Academic journal article Bulletin of the World Health Organization

Management of Severely Ill Children at First-Level Health Facilities in Sub-Saharan Africa When Referral Is Difficult. (Research)

Academic journal article Bulletin of the World Health Organization

Management of Severely Ill Children at First-Level Health Facilities in Sub-Saharan Africa When Referral Is Difficult. (Research)

Article excerpt

Voir page 529 le resume en francais. En la pagina 529 un resumen en espanol.


In developing countries, most of the 11 million deaths per year of children aged under five years occur in areas in which adequate medical care is not available (1). First-level health facilities--the closest health care services available to most sick children in developing countries--generally are run by medical staff who are not physicians. These clinics do not have beds for admitting patients, and essential drugs and supplies often are not available (2). Recently, WHO and UNICEF developed the Integrated Management of Childhood Illness (IMCI) as a strategy to improve childhood survival (3). This strategy rationalized the management of patients at first-level facilities to try to reduce childhood mortality. The IMCI strategy uses simple signs and symptoms to assess and classify illness, thus allowing health workers at first-level facilities to identify which children have minor illnesses that need symptomatic treatment (e.g. oral rehydration therapy), which need specific therapy that can be given at the first-level facility (e.g. antimicrobial or antimalarial therapies), and which need referral to a hospital. The IMCI categorizes three types of referral (Box 1).

Box 1. Integrated Management of Childhood Illness (IMCI)
categories of referral

Urgent referral

Any child who exhibits one of the general danger signs under IMCI

* convulsions
* inability to drink
* vomiting everything
* unconsciousness or lethargy
* specific combinations of signs and symptoms that identify severe
illness (3).

Non-urgent referral

The child coughs for more than 30 days or has a fever for more than
7 days.

Other referrals

Referral of "other problems" not identified by the IMCI classification,
but still in need of specialized management--for example, trauma,
osteomyelitis of long duration, etc. (1, 3).

Field studies of IMCI guidelines have shown that 10-34% of assessed children need to be referred (4-7), but no data on the frequency of children who require referral are available during routine implementation of IMCI. The IMCI guidelines for first-level care of children assume that referral is an option for staff at first-level centres; however, in many settings, referral is difficult or impossible (4) for several reasons: distance, geographical difficulty of access, climatic conditions, cost, cultural perceptions, or perceived poor quality of service at the referral institution. When referral is impossible and the only option is to manage the patient at the first-level facility, health workers at these facilities may have to make critical decisions about whether to pursue referral or to manage the child locally. Currently, no guidelines address the management of infants and children with severe illness at a first-level facility when referral is impossible. Information on the frequency of these severe classifications is needed so that such guidelines can be developed. Knowledge about what supplies and equipment are available at these remote sites is also crucial in order to determine which additional supplies would be needed to manage a severely ill child at a first-level facility. Finally, for these guidelines to be implemented, it is important to know what procedures the health workers are allowed to perform and what regulatory obstacles are present. The current study aimed to obtain this information from selected areas of three countries where referral is difficult or impossible.


Selection of countries, districts, and health centres

The study was performed in Uganda, the United Republic of Tanzania, and Niger. These three African countries have introduced IMCI and also have areas in which referral is considered difficult or impossible because of geomorphological factors or distance. All the major childhood diseases covered by IMCI are present in these three countries (acute respiratory infections, diarrhoeal diseases, malaria, measles, malnutrition, and neonatal problems). …

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