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Training in case management: Lessons learnt working in the Lake Zone, Tanzania, 2012-2014
Over the past three years, the Tibu Homa Project (THP) has been implementing an intervention to improve case management of children under five with fever in the Lake Zone (Kagera, Mara, Mwanza, Geita, Shinyanga, Simiyu regions) of Tanzania through health facility system strengthening. The Lake Zone was identified by the Ministry of Health and Social Welfare (MOHSW) and the United States Agency for International Development (USAID) because of its high under-five mortality rate, above the national average, and a high prevalence of malaria.
The project used a new, adapted integrated management of childhood illness (IMCI) guideline that among other things directs children with fever to be treated for malaria only upon laboratory evidence and that guides the management of other malaria-negative patients for other causes of fever. Improving case management (CM) demanded a number of interventions to address issues of inefficient patient flow, evidence-based treatment of confirmed malaria, stock-out of essential medicines and supplies, patient information documentation, and use of data for decision making.
THP worked with Regional/Council Health Management Teams (R/CHMTs) to establish pediatric quality improvement teams (PQITs) that received training in improved diagnosis and treatment of children with severe febrile illnesses, logistic management, quality malaria rapid diagnostic test (mRDT) training, and data management. These teams, with the support of health facility management and a team of R/CHMT, logistic, quality improvement and clinical mentors, led efforts in their facilities to improve case management. The trainings were done using the national training guidelines. R/CHMTs, logistics, quality improvement and clinical mentors also received training in improvement methods and in supportive supervision and mentorship in their respective areas and provided regular monthly supportive supervision/mentorship visits.
The PQITs identified gaps in case management, tested and implemented changes to address the gaps, and assessed and documented their performance on a monthly basis. They met quarterly to share improvement results.
Case management implementation started in three initial regions of Mwanza, Mara, and Kagera and more recently spread to involve some of the remaining health facilities in the initial regions and to the new regions of Shinyanga, Simiyu, and Geita. As of March 2014, 30% of health facilities have been covered and 1279 HCWs haven been trained in case management, quality improvement, logistic supply management, and data management. Altogether a pool of 176 trained mentors has been established and is already involved in health facility monthly visits.
In all, 395 health facility pediatric improvement teams were established. As a result of their work, new patient flow maps have been implemented, resulting in more efficient clinics and inpatient services and an increase in percent of children being tested for malaria. This allows for evidence-based malaria treatment and getting febrile children managed appropriately for other causes of fever as shown by improvement in compliance to Referral Care Manual and IMCI guidelines. Health facilities have also shown improvement in patient information documentation, data management, sharing, and use for decision making for further improvement.
Establishment of PQITs and training them with a package that addressees quality improvement, clinical care , logistic supply management and patient information documentation and making use of data for decision making coupled with regular mentorship and supportive supervision have led to significant case management improvements.