Quality of child healthcare at primary healthcare facilities: a national assessment of the Integrated Management of Childhood Illnesses in Afghanistan.

Objective: To assess quality of the national Integrated Management of Childhood Illness (IMCI) program services provided for sick children at primary health facilities in Afghanistan.

Design: Mixed methods including cross-sectional study.

Setting: Thirteen (of thirty-four) provinces in Afghanistan.

Participants: Observation of case management and re-examination of 177 sick children, exit interviews with caretakers and review of equipment/supplies at 44 health facilities.

Intervention: Introduction and scale up of Integrated Management of Childhood Illnesses at primary health care facilities.

Main outcome measures: Care of sick children according to IMCI guidelines, health worker skills and essential health system elements.

Results: Thirty-two (71%) of the health workers were trained in IMCI and five (11%) received supervision in clinical case management during the past 6 months. On average, 5.4 out of 10 main assessment tasks were performed during cases observed, the index being higher in children seen by trained providers than untrained (6.3 vs 3.5, 95% CI 5.8-6.8 vs 2.9-4.1). In all, 74% of the 104 children who needed oral antibiotics received prescriptions, while 30% received complete and correct advice and 30% were overprescribed, and more so by untrained providers. Home care counseling was associated with provider training status (41.3% by trained and 24.5% by untrained). Essential oral and pre-referral injectable medicine and equipment/supplies were available in 66%, 23%, and 45% of health facilities, respectively.

Conclusion: IMCI training improved assessment, rational use of antibiotics and counseling; further investment in IMCI in Afghanistan, continuing provider capacity building and supportive supervision for improved quality of care and counseling for sick children is needed, especially given high burden treatable childhood illness.