012 skills in counseling caregivers on home-based care of sick to ensure adequacy and relevance of content and train- children. ing methods, with a special focus on MCH. 4.15 Regular evaluations of the quality of the IMCI training (ii) Support continuous skills improvement of the trainers courses should be undertaken following a standardized meth- of Family Medicine providers at the Khatlon and Sogd odology to ensure quality as well current clinical information Family Medicine Training Centers (2011-2012). is included in the course. (iii) Intensive focus on training of PHC providers from the 4.16 More emphasis should be placed on hands on training, Khatlon and the Sogd regions in basic pediatrics, child strengthening and ensuring continuous supervisory sup- growth monitoring and nutrition within the context port for PHC providers (particularly new graduates), with a of the ongoing health and nutrition projects (2011- particular focus on first ensuring that health managers know 2013). how to conduct supportive supervisory visits. Supervisory (iv) Improving methods of paying primary health care pro- visits should focus on the observation of case management viders through further development of the current per for children under five years, identifying weaknesses, provid- capita system (2011-2012). ing feedback, on-the-job support, as well as development of regular peer-to-peer learning groups for providers. (v) Developing and piloting the use of incentive payments to Family Medicine practitioners at the primary health 4.17 Because the World Bank is one of the main develop- care level, through a results based financing scheme to ment partners that has been and continues to actively support improve the quantity and quality of maternal and child Tajikistan in improving primary health care including the FM health care in selected districts (2011-2015). postgraduate training programs, the findings of this study also have several implications as to how the Bank can strengthen (vi) Improve the current system of quality assurance in its support to the health sector. The main areas where the primary health care facilities (2011-2015). Bank, within the context of its current program of support, will endeavor to work closely with the MOH in the short- to medium-term are as follows: Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 19 ANNEx 1: OBjECTIVES Of THE STUDy AND SURVEy METHODOLOgy This study aims to address the following main objectives: of 214 PHC facilities was obtained and further stratified by those staffed with doctors trained (133) and not trained (81) a) To provide a baseline assessment of the quality of child as Family Medicine practitioners. Data on expected caseload health services provided at the primary health care of children under five was needed in selecting the sample. level; However, as this data was not available, it was decided instead b) To assess the effectiveness of Family Medicine practitio- to pre-select one rayon health center (RHC) in each survey ners in delivering basic child health services; district to ensure that the target sample of 280 children would c) To assess the facility based implementation of the be reached.25 Integrated Management of Childhood Illnesses (IMCI) Nineteen districts in the Khatlon and Sogd regions, RRP approach. (Shakhrinav, Varzob, Tursunzade) and Dushanbe City were Of specific interest is the quality of outpatient care services for selected. Those districts where Family Medicine has been sick children aged two months to five years, particularly: implemented with the support of various development agen- cies (World Bank, Project SINO, USAID, ADB) were select- • the level of care provided; ed, with the exclusion of those where a similar assessment was • quality of counseling provided and caretakers’ under- undertaken by WHO/UNICEF in 2009. standing of home treatment for their sick child; Systematic random sampling was used. For each stratum, the • availability of the following key health system supports: first facility was identified by a generated random number, drugs and vaccines, equipment and supervision; and the rest of the facilities were identified by a sampling • recommendations for ways to improve the quality of interval. In total, 70 PHC facilities were selected, out of which services 45 PHC had trained doctor(s) in Family Medicine and 25 PHC without FM doctors were selected to serve as a control Survey Methodology group for identification of differences in practice if any. The study design was a cross-sectional survey. The specific Inclusion criteria. Children meeting all the following criteria instrument that was used for the survey was the Integrated were enrolled in the study: Management of Childhood Illnesses (IMCI) Health Facility Survey. This methodology was developed by WHO/UNICEF • Children aged two months to five years and has been used over the last several years in multi-country • Sick children brought to the facility for a particular evaluations of the quality of PHC child health services in medical condition countries that have implemented the IMCI Strategy.24 This • First visit to the facility for the given condition health facility survey measures health worker practices in a number of areas, including correct assessment, correct classifi- • Caretakers consent to participate in the survey cation and treatment of sick children and correct counseling of In total, 300 children were enrolled in the study. caretakers. These measures of health worker practice are called outcome measures and the clinical guidelines for first-level Survey instruments. The survey employed instruments pre- health facilities developed for the Integrated Management of viously used in the IMCI survey conducted in Tajikistan in Childhood Illness (IMCI) are used as the clinical standard 2009 by WHO/UNICEF. The instruments were available in against which health worker practices are compared. Russian and had been already adapted to the local context. A few changes were suggested by the experts during the training Sampling. The survey evaluated services provided by doctors of the surveyors. Five main forms were used as recommended retrained in Family Medicine in Dushanbe City, and selected by the standard IMCI methodology; EC: Enrolment form; rayons of Khatlon, Sogd and RRP. The sampling frame Form 1: Observation of health facility provider’s management included PHC facilities staffed by doctors and excluded those of a sick child; Form 2: Exit interview with the caretaker of staffed only by mid-level health care providers. A total list the sick child; Form 3: Reexamination of the sick child by a 24 Evaluations done in Bangladesh, Brazil, Peru, Tanzania & Uganda, 25 According to the survey guidelines, the sample should include at least details available at http://www.who.int/imci-mce/ 30 facilities and a minimum of four sick children must be observed per facility to enable valid conclusions to be drawn. 20 Quality of Child Health Services in Tajikistan surveyor; Form 4: Assessment of facili- Table A1: Sampling Frame and Survey Sample ties’ services and supplies. Region facilities with trained facilities without trained Surveyors selection and training. doctors in fM doctors in fM The following requirements were set to select supervisors and survey- Sampling frame Sample Sampling frame Sample ors: health background (preferably Dushanbe 1 1 13 11 in pediatrics), familiarity with the Khatlon 30 12 41 6 national IMCI guidelines, knowl- edge of IMCI principles and prac- RRP 56 19 16 1 tices, previous exposure to survey Sogd 47 13 24 7 fieldwork. Total 133 45 81 25 A list of surveyors and supervisors meeting the above criteria was sug- Data management: The supervisor of each survey team was gested by the Ministry of Health of Tajikistan, and also taken responsible for the submission of completed questionnaires. into consideration were those who participated in the 2009 Following that, the questionnaires were checked for com- IMCI survey. In total, 18 surveyors/supervisors were selected pleteness and accuracy by the field coordinator. Data entry and six teams comprised of a supervisor and two surveyors took place at the National Center of Medical Statistics and were formed. A three-day training workshop took place at Information. Data entry was done in the EpiData software the Scientific Center of Pediatrics and Pediatric Surgery on that enabled data export into other statistical programs. September 28-30, 2010. The training was conducted by Dr. Maya Kherkheulidze with support of the national IMCI Data analyses. The data analysis was done at Curatio experts. The training included presentation of the survey International Foundation office using SPSS software. Standard tools, role-plays, practical work at the outpatient department priority and supplementary indicators were analyzed accord- of the Center of Pediatrics and Pediatric Surgery and discus- ing to the calculation methods provided by the WHO manu- sion of logistical issues. The manual describing rules for the al. Additional analysis was done by regions, type of providers forms completion was developed and distributed to each (family doctors, pediatricians and other), and IMCI training surveyor along with the detailed fieldwork schedule. status. For comparing categorical data, Pearson chi-squared test was used and comparison of the means for more than two Data collection. Fieldwork took place from October 2 – 16, groups was done using the analysis of variance (ANOVA). 2010. Each team visited the facility during one working day. Level of significance was set at 0.05. External quality control of the fieldwork was carried out by a local research company “Zerkalo,â€? specifically contracted for Study limitations. The survey found 17 out of the 25 control this task. In addition, monitoring visits were conducted by PHC facilities were actually staffed with family doctors, while the National IMCI Program Coordinator, the Director of the originally they were sampled as facilities not staffed with Scientific Center of Pediatrics and Pediatric Surgery, and the family doctors, based on the information provided. Thus, the project staff. No major violations of the survey principles were final survey sample limited conducting analysis by type of noticed. To facilitate the data collection process and ensure provider, as the biggest proportion captured through the sur- that doctors were in place, managers of the PHC facilities vey is family doctors. Also, there is a possibility that findings were informed in general about possible visits. However, the may be biased by the Hawthorne Effect; where doctors may aim and content of the survey was not disclosed in advance. perform better than usual due to the presence of the research In two cases, the facilities were substituted with other facilities team/observers. from the substitution list, due to the absence of the doctor during the team visit. Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 21 ANNEx 2: DESCRIPTIVE STATISTICS The sample included 300 chil- Table A2: PHC Facilities Visited dren aged two months up to five years. In total, 70 Primary Health PHC type Dushanbe Khatlon Sogd RRP Total Care (PHC) facilities were visited Urban Health Center 12 1 4 1 18 in Dushanbe City, the Khatlon Rayon Health Center 8 3 2 13 and Sogd regions, and the RRP (Table 3). The complete list of Rural Health Center 9 13 17 39 visited facilities is provided in Total 12 18 20 20 70 Annex 2. The surveyor’s independent reexamination of each child was The health care providers received between three to nine days used as the ‘gold standard.’ Children caretakers were also of IMCI training. The majority of children (46%) were seen interviewed (in total 294). Facilities, services and supplies by doctors trained in a nine-day IMCI course. Only 8 percent were assessed and administrative staff were interviewed in all of children were managed by non-IMCI-trained health care 70 PHC. In total, 130 primary health care providers were providers (see Figure A1). surveyed. Almost all of the children enrolled in the study were Most of the health care workers underwent the nine-day managed by doctors. The majority of the health care provid- course within their six-month Family Medicine retraining ers were family doctors (81.5%), followed by pediatricians program. (17%). Two children were managed by an otolaryngologist and a feldsher. Health care workers were asked about their training experience in IMCI, specifically timing, duration and Characteristics of Cases Observed place of training. The observed cases were almost equally distributed among Figure A1: Cases Seen by Health Care Providers’ IMCI Training Status 100 13 90 % of cases observed by health workers 29 80 53 70 77 52 19 60 50 4 40 24 30 52 8 29 20 8 19 10 7 6 0 Dushanbe Khalton Sogd RRS No Training 3-5 Days 7 Days 9 Days Duration of IMCI Training 22 Quality of Child Health Services in Tajikistan the regions. About half of the children Table A3: Health Care Provider Type and IMCI Training Status (46%) enrolled in the study were under the age of one year and the majority IMCI training family Doctors Pediatricians Other Total (77.3%) were less than two years of age. 3-5 days 42 1 0 43 (33.1%) The mean time spent by a provider 7 days 25 0 0 25 (19.2%) in managing a case was 20.5 minutes. Following the providers’ examination, all 9 days 39 13 2 54 (41.5%) children enrolled in the study were re- Not trained In IMCI 0 8 0 8 (6.2%) examined and classified by the surveyors (“gold standardâ€?). Total 106 22 2 130 Table A4: Characteristics of the Sample Characteristics Dushanbe Khatlon Sogd RRP Total Children observed 65 (21.7%) 69 (23%) 80 (26.7) 86 (28.7) 300 Sex n=65 n=69 n=80 n=86 n=300 Girls 27(14.5%) 40(58.0%) 54(67.5%) 44(51.2%) 165(55.0%) Boys 38(58.5%) 29(42.0%) 26(32.5%) 42(48.8%) 135(45.0%) Age (both sexes) n=65 n=69 n=80 n=86 n=300 <1 year (2-11 months) 25(38.5%) 34(49.3%) 39(48.8%) 40(46.5%) 138(46.0%) 1 year (12-23 months) 17(26.2%) 20(29.0%) 28(35.0%) 29(33.7%) 94(31.3%) 2 years (24-35 months) 11(16.9%) 8(11.6%) 6(7.5%) 9(10.5%) 34(11.3%) 3 years (36-47 months) 9(13.8%) 5(7.2%) 7(8.8%) 5(5.8%) 26(8.7%) 4 years (48-59 months) 3(4.6%) 2(2.9%) 0(.0%) 3(3.5%) 8(2.7%) Average time of examination Per case observed: Range (min-max minutes) 5-80 4-65 3-77 12-79 3-80 Median (minutes) 20 20 16 16 17 Mean (minutes) 23.2 21.9 19.1 18.8 20.5 Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 23 ANNEx 3: LIST Of SURVEyED PHC fACILITIES Table A5: Study PHC Facilities by Region N Region Rayon facility type facility name 1 Dushanbe Dushanbe UHC â„–1 2 Dushanbe Dushanbe UHC Dushanbe 3 Dushanbe Dushanbe UHC â„–4 4 Dushanbe Dushanbe UHC â„–5 5 Dushanbe Dushanbe UHC â„–2 6 Dushanbe Dushanbe UHC â„–3 7 Dushanbe Dushanbe UHC â„–6 8 Dushanbe Dushanbe UHC â„–7 9 Dushanbe Dushanbe UHC â„–10 10 Dushanbe Dushanbe UHC â„–11 11 Dushanbe Dushanbe UHC â„–12 12 Dushanbe Dushanbe UHC â„–14 13 Khatlon A. Djami UHC A. Djami 14 Khatlon A. Djami RaHC A. Djami 15 Khatlon Dangara RaHC Dangara 16 Khatlon Dangara RuHC Chorsada 17 Khatlon Dangara RuHC Gidjovak 18 Khatlon Dangara RuHosp Sebiston 19 Khatlon Dangara RuHC Guliston 20 Khatlon Kabodien RaHC Kabodien 21 Khatlon Kabodien RuHC Kamarov 22 Khatlon Kuliab RaHC Kuliab 23 Khatlon Kumsangir RaHC Kumsangir 24 Khatlon Kumsangir RuHC â„–2 25 Khatlon Muminabad RaHC Muminabad 26 Khatlon Muminabad RuHC Khonatarosh 27 Khatlon Nurek RuHC Dukoni 28 Khatlon Shaartuz RaHC Shaartuz 29 Khatlon Shaartuz RuHC Binokor 30 Khatlon Shurobod RaHC Shurobod 31 RRP Shakhrinav RaHC Shakhrinav 32 RRP Shakhrinav RuHC Uzun 33 RRP Shakhrinav RuHC Chuzi (continued on page 25) 24 Quality of Child Health Services in Tajikistan N Region Rayon facility type facility name 34 RRP Shakhrinav RuHC Kadi Chubor 35 RRP Shakhrinav RuHC Oiim 36 RRP Shakhrinav RuHC Khasanov 37 RRP Varzob RaHC Varzob 38 RRP Varzob RuHC Chormagzakon 39 RRP Varzob RuHC Kharangon 40 RRP Varzob RuHC Gushari 41 RRP Tursunzade RaHC Tursunzade 42 RRP Tursunzade RuHC Durbent 43 RRP Tursunzade RuHC Chkalov 44 RRP Tursunzade RuHC Leninizm 45 RRP Tursunzade RuHC Khusnabod 46 RRP Tursunzade RuHC Frunze 47 RRP Tursunzade RuHC Karatag 48 RRP Tursunzade RuHC Ifiranos 49 RRP Tursunzade RuHC Guliston 50 RRP ТурÑ?унзаде RuHC Ok Telpak 51 Sogd Khudjand UHC Khudjand 52 Sogd Khudjand UHC â„–6 53 Sogd Chkalovsk UHC Chkalovsk 54 Sogd Asht RaHC Asht 55 Sogd Asht RuHC Asht 56 Sogd Asht RuHC Oshoba 57 Sogd Asht RuHC Djigda 58 Sogd Isfara RaHC Isfara 59 Sogd Isfara RuHC Matpari 60 Sogd Isfara RuHC Chorkishlok 61 Sogd Isfara RuHC Oftobrui 62 Sogd Kanibadam RaHC Kanibadam 63 Sogd Kanibadam RuHC Kuchkak 64 Sogd Kanibadam RuHC Djigdalik 65 Sogd Kanibadam RuHC Firusoba 66 Sogd Kanibadam RuHC Zarbend 67 Sogd Kanibadam RuHC Lokhuti 68 Sogd Kanibadam RuHC Khamirchui 69 Sogd Spitamen RaHC â„–1 70 Sogd Spitamen RuHC Kurkat Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 25 ANNEx 4: IMCI PRIORITy INDICATORS Priority indicators findings (N) A Assessment of the sick child PI.1 Child checked for three danger signs 45.7% (300) PI.2 Child checked for the presence of cough, diarrhea, and fever 71.3% (300) PI.3 Child’s weight checked against a growth chart26 26.7% (300) PI.4 Child vaccination status checked 82% (300) PI.5 Index of integrated assessment (mean) 6.85 PI.6 Child under two years of age assessed for feeding practices 45.3% (232) B Classification and treatment of the sick child PI.7 Child needing an oral antibiotic for an IMCI condition and prescribed a 42.0% (69) recommended antibiotic correctly27 PI.8 Child not needing antibiotic and who leaves the facility without antibiotic 55.9% (222) C Vaccination and counseling of the sick child PI.9 Caretaker of sick child is advised to give extra fluids and continue feeding 45.5% (290) PI.10 Child needing vaccinations leaves the facility with all needed vaccinations 69.6% (69) PI.11a Caretaker of a child who is prescribed ORS, and/or an oral antibiotic, 71.6% (183) who knows how to give the treatment PI.11b Caretaker of a child who is prescribed ORS, who knows how to give the treatment 74.3% (101) PI.12 Child needing referral who is referred to a higher level of the health system 40% (10) D Availability of health facility supports PI.13 Health facility received at least one supervisory visit that included observation 27.1% (70) of case management during the previous six months PI.14 Index of availability of essential oral treatments28 (mean) 3.16 PI.15 Index of availability of injectable drugs for pre-referral treatment29 (mean) 1.17 PI.16 Health facility has the equipment and supplies to support full vaccination services30 90% (70) PI.17a Index of availability of five vaccines31 (including BCG) (mean) 3.24 PI.17b Index of availability of four vaccines32 (excluding BCG) (mean) 2.94 PI.18a Health facilities with at least 60% of workers managing children 52.9% (70) trained in IMCI (doctors) PI.18b Health facilities with at least 60% of workers managing children 17.1% (70) trained in IMCI (doctors & nurses) 26 Includes also weight check using standard tables and formulas. 27 Oral antibiotic are needed for the following IMCI conditions: pneumonia, dysentery, acute ear infection, streptococcal sore throat, possible bacterial infection. 28 List of essential oral treatment medications includes five drugs: ORS, amoxicillin, ciprofloxacin, paracetamol and iron supplements. 29 List of injectable drugs for pre-referral treatment includes gentamycin, benzylpenicillin and chloramphenicol. 30 List of equipment and supplies for full vaccination services includes self-destructed needles/syringes, safety boxes, functioning refrigerator with correct temperature inside, cold box with ice packs frozen. 31 Recommended vaccines include BCG, Polio, DPT or Pentavalent vaccine, Measles, Hepatitis B. 32 Recommended vaccines include Polio, DPT or Pentavalent vaccine, Measles, Hepatitis B. 26 Quality of Child Health Services in Tajikistan Summary Table on Supplemental IMCI Indicators Supplemental indicators findings % (N) A Screening and assessment of the sick child SI.1 Child checked for other problems 33.7% (300) SI.3 Child with very low weight is assessed for feeding problems 45% (40) B Classification and treatment of the sick child SI.4 Child with very low weight is correctly classified 42.5% (40) SI.5 Child is correctly classified 49.3% (290) SI.6 Child with pneumonia correctly treated 33.3% (12) SI.7 Child with dehydration treated correctly 84% (25) SI.9 Child with anemia correctly treated 21.6% (51) SI.10 Child receives first dose of treatment at facility 7.6% (66) SI.11 Child checked for lethargy 100% (2) SI.12 Child with severe illness correctly treated 20% (10) C Counseling of the sick child SI.13 Child prescribed oral medication whose caretaker is advised on how 40.8% (103) to administer the treatment SI.14 Sick child whose caretaker is advised on when to return immediately 66.9% (290) SI.15 Child with very low weight whose caretaker received correct counseling 35% (40) SI.16 Child leaving the facility whose caretaker was given or shown a mother’s card 24.8% (290) D Availability of health facility supports SI.17 Health facility has essential equipment and materials 38.6 (70) SI.18a Health facility has IMCI chart booklet and mother’s counseling cards 25.7% (70) SI.18b Health facility has IMCI chart booklet 58.6% (70) Human Development Sector Unit | Central Asia Country Unit | Europe and Central Asia Region THE WORLD BANK 27 References 1 American Academy of Family Physcians (2010). 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