title: Insight into implementation of facility-based integrated management of childhood illness strategy in a rural district of Sindh, Pakistan.
abstract: BACKGROUND
  Integrated management of childhood illnesses (IMCI) strategy has been proven to improve health outcomes in children under 5 years of age. Pakistan, despite being in the late implementation phase of the strategy, continues to report high under-five mortality due to pneumonia, diarrhea, measles, and malnutrition - the main targets of the strategy.
  
  
  OBJECTIVE
  The study determines the factors influencing IMCI implementation at public-sector primary health care (PHC) facilities in Matiari district, Sindh, Pakistan.
  
  
  METHODS
  An exploratory qualitative study with an embedded quantitative strand was conducted. The qualitative part included 16 in-depth interviews (IDIs) with stakeholders which included planners and policy makers at a provincial level (n=5), implementers and managers at a district level (n=3), and IMCI-trained physicians posted at PHC facilities (n=8). Quantitative part included PHC facility survey (n=16) utilizing WHO health facility assessment tool to assess availability of IMCI essential drugs, supplies, and equipments. Qualitative content analysis was used to interpret the textual information, whereas descriptive frequencies were calculated for health facility survey data.
  
  
  RESULTS
  The major factors reported to enhance IMCI implementation were knowledge and perception about the strategy and need for separate clinic for children aged under 5 years as potential support factors. The latter can facilitate in strategy implementation through allocated workforce and required equipments and supplies. Constraint factors mainly included lack of clear understanding of the strategy, poor planning for IMCI implementation, ambiguity in defined roles and responsibilities among stakeholders, and insufficient essential supplies and drugs at PHC centers. The latter was further substantiated through health facilities' survey findings, which indicated that none of the facilities had 100% stock of essential supplies and drugs. Only one out of all 16 surveyed facilities had 75% of the total supplies, while 4 out of 16 facilities had 56% of the required IMCI drug stock. The mean availability of supplies ranged from 36.6 to 66%, while the mean availability of drugs ranged from 45.8 to 56.7%.
  
  
  CONCLUSIONS
  Our findings indicate that the Matiari district has sound implementation potential; however, bottlenecks at health care facility and at health care management level have badly constrained the implementation process. An interdependency exists among the constraining factors, such as lack of sound planning resulting in unclear understanding of the strategy; leading to ambiguous roles and responsibilities among stakeholders which manifest as inadequate availability of supplies and drugs at PHC facilities. Addressing these barriers is likely to have a cumulative effect on facilitating IMCI implementation. On the basis of these findings, we recommend that the provincial Ministry of Health (MoH) and provincial Maternal Neonatal and Child Health (MNCH) program jointly assess the situation and streamline IMCI implementation in the district through sound planning, training, supervision, and logistic support.
authors.affiliation: Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan. nousheen.pradhan@aku.edu
authors.forename: Nousheen Akber
authors.initials: NA
authors.lastname: Pradhan
authors.forename: Narjis
authors.initials: N
authors.lastname: Rizvi
authors.forename: Neelofar
authors.initials: N
authors.lastname: Sami
authors.forename: Xaher
authors.initials: X
authors.lastname: Gul
mesh_terms: D000328:Adult; D002662:Child Health Services / Q000458:organization & administration*; D046688:Child Mortality; D002675:Child, Preschool; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration*; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D008297:Male; D008875:Middle Aged; D010154:Pakistan / Q000453:epidemiology; D011320:Primary Health Care / Q000458:organization & administration; D016730:Program Development; D019035:Rural Health Services / Q000458:organization & administration*
keywords: IMCI; IMCI Pakistan; IMCI implementation barriers and supports; child health; primary health care in children under five; under-five morbidity; under-five mortality