One year old Shamsia and her mother Lantana at a stabilisation centre. After suffering from acute malnutrition, Shamsia made a full recovery. Photo: Jonathan Hyams/SavetheChildren

Pneumonia is the biggest child killer in developing countries. Simple medical procedures can improve diagnosis and save lives. Yet, studies show that many clinicians do not perform these procedures. Why?

In Sub-Saharan Africa, one in nine children dies before the age of five. Diarrhea and pneumonia, diseases that normally are easy to cure, are the most common causes of death. Guidelines for the Integrated Management of Childhood Illness (IMCI) were introduced by the WHO and UNICEF in the mid-90’s to reduce child mortality, by helping health workers diagnose and treat children in countries with a poor health infrastructure. IMCI training has so far been implemented in more than 113 countries, but several studies show that clinicians frequently skip the IMCI procedures.

Large know-do gap
In a recently published article in the scientific journal Social Science and Medicine, researchers from the Chr. Michelsen Institute (CMI) and the National Institute of Medical Research (NIMR) identify and discuss reasons why many clinicians do not adhere to the guidelines.

An important finding is that lack of knowledge of the IMCI procedures is not the main constraint. 81 percent of the clinicians participating in the study had received IMCI training. Yet, they performed only 28.4 percent of the relevant assessment tasks. A test showed that they were able to do far more than this.

-Our data show that the low adherence to IMCI guidelines is not only a result of lack of knowledge. There is a large gap between what health workers know and what they do when they physically examine a patient, says Siri Lange, senior researcher at CMI.

* The study is based on observations of, and interviews with, clinical officers in government- and faith-based health facilities in rural Tanzania.

*In 2007, adherence to the guidelines was measured through direct observation of 933 outpatient consultations performed by 103 trained clinicians in 82 health facilities spread across nine districts.

*In 2009, there was a qualitative follow-up study with in-depth interviews with 40 clinicians in 30 health facilities.


High confidence in own experience
A central finding is that many clinicians do not believe that diligently following the IMCI guidelines will make a difference for health outcomes. Diagnosing a sick child is a matter of professional pride, and clinicians participating in the study argue that they rely on experience when they assess their patients, choosing the questions and examinations they find most relevant.

Some of the clinicians also argued that some of the questions in the guidelines are unnecessary because the caretakers will automatically reveal relevant information.

-This may be the right call for some patients. Yet, it is a risky strategy. There is a possibility that clinicians do not pick up on patients who are in need of extensive treatment if they do not adhere to the guidelines, says Ottar Mæstad, director at CMI.

Saving time and energy
Although the IMCI guidelines are simple procedures, many clinicians claim that the step-by-step approach is  too time consuming, and that they do not have the capacity to follow them. Yet, survey data reveals that, despite large variations between health facilities, the average number of patients per clinician is low, and that clinicians in outpatient departments typically spend less than two hours a day on patient consultations.

- Still, the workload cannot be measured simply by counting the number of patients per day. Health workers in rural areas frequently work extremely long hours due to for example deliveries and emergency cases.  In addition, a large majority of the health workers supplement their income by activities such as farming or informal trade.  This reduces the time they can spend on patients at the health facilities. The heavy total workload and the constant worry to make ends meet may also have a negative effect on their ability to concentrate and perform, says Lange.

Weak intrinsic motivation
Health workers themselves also explain low adherence to the IMCI guidelines by weak intrinsic motivation and low work morale. They claim that their motivation has deteriorated due to weak recognition of their work within the health system. Low pay is regarded as one out of several indicators that their work is not sufficiently appreciated, and that they therefore do not have an “obligation” to perform well.

- This suggests that the public ethos and professional conscience has been seriously weakened, says Mæstad.

Moving forward
Health workers need to acknowledge – more strongly than they presently do – the contribution of the IMCI procedures to reduced child mortality. This will require a more consistent focus on the importance of IMCI from leaders and supervisors, and probably also deeper knowledge among clinicians about the medical significance of the tool. Technical knowledge about what to do is not sufficient.

The intrinsic motivation of the health workforce needs to be nurtured more strongly than in the past. Health workers must be recognized for the work they are doing. - Recognition can come in many different ways, but in this context it is difficult to talk about recognition without also discussing salaries, says Mæstad. Higher salaries could also relieve some of the distractions that seem to induce health workers to adopt simple rules of thumb in their clinical practice; however, based on past experience, there is little reason to believe that higher salary alone will solve these issues. Strengthening health worker motivation is a highly complex task, and our knowledge of how to do it in this context is still quite limited.