INTEGRATED MANAGEMENT OF CHILDHOOD

ILLNESS (IMCI)

Planning, Implementing and Evaluating

Pre-Service Training

WORKING DRAFT: AUGUST 2001

Department of Child and Adolescent Health and Development (CAH)

Family and Community Health (FCH)
World Health Organization, Geneva
 Integrated Management of Childhood Illness (IMCI):
Planning, Implementing and Evaluating Pre-Service Training

CONTENTS

PART A: Introduction

1. Overview of the IMCI Strategy 1

2. Rationale for Introducing IMCI into Medical and
Paramedical Education 4
3. Purpose of this Guide 7

PART B: Planning, Implementing and Evaluating

IMCI Pre-Service Training 8

1. PHASE ONE - ORIENT AND PLAN 12

1.1 Orient and Plan: Tasks at National Level 14

Analyse the Situation 15
Orient Opinion Leaders and Decision-Makers 17
Create a National Coordinating Group 20
Develop a National Plan 23
Assist Teaching Institutions to Orient Staff and Plan 26

1.2 Orient and Plan: Tasks at the Teaching Institution 30

Analyse the Situation 31
Orient Decision-Makers 34
Create an IMCI Working Group 37
Train Key Planners 39
Plan for the Introduction of IMCI Teaching 42
Request Endorsement of the Plan 46

2. PHASE TWO - PREPARE AND CONDUCT THE

FIRST ROUND OF IMCI TEACHING 47

2.1 Prepare and Conduct the First Round of IMCI

Teaching: Tasks at National Level 49
Assist Teaching Institutions to Prepare for and
Monitor Teaching 49

i
 2.2 Prepare and Conduct the First Round of IMCI
Teaching: Tasks at the Teaching Institution 53
Define Times, Places, Activities and Materials 53
Train Relevant Teachers and Clinical Staff 57
Prepare Clinical Practice Sites 60
Prepare Materials 63
Coordinate Teaching 70
Conduct and Monitor Teaching 72

3. PHASE THREE - REVIEW AND REPLAN IMCI TEACHING 76

3.1 Review and Replan IMCI Teaching:

Tasks at National Level 78
Assist Teaching Institutions to Review and Replan Teaching 78

3.2 Review and Replan IMCI Teaching:

Tasks at the Teaching Institution 82
Review the Plan of Action 82
Assess the Methods and Materials Used 85
Measure the Outcome of Teaching 89
Revise the Plan of Action 91

4. PHASE FOUR - EVALUATE IMCI TEACHING 94

4.1 Evaluate IMCI Teaching:

Tasks at the Teaching Institution 97
Evaluate the Process and Outcomes of IMCI teaching 97
Use the results of evaluations to strengthen teaching 102

4.2 Evaluate IMCI Teaching:

Tasks at National Level 104
Evaluate the effectiveness and costs of IMCI teaching 104
Share the results of evaluations 112

ANNEX 1: Orient and Plan

ANNEX 2: Prepare and Conduct the First Round of IMCI Teaching
ANNEX 3: Review and Replan IMCI Teaching
ANNEX 4: Evaluate IMCI Teaching

ii
 PART A: Introduction

1. Overview of the IMCI Strategy

Although the annual number of deaths among children less than five years old has
decreased by almost a third since the 1970s, this reduction has not been evenly
distributed throughout the world. According to the 1999 World Health Report,
children in low- to middle-income countries are 10 times more likely to die before
reaching the age of five than children living in the industrialized world. In 1998, more
than 50 countries still had childhood mortality rates of over 100 per 1,000 live births.1

Every year more than 10

million children in these
countries die before they reach
their fifth birthday. Seven in
10 of these deaths are due to
acute respiratory infections
(mostly pneumonia),
diarrhoea, measles, malaria, or
malnutrition — and often to a
combination of these
conditions (Figure 1).

Projections based on the 1996

analysis The Global Burden of
Disease2 indicate that these
conditions will continue to be
major contributors to child
deaths through the year 2020
unless significantly greater
efforts are made to control them. Every day, millions of parents take children with
potentially fatal illnesses to first-level health facilities such as clinics, health centres
and outpatient departments of hospitals. In some countries, three in four episodes of
childhood illness are caused by one of these five conditions. And most sick children
present with signs and symptoms related to more than one. This overlap means that a
single diagnosis may not be possible or appropriate, and that treatment may be
complicated by the need to combine therapies for several conditions. Surveys of the
management of sick children at these facilities reveal that many children are not
properly assessed and treated and that their parents are poorly advised.3

1
World health report 1999, making a difference. Geneva, World Health Organization, 1999.
2
Murray CJL and Lopez AD, The global burden of disease: a comprehensive assessment of mortality and disability
from diseases injures, and risk factors in 1990 and projected to 2020. Geneva, World Health Organization, 1996.
3
Report of the Division of Child Health and Development 1996-1997. Geneva, World Health Organization, 1998.

1
 Part A - Introduction
Overview of the IMCI Strategy

At this level, in most countries, diagnostic supports such as radiology and laboratory
services are minimal or non-existent; and drugs and equipment are scarce. Limited
supplies and equipment, combined with an irregular flow of patients, leave health care
providers at first-level facilities with few opportunities to practise complicated clinical
procedures. Instead, they must often rely on history and signs and symptoms to
determine a course of management that makes the best use of available resources.

Providing quality care to sick children in these conditions is a serious challenge. In

response to this challenge, WHO and UNICEF developed a strategy known as
Integrated Management of Childhood Illness (IMCI). Although the major stimulus for
IMCI came from the needs of curative care, the strategy combines improved
management of childhood illness with aspects of nutrition, immunization, and other
important disease prevention and health promotion activities. The objectives are to
reduce deaths and the frequency and severity of illness and disability, and to
contribute to improved growth and development.

The strategy includes three main components:

· Improvements in the case-management skills of health staff through the

provision of locally adapted guidelines on IMCI and through activities to
promote their use

· Improvements in the health system required for effective management of

childhood illness

· Improvements in family and community practices

The core of the IMCI strategy is integrated case management of the most common
childhood conditions, with a focus on the most important causes of death. The IMCI
clinical guidelines promote an evidence-based, syndromic approach to case
management that supports the rational, effective and affordable use of diagnostic tools
and drugs. Evidence-based case management stresses the importance of evaluating
evidence from clinical research and cautions against the use of intuition, unsystematic
clinical experience, and untested pathophysiologic reasoning for decision-making.4

In addition to comprehensive assessment and management of common childhood

illnesses, the IMCI guidelines include methods for:

· Checking a child's immunization and nutrition status;

· Teaching parents how to give treatments at home;

· Assessing a child's feeding and counselling to solve feeding problems; and

· Advising parents about when to return to a health facility.

4
Chessare JB. Teaching clinical decision-making to pediatric residents in an era of managed care. Paediatrics,
1998, 101 (4 Pt), 762-766.

2
 Part A - Introduction
Overview of the IMCI Strategy

WHO and UNICEF recommend a phased approach to planning and implementing the
IMCI strategy in countries. The following phases are described in detail in the IMCI
planning guide: Gaining experience with the IMCI strategy in a country.5

Phase I: Introduction of IMCI in a country, which includes thorough orientation of

decision makers, the establishment of a national IMCI management and coordination
group, training of key Ministry of Health (MOH) staff in the IMCI clinical guidelines
and MOH endorsement of the strategy;

Phase II: Gaining experience through early implementation, which includes

development of a national plan, selection of initial districts for implementation,
adaptation of the IMCI clinical guidelines and materials, training of course facilitators
and planning at district level;

Phase III: Expansion of activities and coverage, which includes expansion of IMCI
activities in districts already covered, and expansion to cover additional districts.

5
IMCI planning guide: Gaining experience with the IMCI strategy in a country. Geneva, World Health
Organization, 1999 (unpublished document WHO/CHS/CAH/99.1; available on request from the Department of
Child and Adolescent Health and Development, World Health Organization, 1211 Geneva 27, Switzerland -
Fax: +41 22 791 4853, email: [email protected]).

3
 Part A - Introduction
Rationale for Introducing IMCI into Medical and Paramedical Education

2. Rationale for Introducing IMCI Into Medical and

Paramedical Education
Children account for 30 to 70 per cent of all patients seen in busy outpatient clinics
with limited resources and equipment in low- and middle-income countries.6 Because
problems seen in outpatient clinics are typical of what most graduates from medical
and paramedical schools will encounter later in their careers, it is essential for
students to develop core knowledge and skills related to outpatient paediatrics as part
of their basic education.7

Most children who die in outpatient clinics do so within the first few hours after
arriving there.8 To avoid unnecessary deaths, students need to learn rapid yet
relatively simple actions to determine if a child needs urgent hospital care, if the child
can be treated in the clinic, or if the child can be safely cared for at home. When a
child can be cared for in the clinic or at home, students need to know how to
comprehensively examine and manage the child with available resources, and give
preventive care such as immunizations and vitamins. They also need to know how to
prescribe appropriate drugs in correct combinations and amounts, and how to counsel
a child's caretaker about treatment, feeding and when to return to a health facility. The
clinical guidelines for Integrated Management of Childhood Illness (IMCI) include all
of the above elements of basic outpatient care for children up to five years of age.

Medical and paramedical students are rarely given opportunities to develop essential
outpatient clinical skills during their undergraduate training, although such skills are
needed. In most countries, 70 to 90 percent of all paediatric and child health
clerkships are conducted in the inpatient environment. These clerkships tend to
provide little more than random exposure to severe illnesses and very little practice in
interviewing parents and managing patients. In addition, nearly 100 percent of all
clerkships take place in specialized teaching hospitals with relatively good supplies
and equipment. This is in stark contrast to the environment where many new
graduates actually practise – that is in outpatient community clinics with limited
resources and equipment.9

In many countries, national institutions have begun asking paramedical and medical
schools to increase the amount of time in their curricula for clinical training in
outpatient settings, because these settings provide experience that is particularly
relevant to future professional practice.10 In addition, international organizations such
as the World Federation for Medical Education have recognized the importance of
outpatient care in the undergraduate curriculum. They have advocated for: (a)

6
Verma M and Singh T. Undergraduate pediatric education in India: Current concepts. Indian Pediatrics,1995, 32: 9-
12.
7
Lachman P and Zwarenstein M. Child health and health care utilisation. A community-based survey in Mitchell's
Plain. CP. South Africa Medical Journal,1990, 77(9): 467-70.
8
Mukasa G. Seeing the sickest first. Child Health Dialogue,1998. 4(13): 3.
9
Sahler OJ. Pediatric Medical Student Education: New and déjà vu. Archives of Pediatrics and Adolescent
Medicine,1999,153:223-225.
10
Carl E et. al. Trends in clinical education of medical students: Implications for pediatrics. Archives of Pediatric and
Adolescent Medicine,1999,153: 297-302.

4
 Part A - Introduction
Rationale for Introducing IMCI into Medical and Paramedical Education

widening the settings in which education takes place, (b) coordinating education with
health services delivery, (c) using national health priorities to set the context for
education, and (d) integrating science and clinical practice.11 However, no clear
strategy has been proposed for how to implement these recommended changes.

To ensure that all categories of health care professionals develop essential

competencies in child health, it will not be enough for students simply to spend more
time in the outpatient ward. The amount of knowledge applicable to outpatient
paediatrics is vast and growing exponentially. To guide student learning and reduce
factual overload, educators need to clearly define the core or critical knowledge,
experience and skills that students must acquire.12 The IMCI clinical guidelines, with
their clear focus on the prevention and cure of the most common and lethal childhood
conditions, define the most essential knowledge and skills needed to effectively
manage sick children in outpatient clinical settings. Training that incorporates the
learning objectives of IMCI will enable students to develop a firm foundation of core
knowledge and skills on which to build a theoretical and applied approach to clinical
practice.

All health professionals who care for sick children, including doctors, need to develop
core knowledge and skills in the outpatient management of sick children. Nurses,
midwives and other health professionals play a key role in the management and
prevention of childhood illnesses. In addition, doctors often train and supervise other
cadres of health staff. In order to be effective trainers and supervisors, doctors need to
understand and agree with national clinical guidelines such as IMCI – and they need
to apply those guidelines in their own practices. The incorporation of IMCI into
undergraduate medical education is, therefore, a logical step toward strengthening
clinical practices not only among doctors but also among other categories of health
professionals.

To effectively apply the essential clinical skills encompassed in the IMCI clinical
guidelines, graduates need to work within a functioning health system and receive
adequate support from families and communities. For this reason, medical, nursing
and other health professional schools should plan to address all three components of
the IMCI strategy. This will ensure not only that graduates know how to prevent and
manage common serious childhood conditions, but also that they understand what is
needed to improve health systems and strengthen the ability of families and
communities to support the prevention and management of common serious
childhood conditions.

The introduction of IMCI into medical and paramedical education presents an

opportunity for teaching institutions to set clear priorities for learning. IMCI helps
build an integrated approach to the teaching of common child health problems by
encouraging coordination between different teaching units and sub-units over several
academic years. In addition, IMCI prepares health professionals to work within a

11
Forsyte K and Rotem A. Meeting the needs of medical students training in paediatrics and child health. Journal of
Paediatric Child Health, 1999, 35: 11-13.
12
Baum JD. Core knowledge, skills and attitudes for undergraduates: Kindling curiosity. Archives of Disease in
Childhood, 1995, 73(3): 268-9.

5
 Part A - Introduction
Rationale for Introducing IMCI into Medical and Paramedical Education

national health system and to support public health strategies while providing quality
care to sick children using scarce resources and equipment in a rational manner.

6
 Part A - Introduction
Purpose of this Guide

3. Purpose of this Guide

The purpose of this guide is to assist national authorities (e.g. Ministries of Health
(MOH), Ministries of Education (MOE), etc.); national professional and academic
associations (e.g. national paediatrics societies, national associations of medical
schools, etc.); administrators and staff of teaching institutions; WHO staff and
consultants; and technical and donor organizations in strengthening the teaching of
child health through the incorporation of IMCI into relevant academic programmes.
The recommendations presented in this guide are based on the experiences of a
number of different countries and teaching institutions that have successfully
introduced IMCI into academic programmes for doctors, nurses and other health
professionals.

7
 Part B: Planning, Implementing and Evaluating IMCI Pre-Service Training

PART B:
Planning, Implementing and Evaluating IMCI Pre-
Service Training

Before introducing IMCI pre-service training in a country, experience has shown that
it is crucial to:

· Adapt the IMCI clinical guidelines to the local circumstances of the country;

· Test the adapted guidelines; and

· Gain some experience using the guidelines (e.g. through in-service training
courses that also serve to build a pool of facilitators, clinical instructors and
decision-makers who are familiar with IMCI).

Following these actions, the process of planning, implementing and evaluating IMCI
pre-service training may be carried out in the following four phases:

Phase One: Orient and Plan

Phase Two: Prepare and Conduct the First Round of IMCI Teaching

Phase Three: Review and Replan IMCI Teaching

Phase Four: Evaluate IMCI Teaching

These phases set in motion a cyclical process that can be used to revise and strengthen
teaching over time (see figure 2). The cyclical process facilitates continued reviews
and updates of IMCI teaching. It can also facilitate the strengthening of teaching in
other subjects such as breastfeeding counselling, the referral care of sick children, and
adolescent health and development.

This guide suggests tasks to be completed by national or state-level coordinators of

IMCI pre-service training, and by administrators and staff at teaching institutions.
Although tasks managed at the national level are similar to those managed by
teaching institutions, they are described separately in this guide, because different
people and resources are needed at each level.

Tasks at the national (or state) level can be carried out by representatives of: national
authorities such as the Ministry of Health (MOH) and Ministry of Education (MOE);
academic or professional associations; or a pre-service training coordinating group
that includes representatives from national authorities, professional associations and
the academic community. At the teaching institution level, the formation of an IMCI
Working Group is strongly encouraged. The working group should take responsibility
for planning and coordinating activities within its teaching institution.

8 August 2001
 Part B: Planning, Implementing and Evaluating IMCI Pre-Service Training

Figure 2

Phases of Strengthening Pre-Service Training

PHASE 1: PHASE 2:

Orient Prepare
and and
Plan Conduct
Train Teachers
Teaching
Revise Plans
Prepare Clinics

Assess Outcomes Prepare Materials

Coordinate Teaching
PHASE 4: PHASE 3:
Review Plans
Evaluate Review Monitor Teaching
Teaching and
Replan

Tasks at the national or state level aim to create a favourable political environment for
IMCI teaching. They also support teaching institutions in preparing, implementing,
reviewing, replanning and evaluating IMCI teaching. At the same time, tasks at the
teaching institution level aim to: orient opinion leaders and decision-makers; plan for
the introduction of new teaching; prepare relevant teaching staff, materials and
clinical practice sites; coordinate teaching between different academic units and
subunits; and monitor, review and revise new teaching. It is important to establish
strong links between national or state coordinators and the IMCI Working Group at
each teaching institution.

For each recommended task, this guide provides the following information:

· Objectives of the task

· Suggested timing

· Who should be responsible and/or involved

· Description of the task

· Activities and materials that can be used to carry out the task

It is not necessary to complete all tasks and all activities described in this guide. The
National Coordinating Group and teaching institutions should select appropriate tasks
and activities in accordance with their unique circumstances, needs and available

9 August 2001
 Part B: Planning, Implementing and Evaluating IMCI Pre-Service Training

resources. In addition, each group should implement selected tasks and activities in a
sequence that is most appropriate to their situation.

Certain tasks or activities may be omitted. For example, if a country has only one
medical school, the National Coordinating Group may choose not to develop a
national plan of action for introducing IMCI into medical schools. Furthermore, some
tasks or activities may be repeated. For example, a National Coordinating Group may
choose to conduct several orientation workshops for different types of teaching
institutions. Other tasks may be combined or done informally. For example, the
Ministry of Health may sponsor a national orientation meeting during which a
National IMCI Coordinating Group is formed.

Experience has shown, however, that some tasks are essential or critical for the
successful and sustainable introduction of IMCI pre-service training. For this reason,
tasks that are considered critical are designated with an asterisk in this guide. Figure 3
lists all of the phases and tasks that are described in this guide.

10 August 2001
 Part B: Planning, Implementing and Evaluating IMCI Pre-Service Training

Figure 3

Phases and Tasks for Incorporating IMCI Into

Pre-Service Training

PHASE ONE: ORIENT & PLAN

1.1 NATIONAL COORDINATOR(S) 1.2 TEACHING INSTITUTION(S)

o Analyse the Situation o Analyse the Situation*
o Orient National Opinion Leaders and o Orient Decision-Makers*
Decision-Makers* o Create an IMCI Working Group*
o Create a National Coordinating o Train Key Planners*
Group o Plan for the Introduction of IMCI
o Develop a National Plan Teaching*
o Assist Teaching Institutions with Staff o Request Endorsement of the Plan

PHASE TWO: PREPARE & CONDUCT THE FIRST ROUND OF IMCI TEACHING
2.1 NATIONAL COORDINATOR(S) 2.2 TEACHING INSTITUTION(S)
o Assist Teaching Institutions in o Define Times, Places, Activities and
Preparing for and Monitoring Materials*
Teaching* o Train Relevant Teachers and Clinical
Staff*
o Prepare Clinical Practice Sites*
o Prepare Materials*
o Coordinate Teaching*
o Conduct and Monitor Teaching*

PHASE THREE: REVIEW & RE-PLAN IMCI TEACHING

3.1 NATIONAL COORDINATOR(S) 3.2 TEACHING INSTITUTION(S)
o Assist Teaching Institutions in o Review the Plan of Action*
Reviewing and Replanning o Assess the Methods and Materials
Teaching* Used
o Measure the Outcome of Teaching
o Revise the Plan of Action*

PHASE FOUR: EVALUATE

4.1 NATIONAL COORDINATOR(S) 4.2 TEACHING INSTITUTION(S)
o Evaluate the effectiveness of IMCI o Assist the evaluation of IMCI
Teaching teaching
o Share the results of evaluations* o Use the results of evaluations to
strengthen teaching

_______________________
* Critical Task

11 August 2001
 Phase One - Orient and Plan

1. PHASE ONE – ORIENT AND PLAN

Tasks at the national or state level Page

¨ Analyse the situation 15

¨ Orient national opinion leaders and decision-makers* 17
¨ Create a National Coordinating Group 20
¨ Develop a national plan 23
¨ Assist teaching institutions with staff orientation and 26
planning*

Tasks at the teaching institution level

¨ Analyse the situation* 31

¨ Orient decision-makers* 34
¨ Create an IMCI Working Group* 37
¨ Train key planners* 39
¨ Plan for the introduction of IMCI teaching* 42
¨ Request endorsement of the plan 46

* Critical Task

Experience has shown that before introducing IMCI into pre-service training it is
important to: adapt the IMCI clinical guidelines to the circumstances of a country or
state; try out the adapted guidelines in selected health facilities; and train a pool of
facilitators for the IMCI in-service training course.

Before they can change teaching programmes, opinion leaders and decision-makers in
the academic and child health community must first recognize the benefits and
consequences of the IMCI strategy and clinical guidelines. Once this understanding is
achieved, a clear plan for introducing IMCI into existing academic programmes will
help guide the change process.

The tasks described in this phase aim to:

· Generate understanding, acceptance and support of the IMCI strategy and clinical
guidelines among national authorities, the academic community and members of
professional associations; and

12 August 2001
 Phase One - Orient and Plan

· Create written plans of action for the introduction of IMCI teaching, both at the
national level and at the teaching institution level.

In each country, the National Coordinating Group and teaching institutions should
select appropriate tasks to implement, based on the specific needs and resources of the
country. Tasks that have proven critical to the success of this phase are marked with
an asterisk (*) in the table above. Facilitators may carry out tasks in the same order
presented in this guide, or they may change the sequence to suit local needs and
circumstances. Experience has shown, however, that persons who organize and
conduct orientation and planning activities should be thoroughly trained in IMCI.

During the orientation and planning phase, strong links between the National
Coordinating Group and teaching institutions are essential. National organizations,
such as the Ministry of Health, National Paediatrics Society or National Association
of Nurses should foster understanding and acceptance of IMCI among key opinion
leaders and decision-makers, both inside and outside teaching institutions. The
National Coordinating Group for pre-service training should identify the types of
teaching institutions that will introduce IMCI, and then assist those institutions in
orienting decision-makers, training staff, and planning for IMCI teaching.

At teaching institutions, decision-makers and staff should identify which academic

units and subunits will teach IMCI. They should then orient and train staff within
those units, and prepare a feasible and comprehensive plan of action for introducing
IMCI into relevant academic programmes.

13 August 2001
 Phase One - Orient and Plan: Tasks at National Level

1.1 Orient and Plan: Tasks at National Level

Teaching institutions will need support

and assistance from national
authorities, particularly from the 1.1 NATIONAL COORDINATOR(S)
National IMCI Coordinating Group.
In addition, they will need support o Analyse the situation
from members of the academic o Orient national opinion leaders
community and from professional and decision-makers*
associations – such as the national o Create a National Coordinating
associations of paediatrics and nursing Group
– in orienting key teaching and
o Develop a national plan
administrative staff and in planning for
the introduction of IMCI teaching. o Assist teaching institutions with
However, before a national staff orientation and planning*
coordinating group can provide
support to teaching institutions,
members of the group must be
convinced themselves of the need to include IMCI in basic paramedical and medical
education.

Many countries choose to identify a national focal person and to create a National
Coordinating Group for IMCI Pre-Service Training. The National Coordinating
Group for IMCI Pre-Service Training is frequently a sub-group of the National IMCI
Task Force. The group often consists of representatives from national authorities, the
academic community, professional associations, and relevant technical or donor
agencies. If formed, this group can carry out many of the national-level activities
described in this guide. In addition, WHO staff members or consultants may provide
technical assistance with some activities, upon request.

The following tasks are suggested at the national level during the orientation and
planning phase:

· Analyse the situation;

· Orient national opinion leaders and decision-makers;*
· Create a National Coordinating Group;
· Develop a national plan; and
· Assist teaching institutions with staff orientation and planning. *

Two of the above tasks are considered critical to the success of IMCI pre-service
training: orienting national opinion leaders and decision-makers to the IMCI strategy
and clinical guidelines; and assisting teaching institutions with staff orientation and
planning for the introduction of IMCI teaching. Each of the tasks for orientation and
planning at the national level is described in more detail below.

*
Critical task

14 August 2001
 Phase One - Orient and Plan: Tasks at National Level

Analyse the Situation

Information should be collected

about the different types of health
1.1 NATIONAL COORDINATOR(S)
personnel who care for sick
children at first-level facilities such
as clinics, health centres and þ Analyse the situation
outpatient departments of hospitals. o Orient national opinion leaders and
In addition, information should be decision-makers*
collected about the teaching o Create a National Coordinating Group
institutions that train those
o Develop a national plan
personnel, as well as about the
people and associations that o Assist teaching institutions with staff
influence curricula in those orientation and planning*
teaching institutions. This
information can inform important
decisions about how to introduce IMCI into paramedical and medical education.

Objectives

The objectives of the situation analysis are to:

· Identify the types of health personnel who provide care to sick children at
first-level health facilities such as clinics, health centres and outpatient
departments of hospitals;

· Identify where and how health personnel at first-level facilities receive their
basic training; and

· Identify the persons and groups who influence curricula in institutions where
first-level health personnel receive their basic training.

Timing

It is best to conduct a situation analysis before a detailed plan is created for

introducing IMCI into paramedical and medical education. Information collected
during the situation analysis will help in identifying appropriate target audiences
for orientation activities, and in preparing suggestions for the introduction of
IMCI pre-service training.

Who Should Conduct the Analysis?

Persons designated to lead national or state efforts to introduce IMCI pre-service

training should analyse the situation. These might include representatives of:

· The National IMCI Task Force;

15 August 2001
 Phase One - Orient and Plan: Tasks at National Level

· National authorities such as the Ministry of Health, Ministry of Education or

Commission on Higher Education;
· Professional associations such as the National Paediatrics Society, the
National Association of Nursing, the National Association of Midwifery, etc.;
· Governing bodies of teaching institutions such as the National Association of
Nursing Schools and the National Association of Medical Schools; and
· Teaching institutions.

Description

The purpose of this task is to gather information that can be used to orient opinion
leaders and decision-makers about IMCI, and to begin planning for the
introduction of IMCI pre-service training at the national or state level.

A situation analysis should answer important questions such as:

· What types of health personnel provide first-level, outpatient care to children?

· How and where are these health workers initially trained?

· Who influences what is taught at these institutions?

· At what level is the curriculum developed and revised for different types of
teaching institutions (e.g. by a national curriculum board, within each teaching
institution, etc.)?

· Who makes decisions about the deployment of health personnel after training?

· Who should be involved in the process of introducing IMCI pre-service

training?

· Where should the process begin (i.e. at what teaching institutions or in what
districts or states)?

Suggested Activities and Materials

Information needed to analyse the situation may be collected through meetings,

informal interviews, short written questionnaires, documents and reports.
Extensive or formal interviews and written surveys are not encouraged, because
they require significant time and resources to prepare and conduct. The basic
information needed at this stage can be collected quickly, informally and at little
cost.

Useful sources of information include the Ministry of Health, Ministry of

Education, WHO Country Office, professional associations such as the National
Paediatrics Society, and academic bodies such as national associations of medical
and nursing schools. Also recommended is a review of the country’s adapted

16 August 2001
 Phase One - Orient and Plan: Tasks at National Level

IMCI clinical guidelines, national plan for IMCI implementation, and WHO
reports on IMCI activities in the country.

The situation analysis questionnaire provided in Annex 1 can be used as a starting

point for collecting information.

Orient National Opinion Leaders and Decision-Makers

Experience has shown that

information distribution is not
sufficient, in and of itself, to bring 1.1 NATIONAL COORDINATOR(S)
about change in paramedical and
medical education. First, opinion þ Analyse the situation
leaders and decision-makers who
þ Orient national opinion leaders and
influence what is taught must be decision-makers*
aware of and accept the need to
change the content and process of o Create a National Coordinating Group
teaching. Then they must support o Develop a national plan
and assist the accepted changes. o Assist teaching institutions with staff
orientation and planning*
Objectives

The objectives of orientation are to:

· Create awareness of the IMCI strategy and clinical guidelines among national
authorities, the academic community and professional associations;

· Gain acceptance of IMCI as a core element of basic paramedical and medical

education; and

· Generate support for incorporating IMCI into paramedical and medical

education.

Timing

Experience has shown that the academic community often becomes aware of
IMCI when the strategy is first introduced in a country. Members of the academic
community usually assist national authorities in adapting the IMCI clinical
guidelines to the circumstances of a country, and in planning for the
implementation of the IMCI strategy. Previous exposure to IMCI is often useful
but insufficient. For this reason, a more focused orientation is recommended to
ensure that key representatives of national authorities, the academic community
and professional associations thoroughly understand and accept the academic
rationale, benefits and consequences of IMCI. Thorough understanding and
acceptance is critical for the effective incorporation of IMCI into the basic
education of doctors, nurses and other health professionals.

17 August 2001
 Phase One - Orient and Plan: Tasks at National Level

Target Audience
The target audiences for this task are:

· Representatives from national authorities with influence over the curricula of

paramedical and medical schools, such as members of professional licensing
boards, the Commission on Higher Education, or the training departments of
the Ministry of Health and the Ministry of Education;

· Decision-Makers in the academic community, such as representatives of the

National Association of Nursing Schools, the National Association of Medical
Schools, and the professional certification board, as well as deans of nursing
and medical schools, and heads of Paediatrics Departments or Child Health
Departments; and

· Members of professional associations such as the National Paediatrics Society

and the National Association of Nurses.

Description

The purpose of this task is to generate awareness, understanding and acceptance

of the IMCI strategy and clinical guidelines among government authorities,
members of the academic community and members of professional associations.
Successful orientation should result in a commitment by opinion leaders and
decision-makers to incorporate IMCI teaching into paramedical and medical
education. Achievement of these objectives often depends upon an exchange of
information over an extended period of time that leads to decisions about
necessary changes to academic programmes.

During the orientation phase, it is important to emphasize that in most teaching

institutions it is not necessary to revise the formal written curriculum in order to
introduce IMCI teaching strategy. The broad elements of IMCI are frequently already
included in the curricula of relevant academic programmes. As such, the introduction
of IMCI mainly requires a shift within existing curricula to a stronger focus on
common serious childhood illnesses, malnutrition, communication with the
caretakers of children and clinical practice with outpatient cases.

Awareness of the IMCI strategy and clinical guidelines can be created by briefing
target audiences about the rationale behind the IMCI strategy, and informing them
about positive experiences with the introduction of IMCI pre-service training.

In order to gain acceptance of IMCI and to generate a commitment to

incorporating IMCI into existing teaching schedules, the target audiences should
be well informed about:

· The IMCI strategy, with an emphasis on the need to adapt the strategy and
clinical guidelines to the circumstances and needs of a country;

18 August 2001
 Phase One - Orient and Plan: Tasks at National Level

· The IMCI clinical guidelines, including an overview of the technical basis and
a description of how the guidelines are used for evidence-based patient
assessment and management;

· Approaches taken in countries and teaching institutions to incorporate

teaching of IMCI into the basic education of paramedical and medical staff;

· What students should know, and what students should be able to do, after
learning IMCI (i.e. the IMCI learning objectives);

· What IMCI can offer to students in terms of new knowledge, skills and
attitudes (i.e. academic rationale for IMCI);

· WHO materials that are available to help plan and manage the introduction of
IMCI teaching; and

· The types of teaching, learning and assessment methods and materials

commonly used for IMCI teaching.

National orientation activities should achieve the following outcomes:

· High-level endorsement of the IMCI strategy and clinical guidelines from key
institutions and associations;

· Appointment of a national focal person for IMCI pre-service training who will
coordinate the introduction of IMCI teaching in paramedical and medical
schools; and

· Establishment of partnerships and links between the national coordinating

group, teaching institutions and technical and donor agencies.

Suggested Activities and Materials

Information may be disseminated in various ways to create awareness of IMCI.

The National Coordinating Group for IMCI Pre-Service Training, National IMCI
Task Force, WHO staff and/or consultants, and interested representatives of
academic and professional associations should work together to identify the best
channels for reaching the target audiences described above.

Suggested activities call for the dissemination of information about IMCI, as well
as interactive activities that allow the target audiences to develop a deeper
understanding of IMCI by asking questions and expressing their support or
concerns.

More specifically, the suggested activities are:

19 August 2001
 Phase One - Orient and Plan: Tasks at National Level

· Disseminate information about IMCI through articles in local journals,

newsletters of professional societies or associations, brochures, information
sheets, media events and/or displays at meetings and conferences.

· Lead IMCI presentations or discussions at meetings or congresses of

academic associations, professional societies, and/or government authorities.

· Conduct an orientation workshop, or a series of workshops, with target

audience members geared toward fostering a deeper understanding of IMCI.

Note that under normal circumstances, minimal time (e.g. one to two hours) is
allowed for presentations or discussions at meetings or congresses. For this
reason, it is important to carefully select which information to present, and allow
time for questions and discussion. It is best to give a brief introduction to the
IMCI strategy and clinical guidelines, and then to present what IMCI can offer to
students in terms of new knowledge, skills and attitudes (i.e. academic rationale
for IMCI).

For a more thorough orientation of the target audiences, consider a workshop. A

workshop should last one to two days, depending on the participants' pre-existing
knowledge of IMCI. If the majority of participants have no previous training in
the IMCI clinical guidelines, a two-day workshop is recommended.

Annex 1 includes tables of the people and materials suggested to conduct the
activities described above. Materials that are listed, but not included in Annex 1,
may be requested from WHO CAH headquarters or from a WHO regional or
country office.13

Create a National Coordinating Group

Experience has shown that a

committed focal person at the
national or state level often needs 1.1 NATIONAL COORDINATOR(S)
assistance from a National
Coordinating Group in order to þ Analyse the situation
effectively introduce IMCI þ Orient national opinion leaders and
teaching in a country. A National decision-makers*
Coordinating Group can coordinate
þ Create a National Coordinating Group
and facilitate activities related to
planning, implementing, reviewing o Develop a national plan
and replanning IMCI pre-service o Assist teaching institutions with staff
training. The group may be formed orientation and planning*
as a sub-group of the National
IMCI Working Group (or Task

13
WHO materials may be requested from the WHO representative in a country, the WHO regional office, or the
Department of Child and Adolescent Health and Development (CAH), World Health Organization, Avenue
Appia 20, 1211 Geneva 27, Switzerland (Fax: +41 22 791 4853, email: [email protected]).

20 August 2001
 Phase One - Orient and Plan: Tasks at National Level

Force). Or it may be created as a separate and individual entity. The group can be
created at any time during the implementation of the IMCI strategy in a country, and
should establish strong ties with the Ministry of Health and relevant teaching
institutions.

Although the creation of a National Coordinating Group is considered an optional

task, in countries with more than one medical or paramedical school, this group can
be critical to the effective and timely introduction of IMCI pre-service training. For
example, the group can prevent the duplication of efforts by sharing materials,
activities and experiences with several teaching institutions.

Objectives

The primary objectives of a National Coordinating Group are to:

· Promote broad understanding and acceptance of IMCI among national

authorities, the academic community and professional societies;

· Identify relevant technical and donor organizations and involve them in the
process of planning, implementing and evaluating IMCI pre-service training;

· Assist medical, nursing and other health professional schools in planning,

preparing for, implementing, reviewing and replanning IMCI teaching; and

· Coordinate activities between different implementing partners and teaching

institutions.

Timing

A National Coordinating Group may be formed at any time. For example, a core
National Coordinating Group may be created during a national IMCI session held
at a professional congress, or during a national orientation workshop on IMCI pre-
service training. After its initial formation, the core group can be expanded to
include additional members. A National Coordinating Group may also be formed
during Phase 2: Prepare and Conduct the First Round of IMCI Teaching, to help
coordinate and facilitate the training of teaching staff and the development of
teaching, learning and assessment materials.

Members of the National Coordinating Group

The members of the National Coordinating Group should be interested in and

committed to introducing IMCI into the teaching schedules of medical, nursing
and other health professional schools. A focal person should be appointed to take
responsibility for calling meetings and coordinating the group’s activities.

Ideally, a National Coordinating Group will include representatives from:

21 August 2001
 Phase One - Orient and Plan: Tasks at National Level

· National authorities such as the Ministry of Health, Ministry of Education or

Commission on Higher Education;
· The National IMCI Task Force;
· The academic community, including the National Association of Medical
Schools, National Association of Nursing Schools and national associations of
other types of health professional schools;
· Professional associations such as the National Paediatrics Society, the
National Association of Nursing, and the National Association of Midwifery;
· Teaching institutions; and
· Technical and donor agencies such as WHO, UNICEF, bilateral development
organizations and non-governmental organizations.

Description

The aim of the National Coordinating Group is to coordinate and facilitate the
planning, implementation, review and replanning of IMCI pre-service training.
The working group, therefore, should organize and conduct activities such as:
orienting opinion leaders and decision-makers; training teaching staff; and
developing or revising teaching, learning and assessment materials. The group
also is responsible for exchanging information and materials with various teaching
institutions, and with different technical and donor agencies, in order to define
needs, pool resources and avoid the unnecessary duplication of efforts.

Suggested Activities

A National Coordinating Group for IMCI pre-service training should coordinate

and facilitate many of the activities described in this guide. These activities
include:

· Orienting decision-makers and planning for the implementation of IMCI pre-

service training;

· Training administrators, teachers and relevant clinical staff in the IMCI

strategy and clinical guidelines;

· Identifying, developing and/or revising appropriate IMCI teaching, learning

and assessment materials;

· Identifying and preparing appropriate clinical practice sites for IMCI;

· Reviewing and replanning IMCI teaching at individual institutions; and

· Evaluating IMCI teaching.

22 August 2001
 Phase One - Orient and Plan: Tasks at National Level

Develop a National Plan

If more than one teaching

institution in a country should
1.1 NATIONAL COORDINATOR(S)
introduce IMCI, experience has
shown that it is useful to develop
a national plan for the þ Analyse the situation
introduction of IMCI pre-service þ Orient national opinion leaders and
training. decision-makers*
þ Create a National Coordinating Group
Objectives
þ Develop a national plan
The objectives of developing a o Assist teaching institutions with staff
national plan for the introduction orientation and planning*
of IMCI pre-service training are
to:

· Identify where and how IMCI pre-service training should be introduced in a

country;

· Identify activities that should be facilitated or supported at national or state

level (e.g. orienting decision-makers and training teaching staff);

· Coordinate activities between different groups, organizations and teaching

institutions;

· Identify the resources needed (e.g. human, financial, etc.) to conduct necessary
activities; and

· Estimate when different activities should be conducted (i.e. prepare a

timeline).

Timing

Before a national plan for IMCI pre-service training is created, it is highly

recommended that the persons charged with developing the plan receive a
comprehensive orientation to IMCI and, if possible, thorough training in the IMCI
clinical guidelines. The plan may be developed before activities begin at the
teaching institution level, or it may be created after one or more schools have
gained some experience with the introduction of IMCI teaching.

Who Should Develop the National Plan?

It is important that the persons preparing the national plan understand the IMCI
strategy and clinical guidelines, know what is needed to introduce change at
teaching institutions, and have some influence over what is taught. If a National
Coordinating Group for IMCI Pre-Service Training is created, the members of the

23 August 2001
 Phase One - Orient and Plan: Tasks at National Level

group should be responsible for developing a national plan. If no National

Coordinating Group is formed, an interested group such as the National IMCI
Task Force, the National Paediatrics Society, or the National Association of
Nurses may develop a plan.

Description

A national plan for introducing IMCI pre-service training in a country should:

· List the types of health care providers who manage sick children at first-level
outpatient health facilities;

· List the types of teaching institutions (and the academic programmes therein)
that these health care providers traditionally attend for their undergraduate
education;

· Suggest the order in which various types of teaching institutions should

introduce IMCI (i.e. which teaching institutions should start introducing IMCI
first, second, third, etc.). This includes decisions as to whether several schools
should start together at one time, or whether it is preferable for one school to
complete the process first in order to serve as a “success story” for other
schools;

· Identify any policies at the national, state, health facility, or school level that
might interfere with the teaching or application of IMCI (e.g. situations in
which students are not allowed to prescribe drugs, immunizations are not
given on demand, job descriptions are outdated, etc.);

· Describe how unfavourable policies might be changed or overcome;

· Identify who needs to be trained in IMCI in order to conduct future orientation

and training activities at the national or state level, and for administrators and
staff at teaching institutions;

· Describe how the future facilitators of orientation and training activities will
be trained in IMCI;

· Identify which types of national opinion leaders and decision-makers should

be thoroughly oriented to IMCI;

· Describe how opinion leaders and decision-makers will be oriented;

· Describe how administrators and staff at teaching institutions will be oriented

and trained, including how training will be sustained over time to
accommodate new teachers. This includes decisions as to whether staff from
different schools might participate together in orientation and training
activities, or whether activities should be conducted separately with individual
schools;

24 August 2001
 Phase One - Orient and Plan: Tasks at National Level

· List the types of external assistance that teaching institutions need in order to
plan, implement, review, and replan IMCI teaching. This may include
assistance with the development or revision of teaching, learning and
assessment materials, and assistance with the identification and development
of clinical practice sites;

· Describe who will be responsible at the national level (i.e. focal persons or
coordinating groups) for orienting opinion leaders and decision-makers,
training, planning, preparing materials and clinical practice sites, reviewing,
replanning and evaluating teaching, and other activities;

· Indicate whether the formal written curriculum should be revised in order to

introduce IMCI teaching into a particular type of teaching institution. If
revision is needed, the plan should identify who will do it and how. (Note: In
most teaching institutions, the formal written curriculum does not need to be
revised in order to introduce IMCI teaching.);

· Identify resources (i.e. human, financial and in kind) needed to conduct the
different activities; and

· Estimate when different activities will be conducted (i.e. prepare a time line of
activities).

Suggested Activities and Materials

Before developing a plan, it will be useful to review the Report of an intercountry

workshop on IMCI pre-service training: Geneva, 2.5, November 1999
(WHO/FCH/CAH/00.11).14 This document summarizes experiences and lessons
learned with the introduction of IMCI in more than 13 pre-service training
institutions. The report identifies key steps and materials needed at national and
institutional levels to introduce and support IMCI teaching.

The suggested activities are:

· Conduct a planning meeting or workshop with key decision-makers and

implementers to draft a national plan of action for IMCI pre-service training
(see Annex 1 for a sample agenda of a national planning meeting and outline
of a national action plan).

· Circulate the plan to get agreement or endorsement from persons and groups
who are critical to the implementation of the plan. It is particularly important
to have the plan endorsed by relevant national authorities (e.g. Ministry of
Health, Ministry of Education) and associations (e.g. National Paediatrics

14
Report of an intercountry workshop on IMCI pre-service training: Geneva, 2-5 November 1999. Geneva, World
Health Organization, 2000 (unpublished document WHO/FCH/CAH/00.11; available on request from the
Department of Child and Adolescent Health and Development, World Health Organization, 12211 Geneva 27,
Switzerland – Fax: =41 22 791 4853, email: [email protected]).

25 August 2001
 Phase One - Orient and Plan: Tasks at National Level

Society, National Association of Medical Schools, and National Association

of Nursing Schools). In some countries, a joint strategy or statement issued by
relevant national groups such as the Ministry of Health and the Ministry of
Education may be needed in order to move forward with IMCI pre-service
training.

· Present the plan to partners, donors and relevant national authorities to

request their support.

Assist Teaching Institutions with Staff Orientation and Planning

Teaching institutions will need

support and assistance in orienting
and training staff in IMCI, and in 1.1 NATIONAL COORDINATOR(S)
planning for the introduction of
IMCI teaching. Assistance can be þ Analyse the situation
provided by a National
þ Orient national opinion leaders and
Coordinating Group for IMCI Pre- decision-makers*
Service Training, a national focal
person for IMCI pre-service þ Create a National Coordinating Group
training, or other persons with þ Develop a national plan
knowledge and experience in IMCI
(e.g. members of non- þ Assist teaching institutions with staff
orientation and planning*
governmental organizations,
technical agencies, international
organizations, academic or professional associations, teaching institutions, or WHO
staff and consultants). These same individuals and groups can help teaching
institutions plan for the introduction of IMCI teaching.

Objectives

The objectives of assisting teaching institutions with staff orientation and planning
are to:

· Ensure that opinion leaders and decision-makers at teaching institutions and

clinical practice sites accept and understand IMCI before they begin to plan
for its introduction into relevant academic programmes; and

· Ensure that essential tasks and activities are included in a teaching institution’s
plan of action for introducing IMCI teaching.

Timing

Various types of assistance may be needed over time to help build understanding
of IMCI and to help teaching institutions plan for the introduction of IMCI into
relevant academic programmes. If a teaching institution develops a plan of action

26 August 2001
 Phase One - Orient and Plan: Tasks at National Level

before it requests external assistance, the first step of assistance should be to

review the school’s plan of action.

Who Should Assist Teaching Institutions?

Persons who assist teaching institutions should meet the following criteria:

· Thorough knowledge of IMCI;

· Teaching experience; and

· Knowledge of the WHO guidelines for planning, implementing and evaluating

IMCI pre-service training.

Qualified persons might include the national focal person for IMCI pre-service
training, or members of the National Coordinating Group for IMCI Pre-Service
Training. They may also include representatives from non-governmental
organizations, technical agencies, international organizations, academic or
professional associations, teaching institutions or WHO.

Description

Opinion leaders and decision-makers at teaching institutions and clinical practice

sites need to understand and accept IMCI before they can effectively support the
introduction of IMCI into academic programmes. Decision-Makers at clinical
practice sites include, for example, the directors of a teaching hospital or
community clinic. In addition, key persons who will plan for the introduction of
IMCI teaching at a school (e.g. deans, chairs of academic units, heads of subunits,
teachers, directors of clinical practice sites, etc.) need training in IMCI as well as
assistance in developing a comprehensive and feasible plan of action.

Circumstances and needs of specific teaching institutions will vary. As such,

different approaches can be taken to orient administrators and staff, train planners
and plan for the introduction of IMCI teaching.

Two typical approaches are:

· Representatives from teaching institutions attend regional or national

orientation, training or planning events and then return to their schools to
orient, train and assist staff in planning for the introduction of IMCI teaching;

· Persons with experience in IMCI pre-service training go to individual teaching

institutions to conduct orientation, training and planning activities with
administrators and staff.

Experience has shown that most teaching institutions use a combination of these
two approaches. For example, a representative from a school might attend training
in IMCI and return to the school to conduct IMCI orientation meetings with key

27 August 2001
 Phase One - Orient and Plan: Tasks at National Level

administrators and staff. Then the school administration might send several key
staff members, who will be involved in planning for the introduction of IMCI
teaching, to a national or regional IMCI training course. After the core group of
key staff are trained, a representative from the national IMCI pre-service training
coordinating group may go the school to facilitate a planning workshop with staff.

It is important to note the following:

· In order to develop a comprehensive and feasible plan of action for the

introduction of IMCI teaching, several key planners at a teaching institution
should be trained in the IMCI strategy and clinical guidelines;

· All persons who are critical to the implementation of the plan of action for
IMCI teaching need to be involved in the planning process. For this reason, it
is more effective to invite all key staff to a planning workshop within a
teaching institution, than to send one or two staff members to attend an outside
workshop.

Suggested Activities and Materials

Before assisting teaching institutions, it will be useful to read the Report of an

intercountry workshop on IMCI Pre-Service Training: Geneva, 2.5, November 1999
(WHO/FCH/CAH/00.11). This document summarizes experiences and lessons
learned with the introduction of IMCI in more than 13 pre-service training
institutions.

Two sets of activities may be used to help teaching institutions orient

administrators and staff, train planners, and plan for the introduction of IMCI
teaching. For certain categories of teaching institutions, a curriculum board or
committee may be responsible for planning the introduction of new teaching
content and methods. In such cases, activities may be conducted for a group of
teaching institutions. The set of activities will depend on whether or not teaching
institutions have already developed a plan of action for introducing IMCI
teaching.

If no plan of action has been developed, the suggested activities are to:

· Analyse the situation and orient opinion leaders and decision-makers at the
teaching institution(s). (See section 1.2 of this guide, Analyse the Situation and
Orient Decision-Makers. See also the sample agenda of a national orientation
workshop for IMCI pre-service training in Annex 1);

· Train selected staff members (e.g. chairs of academic units, heads of subunits,
teachers, directors of clinical practice sites, etc.) who will facilitate planning
for the introduction of IMCI teaching. (See section 1.2 of this guide, Analyse
the Situation and Train Key Planners. See also the sample agenda of an IMCI
training course for planners at teaching institutions in Annex 1); and

28 August 2001
 Phase One - Orient and Plan: Tasks at National Level

· Conduct a planning workshop to develop a plan of action for introducing

IMCI into an academic programme (See Plan for the Introduction of IMCI
Teaching in section 1.2 of this guide. See also sample agenda for a planning
workshop for IMCI pre-service training, and outline of a plan of action for the
introduction of teaching on IMCI in Annex 1).

If a plan of action has already been developed, the suggested activities are to:

· Meet with administrators and staff from the teaching institution(s) to assess
their understanding of IMCI and to review their plan of action for introducing
IMCI teaching;

· If needed, analyse the situation and orient opinion leaders and decision-makers
(See section 1.2 of this guide, Analyse the Situation and Orient Decision-
Makers. See also the sample agenda of a national orientation workshop for
IMCI pre-service training in Annex 1);

· If necessary, train selected staff members (e.g. deans, chairs of academic units,
heads of subunits, teachers, directors of clinical practice sites, etc.) to facilitate
the revision of the plan of action for introducing IMCI teaching. (See section
1.2 of this guide, Analyse the Situation and Train Key Planners. See also the
sample agenda of an IMCI training course for planners at teaching institutions
in Annex 1); and

· If necessary, conduct a planning workshop to revise the plan of action. (See

Plan for the Introduction of IMCI Teaching in section 1.2 of this guide. See
also the sample agenda for a planning workshop for IMCI pre-service training,
and the sample outline of a plan of action for the introduction of IMCI
teaching in Annex 1).

29 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

1.2 Orient and Plan: Tasks at the Teaching Institution

Administrators and staff at teaching

institutions need to know what IMCI can
offer to students in terms of new 1.2 TEACHING INSTITUTION(S)
knowledge, skills and attitudes. They also
need to understand what IMCI will require o Analyse the situation*
in terms of new teaching and learning o Orient decision-makers*
processes and materials. The introduction
o Create an IMCI Working Group*
of IMCI into relevant academic
programmes calls for integration of o Train key planners*
teaching across different academic units o Plan for the introduction of IMCI
and subunits, as well as throughout teaching*
different terms or years of an academic
o Request endorsement of the
programme. In addition, IMCI requires plan
clinical teaching and practice at first-level
outpatient facilities, and the ability to make
decisions about teaching at the level of the
academic unit or subunit.

Decision-Makers and planners in teaching institutions and curriculum development

committees need to understand that IMCI:

· Helps establish priorities for teaching and learning that are based on the health
needs of a population;

· Prepares students to support and follow evidence-based clinical guidelines and to

work within a national health system;

· Ensures that common childhood conditions are not overlooked during contacts
with sick children;

· Rationalizes the use of costly resources such as diagnostic tests and drugs;

· Combines actions to both prevent and manage common childhood illnesses and
malnutrition;

· Recognizes the important role played by caretakers of children in preventing and

managing illness and malnutrition;

· Emphasizes the need for effective communication and counselling with the
caretakers of children; and

· Promotes continuity of care through appropriate referral and follow-up of sick

children.

30 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

Once the benefits and consequences of IMCI are understood and accepted, a clear
plan for incorporating IMCI into existing academic programmes is needed to guide
the change process.

Experience has shown that orientation and planning for pre-service training will be
more effective if: the IMCI clinical guidelines have been carefully adapted to local
circumstances; the adapted guidelines have been tested in a few health facilities; and
experience with the adapted guidelines has been gained through activities such as in-
service training – an activity that is also beneficial in building a pool of facilitators,
clinical instructors and decision-makers who understand IMCI.

The following tasks are suggested at the teaching institution level during the
orientation and planning phase:

· Analyse the situation*

· Orient decision-makers*
· Create an IMCI Working Group*
· Train key planners*
· Plan for the introduction of IMCI teaching*
· Request endorsement of the plan

All of the above tasks, except one, are considered critical to the success of IMCI
teaching (as indicated by asterisks). Each suggested task for orientation and planning
at the teaching institution level is described in more detail below.

Analyse the Situation

Because IMCI takes a public

health approach to child health, it
requires integrated teaching of 1.2 TEACHING INSTITUTION(S)
both the theory and practice of
preventing and managing þ Analyse the situation*
common serious childhood o Orient decision-makers*
conditions. In most academic
o Create an IMCI Working Group*
programmes, IMCI teaching
should be integrated not only o Train key planners*
across different teaching units o Plan for the introduction of IMCI
and subunits, but also throughout teaching*
different terms or years of a o Request endorsement of the plan
programme. For this reason,
different teaching units, subunits
and directors of clinical practice
sites must work together to both
plan and implement IMCI teaching.

*
Critical tasks

31 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

Among those who need to be oriented early to IMCI and to participate in the
development of a plan of action for introducing IMCI teaching are:
deans of relevant schools; directors of clinical practice sites; chairs of teaching
units; and heads of subunits such as pharmacology, pulmonology,
gastroenterology, nutrition, social paediatrics.

Objectives

The objectives of analysing the situation at the teaching institution level are to:

· Identify opinion leaders and decision-makers within teaching institutions who

need further orientation to IMCI;

· Identify areas in which topics related to IMCI are already taught (i.e. particular
teaching units, subunits and clinical practice sites);

· Identify the persons within different teaching units, subunits and clinical
practice sites who need training in IMCI in order to assist the development of
a plan of action for IMCI teaching; and

· Ensure that all relevant persons – including administrators of clinical practice

sites – contribute to and endorse a written plan of action for introducing IMCI
teaching.

Timing

All relevant administrators, teaching units and subunits should be identified as

early as possible in order to orient key staff and involve them in the process of
planning for the introduction of IMCI teaching. Experience has shown that it is
sometimes difficult to identify and involve all relevant persons. For this reason, a
core group of key staff will often initiate activities, and additional persons will
become involved over time as an institution gains experience with IMCI teaching.

Who Should Analyse the Situation?

An analysis of the situation may be conducted by:

· Persons within the school who are trained in IMCI and interested in
introducing IMCI teaching.

· A facilitator from outside the teaching institution who is requested to assist

with the introduction of IMCI teaching. (See section 1.1 of this guide, Assist
Teaching Institutions with Staff Orientation and Planning.)

Description

The purpose of this task is to identify the relevant administrators, teaching units
and subunits - including directors of clinical practice sites - who need to be

32 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

informed about IMCI and enlisted to help plan for the introduction of IMCI
teaching. This can be accomplished by first identifying relevant academic
programmes, and then reviewing when (i.e. the year or term of the academic
programme) and where (i.e. the responsible teaching unit) topics related to IMCI
are taught within a programme.

It is important to decide if the formal written curriculum for a particular category

of teaching institution needs to be revised. Usually it is not necessary to revise
written curricula in order to introduce IMCI teaching. In many countries, the
curriculum for paramedical schools is developed at national or state level. If this is
the case for a particular category of teaching institution, a situation analysis may
be conducted for a group of schools together – particularly if the schools share a
common agenda, methods and materials.

When reviewing an academic programme, it is important to consider where

aspects of all three components of the IMCI strategy should be taught.

The three components of the IMCI strategy are:

· Improving the case management skills of health staff to prevent and manage
common serious childhood conditions;

· Improving the health system to support the effective management of common

serious childhood conditions; and

· Strengthening practices within families and communities to support the

prevention and management of common serious childhood conditions.

Some aspects of IMCI – such as breastfeeding counselling or outpatient clinical

practice – may not be taught within a relevant academic programme. It is
important to note any IMCI subjects that are not covered in a programme.
Decisions will be needed about how to introduce new content or subjects into the
programme, and about which teaching unit or subunit should be responsible for
introducing the new content or subject.

Suggested Activities and Materials

Persons responsible for analysing the situation should review the description of
relevant academic programmes and determine where aspects of IMCI should be
taught within those programmes.

The following documents can be reviewed to help identify where aspects of IMCI
should be taught within an academic programme:

· A written description of the academic programme(s) where IMCI will be

introduced;

33 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

· List of Possible Learning Objectives for Integrated Management of

Childhood Illness (IMCI) (see Annex 1);

· The following information sheets from the IMCI information package:

- Management of childhood illness in developing countries: Rationale

for an integrated strategy (WHO/CHS/CAH/98.1A, REV.1 1999)

- Planning national implementation of IMCI (WHO/CHS/CAH/98.1C

REV.1 1999)

- The role of IMCI in improving family and community practices to

support child health and development (WHO/CHS/CAH/98.1G,
REV.1 1999)

· Improving family and community practices: A component of the IMCI

strategy (WHO/CAH/98.2)15

Orient Decision-Makers

Opinion leaders and decision-

makers at teaching institutions
and outpatient facilities used for 1.2 TEACHING INSTITUTION(S)
clinical practice must understand
and accept IMCI before they can þ Analyse the situation*
effectively support its þ Orient decision-makers*
introduction into academic o Create an IMCI Working Group*
programmes. Teaching
institutions that have experience o Train key planners*
with the introduction of IMCI o Plan for the introduction of IMCI
pre-service training have reported teaching*
that the extent to which IMCI is o Request endorsement of the plan
taught largely depends on the
level of IMCI acceptance among
heads of relevant teaching units.

Objectives

The objectives of orienting opinion leaders and decision-makers at teaching

institutions are to:

· Create awareness and understanding of the IMCI strategy and clinical

guidelines;

15
Improving family and community practices: A component of the IMCI strategy. Geneva, World Health
Organization, 1998 (unpublished document WHO/CAH/98.2; available on request from the Department of Child
and Adolescent Health and Development, World Health Organization, 1211 Geneva 27, Switzerland – Fax: +41 22
791 4853, email [email protected]).

34 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

· Gain acceptance of IMCI as a core element of paediatrics or child health; and

· Generate commitment to incorporating IMCI into relevant academic

programmes.

Timing

Experience has shown that it is preferable to orient opinion leaders and decision-
makers before creating a detailed plan of action for introducing IMCI teaching.

Who Should Orient Decision-Makers?

Orientation activities should be conducted by persons who: are trained in IMCI;

have experience with curriculum change; are familiar with the WHO guidelines
for IMCI pre-service training; and can clearly explain the rationale for introducing
IMCI into pre-service training. Such persons might include anyone listed under
the task, Assist Teaching Institutions with Staff Orientation and Planning in
section 1.1 of this guide. An influential staff member within a teaching institution,
who has been trained in IMCI, could also conduct orientation activities.

Description

The purpose of this task is to create awareness, understanding and acceptance of

the IMCI strategy and clinical guidelines among opinion leaders and decision-
makers at teaching institutions and outpatient facilities used for clinical practice.
Key opinion leaders and decision-makers include the heads of teaching units such
as paediatrics, child health, internal medicine and community medicine or health.
They also include students and representatives of the Department of Education or
the Department of Staff Development. Orientation should lead to a commitment
by these persons to incorporate IMCI into relevant academic programmes.

In order to gain acceptance of and commitment to IMCI teaching, opinion leaders

and decision-makers will need information about:

· The IMCI strategy and clinical guidelines, including an overview of the

technical basis and use of the guidelines for evidence-based patient assessment
and management in outpatient settings;

· What students should know, and what students should be able to do, after
learning IMCI (i.e. the IMCI learning objectives);

· What IMCI can offer to students in terms of new knowledge, skills and
attitudes (i.e. academic rationale for IMCI);

· The types of teaching, learning and assessment methods and materials that are
commonly used for IMCI pre-service training; and

35 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

· Effective approaches taken in countries and teaching institutions to

incorporate IMCI into the basic education of paramedical and medical staff.

Decision-Makers and planners in teaching institutions and curriculum

development committees need to understand that IMCI:

· Helps establish priorities for teaching and learning that are based on the health
needs of a population;

· Prepares students to support and follow evidence-based clinical guidelines and

to work within a national health system;

· Ensures that common childhood conditions are not overlooked during contacts
with sick children;

· Rationalizes the use of costly resources such as diagnostic tests and drugs;

· Combines actions to both prevent and manage common childhood illnesses

and malnutrition;

· Recognizes the important role played by caretakers of children in preventing

and managing illness and malnutrition;

· Emphasizes the need for effective communication and counselling with the
caretakers of children; and

· Promotes continuity of care through appropriate referral and follow-up of sick

children.

Section 1.1 of this document, Assist Teaching Institutions with Staff Orientation
and Planning, describes various scenarios for orienting opinion leaders and
decision-makers. In each case, the approach will depend on the circumstances and
needs of the particular teaching institution.

Suggested Activities and Materials

The following types of activities are suggested for building awareness,

understanding and commitment to IMCI among opinion leaders and decision-
makers:

· Disseminate information. This is very similar to the activity described under

the task, Orient National Opinion Leaders and Decision-Makers in section 1.1
of this guide. Information about IMCI can be distributed through articles in
local journals, association newsletters, brochures, information sheets, and
displays at meetings and conferences. Information can also be disseminated
through lectures, discussions, meetings and electronic media (e.g. email,
Internet, telephone, etc.).

36 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

· Conduct national or regional workshops or meetings. Opinion leaders and

decision-makers from teaching institutions may attend IMCI information
sessions at meetings or congresses of academic associations, professional
societies or government authorities. They may also attend national- or state-
level orientation workshops. For more information about the content of
workshops or meetings, see Orient National Opinion Leaders and Decision-
Makers in section 1.1 of this guide.

· Conduct workshops or meetings at teaching institutions. Orientation

sessions, meetings and workshops may be conducted at teaching institutions,
either by IMCI-trained staff members within the school, or by persons
requested from outside the teaching institution. For more information about
workshop and/or meeting content, see Orient National Opinion Leaders and
Decision-Makers and Assist Teaching Institutions with Staff Orientation and
Planning in section 1.1 of this guide.

Create an IMCI Working Group

A single focal person for IMCI pre-

service training may be sufficient
1.2 TEACHING INSTITUTION(S)
at the national or state level.
However, at the teaching institution
level, experience has shown that an þ Analyse the situation*
enthusiastic focal person needs the þ Orient decision-makers*
support and assistance of a larger þ Create an IMCI Working Group*
IMCI Working Group in order to
effectively plan, coordinate and o Train key planners*
sustain IMCI teaching. o Plan for the introduction of IMCI
teaching*
Objectives o Request endorsement of the plan

The objectives of creating an IMCI

Working Group within a teaching
institution are to:

· Encourage full participation of relevant staff in planning, implementing,

reviewing and replanning IMCI teaching;

· Facilitate key activities for planning, preparing, implementing, reviewing and

replanning IMCI teaching; and

· Coordinate IMCI teaching between different teaching units, subunits and

clinical practice sites.

Timing

37 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

An IMCI Working Group should be formed either before or shortly after a plan of
action is drafted for introducing IMCI into an academic programme.

Members of the IMCI Working Group

The IMCI Working Group should include representatives of relevant teaching

units, subunits and the outpatient facility used for clinical practice. At a minimum,
the group should include representatives from the Department of Paediatrics or the
Department of Child Health as well as the Departments of Community Health,
Infectious Diseases, Epidemiology and Social Medicine. For suggestions
regarding how to identify key participants, see the task in this section called
Analyse the Situation.

A focal person for the working group should be designated and given authority to
call meetings and coordinate activities.

The focal person should be:

· An active teacher;

· Trained in the IMCI clinical guidelines (and usually trained as a facilitator for
the IMCI in-service course); and

· Experienced in national adaptation of the IMCI clinical guidelines and/or in

planning for the implementation of IMCI strategy.

Description

The aim of the IMCI Working Group is to coordinate and facilitate planning,
preparation, implementation, review and replanning of IMCI teaching. The group
should be standing (i.e. not ad hoc) and should remain active long enough to
follow at least one group of students through all stages of IMCI instruction and
assessment.

Suggested Activities

The IMCI Working Group can coordinate and facilitate many of the activities
described in this guide. For example, the IMCI Working Group can:

· Orient opinion leaders and decision-makers within and outside the teaching
institution;

· Identify where and how IMCI may be incorporated into existing academic
programmes;

· Create a plan of action for introducing IMCI into relevant academic

programmes;

38 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

· Train teachers and relevant staff at clinical practice sites;

· Develop and/or adapt materials for IMCI teaching, learning and student
assessment;

· Prepare sites for IMCI clinical practice;

· Coordinate IMCI teaching between different teaching units and subunits; and

· Review the progress of implementation of the plan of action and plan for the
strengthening of IMCI teaching.

Train Key Planners

Those charged with developing a 1.2 TEACHING INSTITUTION(S)

feasible and comprehensive plan of
action for introducing IMCI into an
þ Analyse the situation*
academic programme must have a
thorough understanding of the þ Orient decision-makers*
IMCI strategy and clinical þ Create an IMCI Working Group*
guidelines, as well as some
knowledge of how to plan for the þ Train key planners*
revision of teaching. For this o Plan for the introduction of IMCI
reason, staff members from teaching*
teaching institutions who are o Request endorsement of the plan
responsible for planning the
introduction of IMCI, or
representatives of bodies that
develop curricula for a group of teaching institutions, should attend IMCI training
courses.

Objectives

The objectives of training key planners are to:

· Ensure that persons who plan for the introduction of IMCI teaching have a
thorough understanding of the IMCI strategy and clinical guidelines; and

· Ensure that essential tasks and activities are included in the plan of action for
introducing IMCI into an academic programme.

Timing

Key planners should attend an IMCI training course before they finalize a written
plan of action for introducing IMCI into an academic programme or programmes.

Who Should Organize and Conduct Training Courses for Key Planners?

39 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

Key planners may attend IMCI in-service training courses that are already taking
place in the country; or national or state authorities may organize a special IMCI
course for planners. Courses may be conducted by national or district facilitators
of IMCI in-service training, or by staff members at teaching institutions who have
been trained as IMCI course facilitators.

Description

The purpose of this task is to prepare staff to effectively plan for the introduction
of IMCI into relevant academic programmes. Training should foster an
appreciation for the comprehensive yet focused nature of the IMCI strategy and
clinical guidelines. Following training, key planners should understand that IMCI
is not simply a list of common serious illnesses and malnutrition, but a systematic
approach to preventing and managing major childhood conditions in an effective
and integrated manner.

In addition to developing an understanding of the IMCI strategy and clinical

guidelines, training should introduce activities and tools that may be used to plan
and prepare for IMCI teaching.

The IMCI focal person within a teaching institution should receive thorough
training in IMCI. In addition, experience has shown that it is important to train
key persons representing: subunits such as gastroenterology, pulmonology,
infectious diseases, nutrition and social paediatrics; and other relevant teaching
units such as community health, social medicine, infectious diseases and
epidemiology. It is also useful to train staff members from education and staff
development units or subunits. For suggestions about how to identify key persons
for training, see the task called Analyse the Situation in section 1.2 of this guide.

Suggested Activities and Materials

Training courses for key planners may be organized and conducted by the staff at
a teaching institution, by representatives from a curriculum development group, or
by the national or state coordinating group for IMCI pre-service training. The
courses may be conducted at teaching institutions, or at a state or national training
site. Some countries have found it useful to establish a “training centre” at one
teaching institution where staff members from different teaching institutions can
attend IMCI training courses.

Organizers of an IMCI course for key planners will need to select the most
suitable content and approach for training a particular audience. To do this, they
should carefully consider what participants already know, and what participants
should be able to do after training.

In preparing a training course for key planners, the following questions should be
considered:

40 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

· How will participants learn about the IMCI strategy? Key planners need to
understand the rationale, objectives and components of the IMCI strategy.
They should be able to identify relevant learning objectives related to each
component of the IMCI strategy. For this reason, a session on the IMCI
strategy should be included in the course.

· How will participants learn the IMCI clinical guidelines? The time, content
and methods used to teach the IMCI clinical guidelines will vary depending on
the previous training of the course participants. For example, teachers from a
school of nurse midwifery may need to attend a full IMCI clinical training
course. On the other hand, professors of paediatrics, who have significant
clinical experience, may require less time to learn the IMCI guidelines and
more time to question and discuss the technical basis for the guidelines.
Planners of training courses should contact WHO to request sample agendas
of appropriate IMCI clinical courses for different categories of health care
professionals.16 Annex 1 contains a sample Agenda for a 5-day IMCI training
course for university staff.

· Will participants need information about how to plan for IMCI teaching?
Key planners need to understand how to integrate elements of IMCI into
existing academic programmes, and how to organize clinical practice in
outpatient facilities that allows students to practise the full IMCI case
management process. In addition, key planners should know how to develop a
plan of action for introducing IMCI into an academic programme. A session
on how to plan for IMCI teaching is particularly important if support is limited
to help individual teaching institutions plan for the introduction of IMCI
teaching.

· Will participants need an introduction to appropriate methods and materials

for IMCI teaching, learning and student assessment? IMCI encourages
learning that is experience-based (e.g. involving supervised clinical practice)
and problem-based (e.g. involving case studies, role-plays, simulated patients,
etc.). IMCI also emphasizes the development of psychomotor skills through
hands-on clinical practice and formative assessment (i.e. student exercises,
drills, and practice with feedback from teachers to improve performance). For
this reason, training organizers may wish to include a session or sessions on
methods and materials that are appropriate for IMCI teaching, learning and
assessment.

16
Sample agendas may be requested from the WHO representative in a country, the WHO regional office, or the
Department of Child and Adolescent Health and Development (CAH), World Health Organization, Avenue
Appia 20, 1211 Geneva 27, Switzerland (Fax: +41 22 791 4853, email: [email protected]).

41 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

Plan for the Introduction of IMCI Teaching

In most academic programmes,

elements of IMCI will be
integrated across different 1.2 TEACHING INSTITUTION(S)
teaching units and subunits, as
well as throughout several terms þ Analyse the situation*
or years of the programme. Key þ Orient decision-makers*
staff at a teaching institution
should create a written plan of þ Create an IMCI Working Group*
action that identifies the academic þ Train key planners*
programme or programmes where þ Plan for the introduction of IMCI
IMCI will be incorporated. The teaching*
plan should describe when and
o Request endorsement of the plan
where elements of IMCI should
be placed within a relevant
academic programme. In
addition, the plan should describe
how the teaching institution will: orient decision-makers; train teachers and relevant
clinical staff; develop or adapt materials for teaching, learning and student
assessment; prepare clinical practice sites; coordinate IMCI teaching between
different units and subunits; and monitor and review teaching.

Objectives

The objectives of planning for the introduction of IMCI teaching are to:

· Confirm the commitment of administration and staff to introducing IMCI into

relevant academic programmes;

· Identify into what academic programme(s) IMCI should be incorporated; and

· Prepare a written plan of action (including a budget and timeline) to guide the
incorporation of IMCI into each relevant academic programme.

Timing

Planning for the introduction of IMCI teaching may begin at any time. However,
experience has shown that it is generally more effective to orient and train key
decision-makers and planners before they finalize a written plan of action. For
more information, see the tasks called Analyse the Situation, Orient Decision-
Makers and Train Key Planners in section 1.2 of this guide.

Who Should Develop the Plan?

Key representatives of relevant teaching units, subunits and clinical practice sites
should prepare a plan of action for introducing IMCI teaching. Key planners

42 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

should involve students, as well as representatives of the Department of Education

and the Department of Staff Development. They may also request assistance from
national or state authorities, or from the National Working Group for IMCI Pre-
Service Training. For certain categories of teaching institutions, a curriculum
development group may develop a single plan of action at national or state level
for several institutions with similar certificate, diploma or degree programme.

For more information, see the tasks called Create a National Working Group and
Assist Teaching Institutions with Staff Orientation and Planning in section 1.1 of
this guide. See also Analyse the Situation and Create an IMCI Working Group in
section 1.2 of this guide.

Description

The purpose of this task is to plan for the introduction of IMCI teaching. The
outcome should be a written plan of action (including a budget and timeline) for
incorporating IMCI into a relevant academic programme. When developing a plan
of action for the introduction of IMCI, administrators and staff should discuss
where IMCI might fit within existing teaching agendas. Normally, the
introduction of IMCI into a relevant academic programme does not require a
revision of the existing written curriculum. Instead, it should encourage a revision
of teaching content and methods to foster a more holistic view of the child, better
communication with the caretakers of sick children, and clinical practice in
outpatient health facilities.

The planning process may be completed in stages. The first stage would consist of
a small group that develops a preliminary plan of action. This preliminary plan of
action should be reviewed by representatives of relevant teaching units, subunits
and clinical practice sites and subsequently revised, as needed, to produce a final
plan of action.

Experience has shown that the plan for introducing IMCI teaching should:

· Be tailored to the needs and resources of teaching institutions;

· Include learning objectives related to all three components of the IMCI

strategy;

· List the key teaching units, subunits and clinical practice sites that should be
involved in IMCI teaching;

· Identify feasible entry points for IMCI within a relevant academic programme;

· Ensure that IMCI is recognizable to students as both a public health strategy

and as a clinical approach to the management of sick children;

· Strive to integrate different subjects within an existing academic programme,

rather than fragment IMCI into different subjects;

43 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

· Identify opportunities for students to practise the full process of “integrated”

case management, including assessment of feeding problems and counselling
of caretakers;

· Describe how students will be assessed for IMCI knowledge and skills,
including both formative and summative assessment.

· Identify how teachers and relevant clinical staff will be trained in IMCI;

· Indicate how materials for teaching, learning and student assessment will be
developed or adapted;

· Identify mechanisms for creating a sustainable supply of materials and trained

teachers;

· Outline how the implementation of the plan will be monitored and reviewed;

· Indicate whether or not the formal written curriculum should be revised, and if
so, when and how; and

· Include a budget, timeline and possible funding sources.

Suggested Activities and Materials

Three types of activities are suggested in planning for the introduction of IMCI
teaching:

· Conduct a planning workshop. A planning workshop can help launch the

process and add visibility to the critical task of planning. The workshop may
be conducted at a teaching institution with representatives from relevant
teaching units, subunits and clinical practice sites. Appropriate representatives
from the national or state working group on IMCI pre-service training should
participate in the workshop. During the workshop, participants should select
an academic programme where IMCI will be introduced. They also should
identify who will prepare for IMCI teaching, where IMCI clinical practice will
take place, how teachers will be trained, and how materials for teaching,
learning and student assessment will be developed or adapted. (See Annex 1
for a Sample Agenda of a Planning Workshop for IMCI Pre-Service Training,
Outline of a Plan of Action for Introducing IMCI into an Academic
Programme, List of Possible Materials for IMCI Teaching, Learning and
Student Assessment and other useful planning materials.)

· Hold meetings to revise and finalize a written plan of action. Representatives

from relevant teaching units, subunits and clinical practice sites should work
together to review, revise and finalize a written plan of action for introducing
IMCI into an academic programme or programmes. See Annex 1 for an

44 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

Outline of a Plan of Action for Introducing IMCI into an Academic

Programme and a sample timeline.

The plan of action should specify learning objectives for all three components
of the IMCI strategy. The following materials may be consulted when defining
learning objectives for IMCI:

Component 1 - Improving the case management skills of health staff to

prevent and manage common serious childhood conditions. Refer to
the List of Possible Learning Objectives for IMCI in Annex 1 of this
guide.

Component 2 - Improving the health system to support the effective

management of common serious childhood conditions. This
component covers subjects such as: the availability of drugs, vaccines
and other essential supplies and equipment; referral pathways; the
organization of work at health facilities; supervision of health staff;
health information systems (HIS); patient satisfaction; and cost of care
(i.e. insurance). Materials that may help planners identify possible
learning objectives related to this component include the IMCI
planning guide17 and the IMCI information sheet titled Planning
national implementation of IMCI (WHO/CHS/CAH/98.1C REV.1
1999).18

Component 3 - Strengthening practices within families and

communities to support the prevention and management of common
serious childhood illnesses. Materials that may help identify possible
learning objectives for this component include: Improving family and
community practices: A component of the IMCI strategy
(WHO/CAH/98.2)19 and the IMCI information sheet titled, The role of
IMCI in improving family and community practices to support child
health and development (WHO/CHS/CAH/98.1G, REV.1 1999).20

17
IMCI planning guide: Gaining experience with the IMCI strategy in a country. Geneva, World Health
Organization, 1999 (unpublished document WHO/CHS/CAH/99.1, p. 5; available on request from Department of
Child and Adolescent Health and Development, World Health Organization, 1211 Geneva 27, Switzerland – Fax:
+41 22 791 4853, email: [email protected]).

18
Planning national implementation of IMCI. Geneva, World Health Organization, 1999 (unpublished document
WHO/CHS/CAH/98.1C, REV.1 1999; available on request from Department of Child and Adolescent Health and
Development, World Health Organization, 1211 Geneva 27, Switzerland – Fax: +41 22 791 4853, email:
[email protected]).

19
Improving family and community practices: A component of the IMCI strategy. Geneva, World Health
Organization, 1998. (unpublished document WHO/CAH/98.2; available on request from Department of Child and
Adolescent Health and Development, World Health Organization, 1211 Geneva 27, Switzerland – Fax: +41 22 791
4853, email: [email protected]).

20
The role of IMCI in improving family and community practices to support child health and development,
Geneva, World Health Organization, 1999 (unpublished document WHO/CHS/CAH/98.1G, REV.1 1999;

45 August 2001
 Phase One - Orient and Plan: Tasks at the Teaching Institution

The plan of action should include a description of the specific activities

needed to: train teachers; orient decision-makers; develop or adapt materials
for teaching, learning and student assessment; prepare clinical practice sites;
coordinate IMCI teaching between departments and sub-departments; and
monitor and review teaching. The plan should specify the time period over
which the activities will take place (e.g. 12 months, 18 months, etc.). It should
also include a timeline and budget.

· Submit the written plan to national or state authorities (e.g. the National
Working Group for IMCI Pre-Service Training) and to relevant technical
and donor agencies.

Before developing a plan of action, it will be helpful to review the Report of an

intercountry workshop on IMCI pre-service training: Geneva, 2.5, November
1999 (WHO/FCH/CAH/00.11).21 This document summarizes experiences and
lessons learned with the introduction of IMCI in more than 13 teaching
institutions.

Request Endorsement of the Plan

Once the plan of action is finalized,

the IMCI focal person at a teaching
1.2 TEACHING INSTITUTION(S)
institution should circulate the plan
to request agreement or
endorsement from persons and þ Analyse the situation*
groups who will be critical to the þ Orient decision-makers*
implementation of the plan. It is
þ Create an IMCI Working Group*
particularly important for directors
of relevant teaching units, subunits þ Train key planners*
and clinical practice sites to þ Plan for the introduction of IMCI
endorse the plan. It is also teaching*
important to request agreement and
þ Request endorsement of the plan
support from: relevant national
academic associations (e.g.
Association of Medical Schools,
Association of Nursing Schools,
etc.); technical and donor agencies; and relevant national authorities such as the
Ministry of Health and the Commission on Higher Education.

available on request from the Department of Child and Adolescent Health and Development, World Health
Organization, 1211 Geneva 27, Switzerland – Fax: +41 22 791 4853, email: [email protected]).

21
Report of an intercountry workshop on IMCI pre-service training: Geneva, 2.5, November 1999. Geneva,
World Health Organization, 2000 (unpublished document WHO/FCH/CAH/00.11; available on request from the
Department of Child and Adolescent Health and Development, World Health Organization, 1211 Geneva 27,
Switzerland – Fax: +41 22 791 4853, email: [email protected]).

46 August 2001
 Phase Two – Prepare and Conduct the First Round of IMCI Teaching

2. PHASE TWO – PREPARE AND CONDUCT THE

FIRST ROUND OF IMCI TEACHING

Tasks at the national or state level Page

¨ Assist teaching institutions in preparing for and monitoring

teaching* 49

Tasks at the teaching institution level

¨ Define times, places, activities and materials* 53

¨ Train relevant teachers and clinical staff* 57
¨ Prepare clinical practice sites* 60
¨ Prepare materials* 63
¨ Coordinate teaching* 70
¨ Conduct and monitor teaching* 72

* Critical Task

The new content and teaching methods associated with IMCI have the potential to move
throughout a teaching institution and transfer to other subjects. First, however, several
challenges must be overcome to incorporate new teaching, learning and student
assessment processes into an academic programme. These challenges include, for
example: overcrowded agendas; teaching and student assessment that focus on the
development of cognitive rather than psychomotor skills; and limited coordination
between different academic years and different teaching units.

Experience has shown that it is difficult to simply add IMCI to an existing academic
programme. Rather, its implementation often requires a revision of teaching. In most
cases, this means that some content and teaching processes are added, while others are
removed. Support of IMCI teaching means incorporating new methods and materials that
are designed to develop and assess both the knowledge and practical skills of students.
These methods and materials should encourage students to practise the full IMCI clinical
guidelines in an environment where those guidelines are used.

47 August 2001
 Phase Two – Prepare and Conduct the First Round of IMCI Teaching

It is also a challenge to make IMCI identifiable to teachers and students as a case

management process, while at the same time linking it to other subjects. To achieve this,
students must receive a thorough introduction to the IMCI strategy and clinical
guidelines. In addition, IMCI teaching should be carefully linked between different
academic units and with clinical practice sites. Experience has shown that the
introduction of IMCI often requires an increased focus on coordination of teaching
between different academic units.

The tasks described in this phase aim to:

· Clearly define where and how IMCI should be taught within an academic
programme;

· Prepare staff, materials and clinical practice sites for IMCI teaching; and

· Coordinate, implement and monitor teaching.

All of the tasks in this phase are considered critical to the success of IMCI pre-service
training. As explained in Phase One of this guide, the national coordinating group and
teaching institutions may decide to combine or repeat certain tasks. They may complete
tasks in the same order as presented in this guide, or they may adjust the order to better
suit the particular needs and resources of the country.

It can take approximately 6 to 12 months to prepare for the first round of teaching.
During this phase, it is important to clearly define when, where and how IMCI will be
taught within an academic programme. State or national coordinating groups (e.g. IMCI
pre-service training coordinating group, national paediatrics associations, etc.) should
work with teaching institutions to: identify clinical practice sites; train teachers and
relevant clinical staff; and prepare appropriate materials for teaching, learning and
student assessment. Then teaching institutions should carefully coordinate IMCI teaching
between different academic units and with clinical practice sites. In addition, they should
monitor teaching to identify where improvements are needed.

If more than one school in a country will introduce IMCI teaching, the National
Coordinating Group should share information between schools to prevent the duplication
of efforts. Additionally, teaching institutions with a common curriculum (e.g. nursing
schools) may work together at the state or national level to complete many of the tasks
described in this phase.

48 August 2001
 Phase Two – Prepare and Conduct the First Round of IMCI Teaching: Tasks at National Level

2.1 Prepare and Conduct the First Round of IMCI Teaching:

Tasks at National Level

The national or state coordinating

group for IMCI pre-service training
(e.g. National IMCI Coordinating 2.1 NATIONAL COORDINATOR(S)
Group, National Paediatrics Society,
etc.) should support teaching o Assist teaching institutions in
preparing for and monitoring
institutions in preparing for and teaching*
monitoring IMCI teaching. In most
countries, assistance includes training
teaching staff and preparing materials
and clinical practice sites. Teaching
institutions may also need assistance in monitoring and improving new teaching.
Assistance from a national or state coordinating group is, therefore, considered a critical
task during this phase.

Assist Teaching Institutions in Preparing for and Monitoring Teaching

The national or state coordinating group

can help schools identify or organize 2.1 NATIONAL COORDINATOR(S)
IMCI courses for teachers and relevant
clinical staff. It can work with health þ Assist teaching institutions in
facilities where students will practise preparing for and monitoring
teaching*
the IMCI clinical guidelines to ensure
that drugs and equipment are available,
and to confirm that policies and
administrators support the use of IMCI in those facilities. In addition, the national or
state coordinating group can assist teaching institutions in developing or adapting
materials for teaching, learning and student assessment. It can also help schools
identify appropriate activities and materials for monitoring the implementation of
IMCI teaching. Depending on the size and number of teaching institutions involved, it
can take from 6 to 12 months to prepare for the first round of IMCI teaching.

Objectives

The objectives of providing assistance to teaching institutions are to ensure that:

· Materials, clinical practice sites and teaching staff are well prepared for IMCI
teaching; and

· Staff at teaching institutions are able to monitor and improve IMCI teaching.

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 Phase Two – Prepare and Conduct the First Round of IMCI Teaching: Tasks at National Level

Timing

Training a core group of teachers and clinical staff, preparing materials and setting up
clinical practice sites can take several months. For this reason, the national or state
coordinating group should begin assisting teaching institutions soon after they decide
to introduce IMCI.

Who Should Assist Teaching Institutions?

Persons who assist teaching institutions should meet the following criteria:

· Good knowledge of IMCI;

· Teaching experience; and
· Knowledge of the WHO guidelines for planning, implementing and evaluating
IMCI pre-service training.

Qualified persons might include the national focal person for IMCI pre-service
training, or members of the National Coordinating Group for Pre-Service Training.
They may also include representatives from the academic community, professional
associations, non-governmental organizations, technical agencies, international
organizations, other teaching institutions or WHO.

Description

National assistance is important in ensuring that teaching institutions are well

prepared to conduct and monitor IMCI teaching. Teachers should receive thorough
training in IMCI before they begin to adapt or develop materials for IMCI teaching,
learning and student assessment. Whenever possible, teachers and relevant clinical
staff should be trained to both practise the IMCI clinical guidelines and to use
interactive and experience-based teaching methods.

For teaching to be effective, students will need opportunities to practise the IMCI
case management process under supervision with real patients. Ideally, IMCI clinical
practice should be conducted at first-level health facilities – such as clinics, health
centres or outpatient departments of hospitals – where the IMCI guidelines are
supported and used on a routine basis. This means that decision-makers at clinical
practice sites should understand and promote the use of the IMCI clinical guidelines;
and ensure that necessary IMCI supplies and equipment are available.

To facilitate learning in both the classroom and clinic, teaching staff must identify
and use appropriate materials for teaching, learning and student assessment. The
National Coordinating Group should assist schools in acquiring, adapting or
developing IMCI materials for teachers and students. It should assist schools to
incorporate elements of IMCI into materials already used in academic programmes.

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 Phase Two – Prepare and Conduct the First Round of IMCI Teaching: Tasks at National Level

In addition, the National IMCI Coordinating Group should promote the incorporation
of IMCI into textbooks and teaching materials developed and published at the state,
national or international level.

Teachers should monitor new teaching and, when needed, adjust content, teaching
methods and materials to effectively meet the identified learning objectives. The
National Coordinating Group can assist schools to identify and prepare appropriate
methods and materials for the monitoring of IMCI teaching.

Suggested Activities and Materials

The National Coordinating Group can assist in at least four areas:

· Train teachers and relevant clinical staff. Teachers and relevant clinical staff
should receive training in the IMCI clinical guidelines. It is also beneficial to
introduce teachers and relevant clinical staff to effective methods and materials
for IMCI teaching, learning and student assessment. Depending on the status of
in-service training in a country, the National Coordinating Group may identify
ongoing in-service training courses for teachers and clinical staff to attend. Or it
may organize special courses for staff members from teaching institutions.
Courses may be conducted at teaching institutions or at district, state or national
training sites.

Organizers of training courses will need to select the most suitable content and
approach for each category of trainee (e.g. professors of paediatrics, nursing
teachers, clinical tutors, etc.). Some countries have developed special courses for
teachers that include an introduction to the IMCI clinical guidelines, technical
justification for the guidelines and time for discussion of various technical issues.
Field-tests of these courses have found that allowing time for discussion helps
overcome initial resistance to some elements of IMCI.

Some countries have established IMCI training centres at select teaching

institutions to help train teachers and clinical staff from other schools within the
country. A major benefit of a training centre is that it establishes ongoing training
opportunities for new teachers who join schools after IMCI has already been
introduced.

For more information, see the task called Train Relevant Teachers and Clinical
Staff in section 2.2 of this guide.

· Identify and prepare clinical practice sites. The National Coordinating Group
can help orient decision-makers at first-level health facilities where students will
practise IMCI. In addition, the National Coordinating Group can help ensure that
necessary supplies and equipment are available, and that policies – at both
national and facility levels – support the implementation of IMCI.

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For more information, see the task called Prepare Clinical Practice Sites in
section 2.2 of this guide.

· Prepare materials for teaching, learning and student assessment. The National
Coordinating Group should assist teaching institutions in identifying and
preparing appropriate materials. If more than one school will introduce IMCI
teaching, the National Coordinating Group may take the lead in adapting or
revising certain materials, such as an IMCI handbook. The National Coordinating
Group may also provide assistance to schools in reviewing, designing or
reproducing materials. Regardless of who leads the process, the development of
materials will require a long-term commitment that may involve peer reviews and
development workshops. The National Coordinating Group and teaching
institutions should collaborate closely in order to test, refine and finalize
materials.

In addition to working closely with teaching institutions, the National

Coordinating Group can work with national or international associations to
encourage publishers and developers to incorporate IMCI into local or
international textbooks and teaching materials. For example, in Latin America,
elements of IMCI have been incorporated into textbooks published in Chile and
Brazil.

For more information, see the task called Prepare Materials in section 2.2 of this
guide.

· Develop and/or adapt materials to monitor IMCI teaching. The National

Coordinating Group should help teaching institutions develop written
questionnaires; guidelines for interviews or focus group discussions; observation
checklists; and other materials needed to monitor the implementation of IMCI
teaching.

For more information, see the task called Conduct and Monitor Teaching in
section 2.2 of this guide.

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2.2 Prepare and Conduct the First Round of IMCI Teaching:

Tasks at the Teaching Institution

It is recommended that teaching

institutions carry out the following tasks
in preparation for the first round of IMCI 2.2 TEACHING INSTITUTION(S)
teaching:
o Define times, places, activities
and materials*
· Define times, places, activities and
materials; o Train relevant teachers and
clinical staff*
· Train relevant teachers and clinical o Prepare clinical practice sites*
staff; o Prepare materials*

· Prepare clinical practice sites; o Coordinate teaching*

o Conduct and monitor teaching*
· Prepare materials for teaching,
learning and student assessment;

· Coordinate teaching between different

academic units, subunits and clinical practice sites; and

· Conduct and monitor teaching.

All of the above tasks are considered critical to the successful introduction of IMCI
teaching. Experience has shown that it can take approximately 6 to 12 months to
complete preparations for IMCI teaching. Each task is described in more detail below.

Define Times, Places, Activities and Materials

During Phase One, teaching

institutions develop a plan of action 2.2 TEACHING INSTITUTION(S)
for introducing IMCI into a relevant
academic programme. To implement þ Define times, places, activities and
this plan it is necessary to clearly materials*
define when, where and how IMCI o Train teachers and clinical staff*
will be taught. “When” refers to the
o Prepare clinical practice sites*
years or terms of an academic
programme. “Where” relates to the o Prepare materials*
teaching units and clinical practice o Coordinate teaching*
sites. “How” refers to the teaching,
o Conduct and monitor teaching*
learning and assessment methods that
will be used.

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Objectives

The objectives of defining times, places, activities and materials are to:

· Clearly define when, where and how IMCI will be taught within an academic
programme;

· Identify which teachers and relevant clinical staff need training in IMCI;

· Identify what preparations are needed at the clinical practice site(s); and

· Identify how materials should be developed and/or adapted for IMCI teaching,
learning and student assessment.

Timing

The task of defining the times, places, activities and materials for IMCI teaching
should be completed in order to make decisions about which teachers and clinical
staff to train, which preparations to make at clinical practice site(s), and what
materials to develop and/or adapt for IMCI teaching, learning and student assessment.

Who Should Define Times, Places, Activities and Materials?

The IMCI Working Group and/or key persons from relevant academic units, subunits
and clinical practice sites should work together to define the times, places, activities
and materials for IMCI teaching. For more information, see the tasks called Analyse
the Situation and Create a National Coordinating Group in section 1.2 of this guide.

Description

Experience has shown that much of the IMCI content can be incorporated into
existing subjects and activities within an academic programme. The main challenge is
to integrate teaching by different academic units in order to present IMCI as a
comprehensive strategy and case management process. Another challenge is to create
opportunities for students to practise the full IMCI clinical guidelines in an
environment – such as an outpatient clinic – where IMCI is routinely applied.

During the orientation and planning phase, teaching institutions should identify the
specific years or terms where IMCI should be taught within relevant teaching units,
such as paediatrics and community health. To prepare for the first round of IMCI
teaching, it is important to define exactly where IMCI teaching will take place, what
learning objectives or outcomes will be targeted in each year and academic unit, and

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what types of activities and materials will be needed for teaching, learning and
student assessment.

It is important to clearly define:

· Which teaching unit will be responsible for ensuring that the IMCI strategy and
clinical guidelines are taught in the academic programme?

· Where (i.e. academic unit, subunit or clinical practice site) will different theory
and clinical practice sessions on IMCI be conducted and when (i.e. year or term
of academic programme)?

· Which IMCI learning objectives (i.e. learning outcomes) will be targeted in each
year or term and in each teaching unit or subunit?

· How many hours will be devoted to IMCI theory and practice in each year or
term and in each teaching unit or subunit?

· What types of activities or methods will be used for teaching, learning and
student assessment?

· What types of materials will be needed for teaching, learning and student
assessment?

Suggested Activities and Materials

The following actions are suggested in order to define times, places, activities and
materials needed for IMCI teaching:

· Meetings of representatives from relevant teaching units and subunits. The

IMCI Working Group or key persons from relevant academic units, subunits and
clinical practice sites should initially meet to:

- Review possible learning objectives for all three components of the IMCI
strategy;
- Identify where (i.e. in what years and/or terms, and in what teaching units
or subunits) subjects related to IMCI are already taught within an
academic programme;
- Agree where teaching should be revised or added to address learning
objectives for IMCI;
- Agree where students should practise the full IMCI case management
process, including treatment and counselling; and
- Review and discuss possible materials for IMCI teaching, learning and
student assessment.

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During the meetings, it is important to identify where all main elements of IMCI
– particularly those related to the IMCI clinical guidelines – will be taught. For
example, the subunit of paediatric gastroenterology may already teach how to
estimate the degree of dehydration of a child with diarrhoea. Representatives from
this subunit could, therefore, agree to teach IMCI signs for classifying
dehydration.

Similarly, the subunit of paediatric social medicine may already conduct clinical
practice sessions in the outpatient ward of a teaching hospital. Representatives
from this subunit might agree to have students practise the full IMCI case
management process during those sessions. Or they might conclude that not
enough time is allowed during those sessions to practise the full IMCI guidelines,
and that a rotation in a paediatric outpatient clinic should be added to the
academic programme.

Once it is decided where all elements of IMCI should be taught, the academic
units and subunits can work individually to define the specific activities and
materials needed for teaching, learning and student assessment. After this is done,
the group of representatives should meet again to:

- Check that all main learning objectives for IMCI are covered within
the academic programme; and

- Discuss how to develop or adapt materials, train teachers and relevant

clinical staff, and prepare clinical practice sites.

Materials that can be used to conduct this activity are:

- The plan of action created by the teaching institution for introducing

IMCI teaching (see OUTLINE: Plan of Action for Introducing IMCI
into an Academic Programme and a sample timeline in Annex 1);

- List of Possible Learning Objectives for IMCI (see Annex 1);

- The description the components of the IMCI strategy in Plan for the
Introduction of IMCI Teaching (see section 1.2 of this guide);

- Description of Possible Materials for IMCI Teaching, Learning and

Student Assessment (see Annex 2); and

- Planning Matrix: Matching Activities and Materials with Learning

Objectives for IMCI (see Annex 2).

· Meetings or individual work in relevant teaching units. Relevant teaching units

and subunits should clearly define the activities and materials needed for IMCI

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teaching, learning and student assessment. The planning matrix provided in

Annex 2, called Planning Matrix: Matching Activities and Materials with
Learning Objectives for IMCI, will help teaching staff to identify:

- In what years and/or terms elements of IMCI will be taught;

- What IMCI learning objectives will be targeted in each year or term;

- What activities will be used for teaching, learning and student assessment;
and

- What materials will be needed for teaching, learning and student

assessment.

Train Relevant Teachers and Clinical Staff

Once the times, places, activities

and materials for IMCI teaching are 2.2 TEACHING INSTITUTION(S)
defined, it will be clear which
teachers and which staff from the þ Define times, places, activities and
clinical practice site(s) need to be materials*
trained in IMCI. Training should þ Train teachers and clinical staff*
prepare relevant teachers and ¨ Prepare clinical practice sites*
clinical staff both to perform tasks
in accordance with the IMCI ¨ Prepare materials*
clinical guidelines, and to use ¨ Coordinate teaching*
teaching methods that are most
¨ Conduct and monitor teaching*
appropriate for learning IMCI.

Objectives

The objectives of training are to ensure that relevant teachers and clinical staff:

· Have a thorough knowledge and understanding of IMCI;

· Are able to correctly perform the IMCI case management process; and

· Have the skills required to effectively teach IMCI.

Timing

A teaching institution can start to train relevant teachers and clinical staff as soon as
the institution decides to introduce IMCI into an academic programme. If the teaching
institution is large, it may take several months to train all relevant teachers and

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clinical staff. In addition to training existing staff, the teaching institution (i.e. the
IMCI Working Group) should develop a strategy for the ongoing training of incoming
or new teaching staff and assistants. Experience has shown that it is often useful to
schedule training for teachers during student holidays.

Who Should Organize and Conduct Training Courses?

IMCI training courses for relevant teachers and clinical staff may be organized by a
teaching institution (i.e. IMCI Working Group), or by national or state coordinating
groups that are assisting with the introduction of IMCI teaching. The course may be
conducted by staff at a teaching institution who have been trained as facilitators for
the IMCI in-service training course, or by IMCI course facilitators from national,
state or district levels.

Description

The purpose of this task is to prepare relevant teachers and clinical staff to effectively
practise and teach the IMCI strategy and clinical guidelines. Experience has shown
that it is useful to train all persons who will be involved in IMCI teaching, regardless
of how much IMCI content they teach. For example, if the department of
epidemiology will teach students about the main health problems in children under
five years of age, relevant teachers from this department should attend a full IMCI
training course in order to understand the relationship of their teaching to the overall
IMCI strategy and clinical guidelines. In medical schools, interns often assist teaching
staff with clinical practice sessions. In these schools, interns should be trained in
IMCI before clinical practice begins with undergraduate students.

In addition to training teachers and clinical staff in the IMCI strategy and clinical
guidelines, it is useful to introduce them to effective methods and materials for IMCI
teaching, learning and student assessment.

Suggested Activities and Materials

IMCI training courses may be conducted at a teaching institution, or at a regional,

district or national training site. In countries where in-service training courses are
ongoing, teaching institutions can arrange with district training authorities to train
several staff in a course. As mentioned in Phase One of this guide, some countries
have found it useful to establish a training centre at a local teaching institution where
staff from different teaching institutions can attend IMCI training courses, and where
incoming or new staff can be trained.

Organizers of IMCI training courses need to choose suitable content and an

appropriate training approach for each category of trainees. In doing this, they should
consider what the participants of the course already know, and what they will be
expected to do after training.

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 Phase Two – Prepare and Conduct the First Round of IMCI Teaching: Tasks at the Teaching Institution

The following questions should be considered when preparing IMCI courses for
teachers and clinical staff:

· How will participants learn about the IMCI strategy? Teachers and relevant staff
at clinical practice sites need to understand the rationale, objectives and
components of the IMCI strategy. They should be able to recognize and teach
elements of all three components of the strategy. For this reason, at least one
session of the course should present and discuss the IMCI strategy.

· How will participants learn the IMCI clinical guidelines? Teachers and relevant
staff at clinical practice sites should be able to correctly perform the IMCI case
management process. In addition, they should understand the rationale and
technical basis for the IMCI clinical guidelines. The time, content and methods
used for training will vary depending on the previous knowledge and skills, and
the future responsibilities, of the course participants. Persons who plan to conduct
training courses should contact WHO to request sample agendas of appropriate
IMCI clinical courses for different categories of health care professionals. An
example of a possible agenda is provided in Annex 1.22

· Will participants need an introduction to appropriate methods and materials for

IMCI teaching, learning and student assessment? Teachers and relevant clinical
staff should understand and be able to use appropriate methods and materials for
IMCI teaching, learning and student assessment. IMCI encourages experience-
based (e.g. supervised practice with patients) and problem-based (e.g. case
studies, role-plays, simulated patients) learning. IMCI emphasizes the
development of psychomotor skills, particularly through hands-on clinical
practice and formative assessment (e.g. student exercises, drills and feedback
from teachers designed to improve student performance).

Introduction of IMCI teaching requires coordination of activities among different

teaching units and clinical practice sites. It also relies on the ability of teachers to
monitor and adjust their teaching. Therefore, training should include a session or
sessions on methods and materials that are most effective for introducing and
sustaining IMCI teaching. WHO CAH is developing a reference manual and
training course to strengthen classroom and clinical skills needed to teach IMCI.
Additionally, a list of sample topics for sessions on pedagogy, called Training
Teachers and Clinical Staff: Sample Topics for Sessions on Pedagogy, is provided
in Annex 2 of this guide.

22
Sample agendas may be requested from the WHO representative in a country, the WHO regional office, or the
Department of Child and Adolescent Health and Development (CAH), World Health Organization, Avenue Appia
20, 1211 Geneva 27, Switzerland (Fax: +41 22 791 4853, e-mail: [email protected]).

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching: Tasks at the Teaching Institution

The organizers of IMCI training courses may also refer to the IMCI Facilitator
Guide for Modules (WHO/CHD/97.3.I) for information on techniques for
motivating learners, providing individual feedback, leading a group discussion
and coordinating role-playing. Information about how to conduct supervised
clinical practice in outpatient clinics can also be found in the IMCI Facilitator
Guide for Outpatient Clinical Practice (WHO/CHD/97.3.H).

Prepare Clinical Practice Sites

Experience has shown that students

should learn and practise the IMCI 2.2 TEACHING INSTITUTION(S)
clinical guidelines in an
environment where the guidelines þ Define times, places, activities and
are used on a routine basis. For this materials*
reason, it is essential to carefully þ Train teachers and clinical staff*
select and prepare appropriate
þ Prepare clinical practice sites*
health facilities for IMCI clinical
practice. ¨ Prepare materials*
¨ Coordinate teaching*
Objectives
¨ Conduct and monitor teaching*
The objectives of preparing a
clinical practice site are to ensure
that:

· Administrators of the site understand and support IMCI;

· Relevant clinical staff manage sick children according to the IMCI guidelines;
and

· Necessary supplies, equipment and patients are available.

Timing

It can take several months to orient administrators and prepare the staff, supplies and
equipment needed to teach and practise IMCI at a health facility. The IMCI Working
Group at a teaching institution should, therefore, start early to identify and prepare
one or more sites where students can practise managing sick children according to the
IMCI clinical guidelines.

Who Should Prepare Clinical Practice Sites?

The IMCI Working Group should work together with administrators and staff from
health facilities to prepare clinical practice sites for IMCI teaching. The National

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching: Tasks at the Teaching Institution

Coordinating Group for IMCI Pre-Service Training can help to ensure that necessary
supplies and equipment are available. For more information, see the tasks called
Create a National Coordinating Group on IMCI Pre-Service Training, Analyse the
Situation and Create an IMCI Working Group in Phase One of these guidelines.

Description

The purpose of this task is to ensure that students practise IMCI in a first-level health
facility - such as a clinic, health centre or outpatient department of a hospital - where
the IMCI guidelines are supported and used on a routine basis.

The objectives of clinical practice sessions are for students to:

· See examples of signs of illness in real children;

· See demonstrations of how to manage sick children according to the IMCI clinical
guidelines;
· Practise managing sick children and counselling mothers about food, fluids and
when to return;
· Receive feedback from teachers about how well they performed and on how to
strengthen particular skills; and
· Gain experience and confidence using the IMCI clinical guidelines.

In order to achieve these objectives, each clinical practice site should meet the
following criteria:

· Represents a first-level health facility where IMCI is used (e.g. clinic, health
centre, or small hospital);
· Administration and staff are supportive of IMCI;
· Receives a sufficient supply of appropriate patients;
· Informs clients that students are being trained in the facility;
· Trains relevant staff in the IMCI clinical guidelines;
· Manages sick children according to the IMCI clinical guidelines;
· Ensures that a staff member is available to assist with clinical practice activities,
such as selecting cases;
· Has sufficient supplies of the drugs and equipment needed to implement IMCI;
· Has sufficient space and facilities for student practice;
· Makes IMCI chart booklets or wall charts available, or posts them on display; and
· Enables students to practise the full IMCI guidelines, including identifying
treatment and counselling.

Clinical practice sites should be representative of first-level health facilities where

IMCI is normally practised. They should receive enough sick children for each
student to practise managing several cases with a wide variety of IMCI conditions,
clinical signs and classifications. Outpatient community clinics and outpatient wards
of hospitals are frequently used for IMCI clinical practice. Regardless of the type of

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facility, clinical staff at the facility should routinely manage sick children according
to IMCI. For this reason, it is essential to gain the support of decision-makers at the
clinical practice site, and to train relevant clinic staff in IMCI.

If the staff members at a teaching institution decide to provide student transportation

for practise at an outpatient clinic, they should consider how this transportation will
be sustained over time. In many cases, it may be more feasible for students to practise
IMCI in the outpatient ward of a teaching hospital, and then to complete an internship
at a community clinic where IMCI is used on a routine basis. If internships are
organized at community clinics, it is important to remember that key staff at the clinic
should be trained to both practise and teach IMCI.

Clinical practice sites should allow students to practise the full IMCI case
management process, including identifying treatment and counselling the caretakers
of sick children.

Suggested Activities and Materials

The IMCI Working Group should identify clinical sites that are representative of first-
level health facilities and that have an adequate flow of patients under the age of five
years.

The national or state coordinating group, teaching institutions and administrators and
staff at clinical practice sites should then work together to:

· Orient decision-makers. Opinion leaders and decision-makers at a health facility

need to understand and accept IMCI before they can effectively support IMCI
teaching. For more detailed information see the task called Orient National
Opinion Leaders and Decision-makers in section 1.2 of this guide.

· Train relevant clinical staff. See the task titled Train Relevant Teachers and
Clinical Staff in section 2.2 of this guide.

· Ensure that necessary supplies and equipment are available. Staff from the
teaching institution and clinical practice site should work with the National
Coordinating Group for IMCI Pre-Service Training to ensure that the drugs and
supplies needed for IMCI clinical practice are consistently available at health
facilities that conduct IMCI clinical practice. See Annex 2 for a List of Drugs and
Supplies Needed for IMCI Practice in Outpatient Clinics.

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching: Tasks at the Teaching Institution

Prepare Materials

Teaching institutions will need to

identify and prepare materials for 2.2 TEACHING INSTITUTION(S)
IMCI teaching, learning and
student assessment. If several þ Define times, places, activities and
materials*
different materials are needed, staff
should prioritize which materials to þ Train teachers and clinical staff*
prepare first, and which to prepare þ Prepare clinical practice sites*
later. The list of priority materials
should include tools for assessing þ Prepare materials*
the level of IMCI knowledge and ¨ Coordinate teaching*
skills achieved by students. ¨ Conduct and monitor teaching*
All materials for IMCI teaching
should meet the following criteria:

· Be consistent with the adapted IMCI clinical guidelines;

· Correspond to the IMCI learning objectives defined for the specific academic
programme (e.g. bachelor of medicine, bachelor of nursing, etc.);

· Support teaching, learning and assessment methods used by a teaching institution;

and

· Be available and affordable to students and teachers.

Some materials, such as case recording forms for clinical practice, may be difficult
and expensive to reproduce in large quantities. The IMCI Working Groups at
national, state and school levels will need to determine how to create an affordable
and sustainable supply of materials. For example, in some countries, revolving funds
have been established for the development and reproduction of materials. In other
countries, students have been requested to purchase IMCI materials at a low cost.

Objectives

The objectives for this task are to ensure that materials for IMCI teaching, learning
and student assessment:

· Are consistent with the locally-adapted IMCI clinical guidelines;

· Include essential elements of the IMCI strategy and clinical guidelines; and

· Support the methods used by teaching institutions for teaching, learning and
student assessment.

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching: Tasks at the Teaching Institution

Timing

Once key persons decide when, where and how IMCI will be taught within an
academic programme, they can begin to identify and prepare appropriate materials for
IMCI teaching, learning and student assessment.

Who Should Prepare Materials?

The group that develops, adapts or revises materials should include persons with
expertise in: (a) the IMCI strategy and clinical guidelines; and (b) the development of
educational materials (e.g. persons from the Department of Medical Education).
Some materials may be developed, adapted or revised by staff within a teaching
institution. Other materials may be prepared by the national or state Coordinating
Group for IMCI Pre-Service Training, or by an association of teaching institutions.
Regardless of who initiates the task and where the materials are prepared, all
materials should be tested with students at teaching institutions before they are
finalized.

Description

The purpose of this task is to prepare materials that are consistent with the national
IMCI clinical guidelines, cover relevant IMCI learning objectives for a selected
academic programme, and correspond to the teaching, learning and assessment
methods used at specific teaching institutions.

Teachers will need to review the materials that they already use for teaching, learning
and student assessment – e.g. textbooks, handouts, and slides – and decide if these
materials can be revised to include elements of IMCI. They also need to decide if they
should adapt or develop new materials for IMCI teaching. (See Planning Matrix:
Matching Activities and Materials with Learning Objectives for IMCI in Annex 2.)

Many of the materials used in the IMCI in-service training course (e.g. the IMCI chart
booklet and case recording forms) are appropriate for teaching IMCI in medical and
paramedical schools, and may be used with few or no modifications. These materials
should be adapted to correspond to the national IMCI clinical guidelines. In addition,
WHO CAH has developed generic materials for IMCI pre-service training. The
generic pre-service materials also must be adapted to correspond to the locally-
adapted IMCI clinical guidelines before they can be used. Once adapted, all in-service
and pre-service materials can be incorporated, if desired, into materials that are
already in use by teaching institutions. A summary of materials, called Description of
Possible Materials for IMCI Teaching, Learning and Student Assessment, is provided

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 Phase Two – Prepare and Conduct the First Round of IMCI Teaching: Tasks at the Teaching Institution

in Annex 2. The materials in this list can be requested from the Ministry of Health in
a country or from WHO.23

When reviewing their needs, teaching institutions should consider the following types
of materials.

Materials for teachers:

Teachers at medical, nursing and other health professional schools frequently use
overhead transparencies, slides, handouts, videos, wall charts and audiocassettes
to support student learning. They also use local or international textbooks as
references and for student reading assignments. In addition, they often use course
descriptions, lesson plans, tutors’ books or other guides to help structure teaching
and ensure that important topics are covered.

The following materials are available for use by teachers (see Annex 2 for a
detailed description of each item):

· List of Possible Learning Objectives for IMCI (see Annex 1)

· Planning Matrix: Matching Activities and Materials with Learning Objectives
for IMCI (see Annex 2)
· IMCI Reference Library of Selected Materials
· IMCI Technical Seminars
· Photograph Booklet
· Videotapes
· Wall Charts
· Facilitators’ Guides for Outpatient and Inpatient Clinical Practice
· Checklists for Monitoring Outpatient and Inpatient Clinical Sessions (see
Facilitators’ Guides above and example group checklist in Annex 2)

Note: some countries have reduced the cost of reproducing the photograph
booklet by converting the booklet into slides.

Materials for students:

Students at medical, nursing and other health professional schools read a variety
of materials such as textbooks, handbooks, journal articles and handouts. They
also do exercises, solve case studies and use or develop various memory aids to
help them understand and practise a subject.

23
Examples may be requested from the WHO representative in a country, the WHO regional office, or the Department
of Child and Adolescent Health and Development (CAH), World Health Organization, Avenue Appia 20, 1211
Geneva 27, Switzerland (Fax: +41 22 791 4853, e-mail: [email protected]).

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The following materials may be used by students (see Annex 2 for a detailed
description of each item):

· A textbook with IMCI incorporated (based on the IMCI Model Chapter for
Textbooks)
· An IMCI handbook based on the IMCI Model Handbook
· A workbook of IMCI exercises
· IMCI Chart Booklet
· IMCI Mother’s Card
· IMCI Case Recording Form
· Management of the Child with a Serious Infection or Severe Malnutrition:
Guidelines for Care at the First-Referral Level in Developing Countries
(WHO/FCH/CAH/00.1)

Several teaching institutions have created IMCI case studies for students. Some
have developed IMCI exercise books for students. Many countries have reduced
the cost of reproducing the case recording forms by printing the forms rather than
photocopying them; or by producing laminated, reusable forms. Clinics that have
access to computers can create electronic patient recording systems that can be
used to record patient information and track patient histories.

Materials for assessing student knowledge and skills:

Assessment of student knowledge and skills is regarded as routine in most

medical, nursing and other health professional schools.

Assessment is typically used to:

· Ensure that individual students have achieved minimum levels of competency;

· Determine whether students can pass to the next stage of study;
· Provide feedback to students on their progress;
· Decide if the teaching programme has been effective in meeting its objectives;
· Ensure that important subjects are given priority within the curriculum; and
· Offer evidence to regulating authorities that standards are being met.

When academic advancement is contingent on passing assessments, students will

focus their studies on learning the material that will be examined. Conversely if
material is taught but not assessed, students will see no reason to concentrate on
that material. Hence, the philosophy is as follows – if it is in the examinations, it
is important; if it is not in the examinations, it is not important. For this reason, it
is essential to prepare materials for assessing the IMCI knowledge and skills of
students, and to incorporate those materials into the standard process for student
assessment.

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The methods frequently used for student assessment are:

· Written examinations: Questions or problems often range from more

objective multiple choice, true/false or fill-in-the-blank items to less objective
essay and short-answer items.

· Practical examinations: These exams frequently involve direct observation

while a student performs a technical or interpersonal skill in a real or
simulated environment. This often means completing a checklist while a
student performs certain tasks in the clinic or during an Objective Structured
Clinical Examination (OSCE).

· Oral examinations: This is typically a face-to-face interview between an

examiner and a student. Research has shown that the results of this method
tend to be subjective, biased and unreliable, particularly if examiners are
allowed to vary the questions asked from one student to the next.24

· Assignments, projects or reports: This includes completing written

assignments, working on case studies, reporting on an internship or practical
experience, writing a thesis paper, conducting research or summarizing the
published literature on a topic.

It is important to define the purpose of each assessment activity. Will the

assessment measure student knowledge (i.e. understanding of a subject) or
practical skills (i.e. the ability to do something)? Will it help students to improve
their performance by providing feedback (i.e. formative assessment), or determine
if a student should move to the next stage of studies (i.e. summative assessment)?

A good educational strategy will involve frequent activities for formative

assessment to ensure students are receiving opportunities to practise and improve
knowledge and skills that ultimately will be included in a summative assessment.

Schools that have introduced IMCI teaching have been able to incorporate IMCI
into the standard process for student assessment. They also have found that the
introduction of IMCI can strengthen the validity and reliability of student
assessment by giving more focus to the evaluation of practical skills (i.e. through
observation with checklists) and to formative assessment that provides feedback
to students to help them improve their performance.

Teaching institutions can develop a variety of materials for IMCI assessment,

such as questions for written exams (e.g. multiple choice, fill-in-the-blank, short
answer, and case study questions), exercise books and checklists for observing
IMCI clinical skills. To assist teaching institutions, WHO has developed IMCI
24
Newble D and Cannon R, eds. Assessing the Students. In A Handbook for Medical Teachers - Third
Edition. London, Kluwer Academic Publishers BV, 1994: 107-140.

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Guidelines for the Assessment of Students and a video called Video Exercises on
IMCI. (For more information see Description of Possible Materials for IMCI
Teaching, Learning and Student Assessment in Annex 2).

Suggested Activities and Materials

In some countries, a national or state group (i.e. National Coordinating Group for
IMCI Pre-Service Training, National Association of Medical Schools, etc.) may begin
adapting materials - such as the IMCI handbook - for a particular academic
programme (e.g. bachelor of medicine, certificate of nursing, etc.). While a national
group might take responsibility for some materials, teaching institutions themselves
might prepare other materials such as IMCI case studies. Regardless of who initiates
the process, preparation of materials requires a long-term commitment that may
include peer reviews and other events such as materials development workshops.
Teaching institutions should collaborate with the National Coordinating Group on
IMCI Pre-Service Training to test, refine and finalize materials.

The following approaches can be used to prepare materials:

· Use nationally adapted material from the IMCI in-service training course such as
the chart booklet, mother’s card, video and case recording forms;

· Develop new material such as IMCI case studies;

· Adapt generic materials - such as the IMCI model handbook, IMCI model chapter
for textbooks, or the IMCI facilitators’ guide for outpatient clinical practice - to
conform to the locally-adapted IMCI clinical guidelines;

· Incorporate relevant elements of IMCI into materials already used by teaching

institutions such as textbooks, handbooks, tutors’ guides or written examinations.

Experience has shown that teaching institutions often take a step-by-step approach to
incorporating IMCI into existing teaching materials. They start by adapting generic
material to the local IMCI clinical guidelines. They then use drafts of the adapted
material in actual teaching in order to get feedback from teachers and students on how
to improve the material. Finally, they revise the adapted material and incorporate it
into materials already used by the faculty, such as textbooks, handbooks, tutors’
guides, written examinations, etc.

The steps below can be used to develop, adapt or revise materials:

· Estimate the budget needed. Estimate the costs related to designing and
reproducing materials and identify an appropriate source of funding. The funds
may come from the teaching institution itself, a national fund, or an international
agency working in the area of health or education. In addition to identifying

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resources for the development of materials, it is important to identify affordable

ways to reproduce and supply the materials over time.

· Identify a focal person. The focal person will be responsible for coordinating the
production of material from start to finish. He or she may create the materials
alone, or coordinate the work of other writers and developers.

· If needed, form a development or review group. For large, complicated or highly

technical materials, it may be useful to form a small development group (two to
five persons) to assist with the production and review of materials. This group
should include specialists in both the technical content (i.e. IMCI) and in the
development of educational materials. Members of the group can include persons
both within and outside teaching institutions.

· Prepare draft materials. If a review group is formed, circulate draft materials to

the group for their review and comments.

· Review and revise. If material has been circulated for review, revise it based on
the comments of the group. Then create a working draft to be tested in actual
teaching environments.

· Test. Test the working draft with teachers and students during actual teaching.
Obtain feedback from teachers and students on how to improve the materials.

· Finalize. Revise materials based on student and teacher feedback, and finalize for
reproduction or for incorporation into other materials already used by teaching
institutions.

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Coordinate Teaching

IMCI requires staff in different

academic units, subunits and 2.2 TEACHING INSTITUTION(S)
clinical practice sites to present an
integrated approach to common þ Define times, places, activities and
health problems in children. This materials*
coordination requires careful þ Train teachers and clinical staff*
planning, and mechanisms for
sustaining interaction between þ Prepare clinical practice sites*
teaching units and health facilities þ Prepare materials*
used for IMCI clinical practice. þ Coordinate teaching*
Objectives ¨ Conduct and monitor teaching*

The objectives of coordinating

teaching are to ensure that:

· Administrators and staff of relevant teaching units, subunits and clinical practice
sites understand and carry out their respective roles in relation to IMCI teaching;

· All essential elements of the IMCI strategy and clinical guidelines are covered
within an academic programme; and

· Teaching in one academic unit compliments, and does not contradict, what is
taught in other relevant units.

Timing

Coordination between relevant teaching units, subunits and clinical practice sites
should begin with the development of a comprehensive plan for the introduction of
IMCI teaching. Coordination should continue at different levels of intensity for as
long as IMCI is taught in a school.

Who Should Coordinate Teaching?

As described in Phase One of this guide, experience has shown that an enthusiastic
focal person at a teaching institution will need support and assistance from a larger
IMCI Working Group inside the institution. The IMCI Working Group should consist
of representatives from relevant academic units and clinical practice sites in order to
effectively coordinate IMCI teaching. This will ensure the effective planning and
coordination, as well as long-term sustainability, of IMCI teaching.

Description

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Because IMCI is a public health approach to child health, it requires careful

integration of both theory and practice in preventing and managing common serious
childhood conditions. In most academic programmes, IMCI teaching will be
integrated not only vertically across different teaching units, but also horizontally
throughout different years or terms of a programme. Therefore, it is critical for all
relevant teaching units – including clinical practice sites – to understand and carry out
their respective roles in IMCI teaching. Teaching activities will need to be carefully
coordinated to ensure that all elements of IMCI are covered, and to ensure that
teaching in one unit or year coincides with - and does not contradict - what is taught
in another unit or year.

For example, students may be confused if the department of pharmacology teaches

that certain drugs are appropriate for the treatment of acute diarrhoea, while the
department of gastroenterology teaches that no drugs should ever be given to a child
with acute diarrhoea. Similarly, if students learn in fourth year theory that only X-ray
positive cases of pneumonia should be treated with antibiotics, they will be confused
if they learn in fifth year clinical practice that children with fast breathing, and no
chest X-ray, can be classified as having pneumonia and treated with antibiotics.

It is, therefore, critical to have frequent interaction between the staff of relevant
academic units and clinical practice sites throughout the planning, preparation and
implementation of IMCI teaching.

Suggested Activities and Materials

The following types of activities are suggested to coordinate IMCI teaching:

· Regular meetings of the IMCI Working Group. The IMCI Working Group
should meet at least once each month when IMCI teaching is being introduced.
During the meetings the group should discuss achievements and difficulties in
implementing their plan of action for IMCI teaching. The discussions may focus,
for example, on the placement of IMCI teaching, the training of teachers, the
development of materials, the preparation of clinical practice sites, or the
implementation of IMCI teaching. Each meeting should end with a summary of
actions to be taken and who will be responsible for each action. When necessary,
additional administrators, teachers and staff should be invited to contribute to
these meetings.

· Add IMCI to the agenda of regular staff meetings. IMCI can be included on the
agenda of regular staff meetings in relevant academic units and clinical practice
sites in order to discuss achievements and difficulties associated with IMCI
teaching. Following such meetings, it is important to inform the IMCI focal
person or working group about important issues raised or decisions made in
relation to IMCI.

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· Create agreements between teaching units. If necessary, create verbal or written

agreements between different teaching units or with clinical practice sites to
formalize commitments to teach specific elements of IMCI.

When identifying achievements and difficulties associated with IMCI teaching, the
IMCI Working Group should refer to the teaching institution's plan of action for
introducing IMCI into an academic programme (see outline of plan in Annex 1). The
working group may also wish to refer to the Progress Report Questionnaire: IMCI
Pre-Service Training in Annex 3 of this guide.

Conduct and Monitor Teaching

Experience has shown that it is

difficult to simultaneously 2.2 TEACHING INSTITUTION(S)
introduce IMCI teaching into
several different subunits and years þ Define times, places, activities and
of an academic programme. Many materials*
teaching institutions have, þ Train teachers and clinical staff*
therefore, chosen to stagger the
introduction of IMCI teaching. For þ Prepare clinical practice sites*
example, a medical school might þ Prepare materials*
start IMCI teaching in a later term,
þ Coordinate teaching*
such as the fourth year rotation in
paediatrics, and then work þ Conduct and monitor teaching*
backward to incorporate IMCI
theory and practice into earlier
years of the programme. Or a school might start IMCI teaching in early theory
classes, and then work to introduce it into practical sessions in later years of a
programme. Regardless of the sequence of activities, teaching staff need to monitor
the introduction of new teaching.

Monitoring is the process of gathering information about teaching for practical

judgement and decision-making. It is a continuous process that aims to answer the
questions, “How well are we doing?” and, “How can we do better?” Feedback
collected through monitoring should influence the way that IMCI teaching is planned
and carried out in the following year or term of an academic programme.

Objectives

The objectives of monitoring teaching are to:

· Assess whether teaching is being implemented according to the plan of action;

· Identify achievements and difficulties with new teaching; and

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· Specify actions needed to sustain achievements or overcome difficulties.

Timing

Monitoring should begin when IMCI teaching begins. It is best to monitor teaching
consistently throughout a year, term or course - rather than waiting until the end.

Who Should Monitor Teaching?

Teachers themselves can monitor teaching. Additionally, IMCI focal persons or

working groups (both within and outside teaching institutions) may assist teachers in
developing feasible methods and materials for monitoring.

Description

Monitoring is designed to identify shortcomings in the implementation of the plan of

action, and to adjust implementation accordingly. The information collected should
be used to improve the content, methods and materials used for IMCI teaching. If
necessary, it could be used to revise the teaching institution's plan of action. For more
information, see Phase Three of this guide, Review and Replan IMCI Teaching.

When introducing new teaching, staff should be prepared to make adjustments to

teaching content, methods and materials in order to effectively meet their defined
learning objectives. If adjustments require broader action (for example, if the IMCI
handbook needs significant revision) this issue should be presented and discussed
during the review and replanning phase described in Phase Three of this guide.

Two main types of monitoring information can be collected:

· Quantitative data indicating, for example, how many students completed the term,
how many hours were spent on IMCI teaching, how many IMCI sessions were
conducted, and the results of student assessments; and

· Qualitative data that includes suggestions from students and teachers on how to
improve the content, methods and materials used for IMCI teaching.

Data is usually collected on four aspects of teaching:

1. The content of teaching. Does the content build on existing knowledge and
abilities of students? Do students believe the new knowledge and skills are useful
and applicable?

2. The context of teaching. Is the new teaching supported by deans, directors and
teachers? Is the new teaching supported by administrators and staff at clinical

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching: Tasks at the Teaching Institution

practice sites? Does the teaching correspond with what is taught in other related
courses? Are necessary resources and equipment available for teaching?

3. The process of teaching. How many students completed the term? How many
hours were spent on IMCI teaching? How many IMCI sessions were conducted?
What was the ratio of students to instructors? Did students benefit from the
methods used for teaching, learning and assessment? Was information presented
in a clear and understandable way? Were appropriate teaching, learning and
assessment materials used (i.e. adequate supply, relevant, understandable)?

4. The immediate outcomes of teaching. Do students demonstrate expected levels of

knowledge and skills?

Teaching staff should review monitoring data as it is collected, and take action to
overcome difficulties that they can resolve themselves. Some difficulties, however,
may require broader action by several teaching units, by the National IMCI
Coordinating Group, or by national or state authorities. For this reason, it is important
for teachers to report monitoring results to the IMCI Working Group within a
teaching institution. This data can then be included in the review and replanning
process.

Suggested Activities and Materials

As mentioned above, teachers should start to collect monitoring information as soon

as they begin IMCI teaching.

The following methods can be used to collect information:

· Discussions or interviews with students, teachers and former students. One-to

one interviews or focus group discussions are useful for in-depth exploration of
ideas or issues. These may also be referred to as feedback sessions or teacher
meetings. To reduce bias and increase the objectivity of the results, interviewers
should be carefully selected. For example, students may feel intimidated and less
inclined to provide candid responses if their own teachers interview them. For this
reason, it may be more effective to recruit and train a student to conduct
interviews with fellow students, and possibly with other teachers. An Example
Focus Group Interview with Students is provided in Annex 3.

· Written Questionnaires. Questionnaires can be developed and administered to

measure student and teacher satisfaction with the content, context, process and
outcome of teaching. Written questionnaires tend to be more objective and easier
to administer than interviews. However, they provide little opportunity to probe
for more information or to complete partial answers.

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· Observation of teachers and students. Teaching sessions can be observed and

recorded. It is important for the observer to determine, in advance, what questions
s/he wishes to answer about the teaching content, context and process. Example
observation forms for IMCI classroom and clinical practice sessions are provided
in Annex 3.

· Review the results of examinations. Reviewing the results of written and

practical examinations will help teachers determine the extent to which the new
teaching has achieved its learning objectives.

Once information is collected, teachers should review the results and identify needed
actions. Teaching staff may individually monitor and adjust their own teaching, or
they may work in teams to share achievements and difficulties, and to brainstorm
about actions needed to overcome difficulties. When reviewing monitoring results, it
is useful to refer to the plan of action for introducing IMCI teaching. (See OUTLINE:
Plan of Action for Introducing IMCI into an Academic Programme in Annex 1.)
Teachers might also refer to the questions in the IMCI Pre-Service Training:
Progress Report Questionnaire in Annex 3.

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 Phase Three – Review and Replan IMCI Teaching

3. PHASE THREE – REVIEW AND REPLAN IMCI

TEACHING

Tasks at the national or state level Page

¨ Assist teaching institutions in reviewing and replanning

teaching* 78

Tasks at the teaching institution level

¨ Review the plan of action* 82

¨ Assess the methods and materials used 85
¨ Measure the outcome of teaching 89
¨ Revise the plan of action* 91

* Critical Task

Change is a cyclical process. An Figure 3

initial plan of action cannot The Planning Cycle and its Relationship to the
anticipate every challenge that will Phases of Strengthening Pre-Service Training
arise during its implementation. For
this reason, teaching institutions – Create a Plan Implement the
with assistance from the National of Action Plan of Action
Coordinating Group for IMCI Pre- (Phase 1) (Phase 2)

Service Training – should monitor

the introduction of IMCI teaching. Revise the Plan Monitor
of Action Implementation
Monitoring is the ongoing process of (Phase 3) (Phase 2)
collecting information and making
small but immediate adjustments to
teaching. In addition to monitoring, Review
Implementation
periodic reviews of implementation (Phase 3)
should be undertaken to assess the
appropriateness, relevance and
effectiveness of teaching. Routine reviews will help identify what modifications are
needed to the plan of action. In most cases, review will lead to replanning, and to a
revision of the plan of action (see Figure 3).

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 Phase Three – Review and Replan IMCI Teaching

Experience has shown that review and replanning activities are usually conducted from 6
to 12 months after a plan of action is created and approved. The process of review and
replanning can be carried out in one or two days, or over several weeks. During the
process, the teaching institution collects and reviews information about IMCI teaching to
identify what activities and resources are needed to sustain or strengthen teaching. The
institution then revises the plan of action to include the new activities and resources.

The tasks described in this phase aim to:

· Identify achievements and difficulties with the implementation of a plan of action;

· Identify actions and resources needed to sustain or strengthen IMCI teaching; and

· Revise the plan of action accordingly.

Some of the tasks suggested in this phase - such as assessing the methods and materials
used - can be conducted prior to the review of the plan of action. Moreover, several tasks
can be combined into a review and replanning visit conducted by a qualified person from
outside a teaching institution.

Whenever possible, it is useful to incorporate monitoring and review activities into the
system that is already used by teaching institutions to monitor and evaluate teaching. It is
important to recognize that the introduction of IMCI teaching also presents an
opportunity to strengthen the processes used to monitor and evaluate teaching.

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 Phase Three – Review and Replan IMCI Teaching: Tasks at National Level

3.1 Review and Replan IMCI Teaching: Tasks at National Level

The national or state Coordinating

Group for IMCI Pre-Service Training
should support teaching institutions in 3.1 NATIONAL COORDINATOR(S)
reviewing and replanning for IMCI
teaching. The group can help in o Assist teaching institutions in
reviewing and replanning
assessing the methods and materials teaching*
used, measuring the immediate
outcomes of teaching, and reviewing
and revising plans of action. This
support is considered a critical at the
national level. To the largest extent possible, the activities in this phase should be
incorporated into the monitoring and evaluation systems already in place at teaching
institutions. In other words, the working group should not create a special monitoring
system specifically for IMCI, but should use the opportunity to expand and strengthen
existing monitoring and evaluation systems.

Assist Teaching Institutions in Reviewing and Replanning Teaching

The national or state Coordinating

Group for IMCI Pre-Service Training 3.1 NATIONAL COORDINATOR(S)
can help teaching institutions review
their plans of action, gather feedback þ Assist teaching institutions in
reviewing and replanning
from teachers and students, and teaching*
identify activities and resources
needed to sustain or strengthen IMCI
teaching. Members of the National
Coordinating Group may help with different tasks over a period of time, or they
may combine several tasks into a review and replanning visit.

Objectives

The objectives of assisting teaching institutions are to:

· Identify achievements and difficulties associated with the implementation of a

plan of action; and

· Define feasible and affordable actions to overcome difficulties and strengthen

teaching.

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Timing

Review and replanning can begin anytime from 6 to 12 months after a teaching
institution begins to implement a plan of action.

Who Should Assist Teaching Institutions?

Persons charged with assisting teaching institutions should have good knowledge
of IMCI, teaching experience, and knowledge of the WHO guidelines for
planning, implementing and evaluating IMCI pre-service training.

Description

The purpose of national-level assistance is to help teaching institutions achieve

their stated objectives for IMCI teaching. Teaching institutions should review
their plans of action several months after implementation begins. This review
should identify what has been achieved and what still needs to be done. It should
produce a description of the main achievements, difficulties and future actions
needed to sustain or strengthen IMCI teaching.

The review should determine whether teachers and students understand, accept
and are able to use the methods and materials available for IMCI teaching,
learning and student assessment. To obtain this information, teaching staff should
gather feedback from students and fellow teachers during teaching sessions. The
task called Conduct and Monitor Teaching in Phase Two of this guide describes
how to gather feedback from students and teachers. If necessary, teaching staff
may collect additional information from students and teachers upon completion of
a rotation, course or term that includes IMCI.

In addition to assessing the methods and materials used, teaching staff should
measure the extent to which expected outcomes were achieved in terms of student
knowledge and skills in IMCI. One way to do this is to review the results of
student assessments. If these results are not available, or if additional information
is needed, a sample of students can be assessed to decide if learning objectives
were met.

In countries or regions where the effectiveness of IMCI teaching has been

evaluated (see Phase Three of this guide), the results of these evaluations should
be examined. The results of a prior evaluation will provide a broader picture of
the effect IMCI teaching has had on the performance of graduates who have
completed a full academic programme.

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 Phase Three – Review and Replan IMCI Teaching: Tasks at National Level

The National Coordinating Group for IMCI Pre-Service Training can support
teaching institutions with any of the tasks described in this phase. The group is
particularly encouraged to assist teaching institutions in revising their plans of
action. When revising a plan of action, some learning objectives may be modified,
and some may be added, particularly on subjects related to IMCI such as
breastfeeding counselling. National or international experience, and knowledge of
available resources, can contribute greatly to the revision of a plan of action.

Suggested Activities and Materials

The national or state Coordinating Group for IMCI Pre-Service Training should
identify qualified persons to assist teaching institutions in reviewing their plans of
action, and in defining activities and resources needed to sustain or strengthen
IMCI teaching. To the largest extent possible, activities should take place within
the monitoring and evaluation systems already used by teaching institutions. It
should not be overlooked, however, that the review process provides an
opportunity to broaden or strengthen existing monitoring and evaluation systems.

Support can be provided to teaching institutions in two primary ways:

· Review and replanning visit. A teaching institution, or group of teaching

institutions, may request assistance in reviewing and replanning IMCI
teaching. They may request a visit from the National IMCI Focal Person, a
member of the National Coordinating Group for IMCI Pre-Service Training, a
WHO staff member, WHO consultant or other qualified person. Depending on
the information needed, the visit can take from one to five days. It may
include gathering feedback from students and teachers. It should include
identifying activities and resources needed to sustain or strengthen IMCI
teaching. Before the visit, representatives from relevant academic units and
clinical practice sites should review their plan of action and collect feedback
and assessment information from students and teachers.

The objectives of a review and replanning visit are to:

- Review the plan of action;

- Describe the achievements and difficulties experienced with the

implementation of the plan of action;

- Assess if IMCI teaching is achieving the stated objectives;

- Identify the actions and resources needed to sustain or strengthen IMCI

teaching; and

- Revise the plan of action.

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 Phase Three – Review and Replan IMCI Teaching: Tasks at National Level

A review and replanning visit may consist of the following activities (these
activities are further described in section 3.2 of this guide):

- Work with key staff to review the teaching institution’s plan of action and
identify achievements and difficulties with its implementation;

- Collect feedback from students and teachers on the quality of teaching,

learning and student assessment;

- Observe classroom or clinical practice session(s);

- Assess the IMCI knowledge and skills of a sample of students and

teachers;

- If an evaluation of the effectiveness of IMCI teaching has been conducted

in a region or country, review the results of the evaluation; and

- Meet with key staff to provide feedback on the findings of the visit and
identify actions and resources needed to sustain or strengthen IMCI
teaching.

A variety of methods can be used to collect feedback from teachers and

students, including written questionnaires, interviews and focus group
discussions. The review visit may include different methods for assessing the
knowledge and skills of students and teachers. Annex 3 contains materials that
can be adapted for a review and replanning visit, and an outline for a report of
a review and replanning visit.

· Assistance with individual tasks and activities. Teaching institutions may

request assistance with individual tasks or activities related to reviewing and
replanning IMCI teaching. Assistance may be requested from the National
IMCI Focal Person, a member of the National Coordinating Group for IMCI
Pre-Service Training, a WHO staff member, WHO consultant or other
qualified person. It might consist of developing materials (e.g. a student
questionnaire to evaluate teaching) or implementing certain activities (e.g.
conducting focus group interviews with teachers and students). Annex 3
provides materials that can be adapted for use in individual tasks and
activities.

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3.2 Review and Replan IMCI Teaching: Tasks at the Teaching

Institution Level
It is recommended that teaching
institutions carry out the following tasks
3.2 TEACHING INSTITUTION(S)
when reviewing and replanning IMCI
teaching:
o Review the plan of action*
· Review the plan of action; o Assess the methods and
materials used
· Assess the methods and materials used o Measure the outcome of
for teaching, learning and student teaching
assessment; o Revise the plan of action*

· Measure the outcome of teaching; and

· Revise the plan of action.

Two of the above tasks are critical to the success of IMCI teaching: review the plan of
action; and revise the plan of action. Each of the above tasks is described in more detail
below.

Review the Plan of Action

Phase One of this guide encourages

teaching institutions to develop a plan 3.2 TEACHING INSTITUTION(S)
of action for introducing IMCI into an
academic programme. The plan of þ Review the plan of action*
action should: define the IMCI
o Assess the methods and materials
learning objectives for the academic used
programme; describe how IMCI will
be incorporated within the o Measure the outcome of teaching
programme; and give an estimated o Revise the plan of action*
timeframe and budget for training
teachers, and preparing materials and
clinical practice sites. In addition, the plan should describe how the teaching
institution intends to monitor and evaluate IMCI teaching. After several months of
implementation, the staff at a teaching institution should review the plan of action to
identify what has been achieved and what still needs to be done.

Objectives

The objectives of reviewing the plan of action are to:

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· Identify which elements of the plan were achieved and which were not;

· Determine why certain activities were incomplete or delayed; and

· Identify actions and resources needed to overcome difficulties and sustain

achievements.

Timing

The original plan of action should specify when the teaching institution would review
implementation. A reasonable time for a review is from 6 to 12 months after
implementation begins.

Who Should Review the Plan of Action?

The IMCI Working Group within a teaching institution should review the plan of
action. The group may request assistance from the National IMCI Focal Person,
National Coordinating Group for IMCI Pre-Service Training, WHO staff, WHO
consultants, or other persons with good knowledge of IMCI, teaching experience, and
knowledge of the WHO guidelines for IMCI pre-service training.

Description

The purpose of the review is to identify which elements of the plan of action were
achieved, where difficulties were encountered, and what actions or resources are
needed to sustain or strengthen IMCI teaching.

Staff at a teaching institution should identify the main achievements, difficulties and
actions needed in the following areas:

a) Orientation: Were opinion leaders and decision-makers oriented as planned? Are

additional or different types of orientation activities needed? If yes, describe.

b) Training of teachers and relevant clinical staff: Were all relevant teachers and
clinical staff trained in IMCI? Did the training prepare staff to correctly perform
the IMCI clinical guidelines? Did the training prepare teachers to use appropriate
methods to teach IMCI? Are additional or different types of IMCI training courses
needed? If yes, explain.

c) Preparation of clinical practice sites: At the health facilities where students

practise IMCI, do decision-makers and staff understand and support IMCI? Are
all relevant clinical staff trained in IMCI? Is there at least one staff member
available to help select cases? Are sick children at the health facility routinely
managed according to the IMCI guidelines? Are drugs and equipment needed for

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IMCI consistently available? Does the facility have a sufficient supply of

paediatric patients? Are students allowed, under supervision, to prescribe oral
drugs, assess the feeding status of children and counsel caretakers? Are any
additional preparations needed? If yes, explain.

d) Materials for teaching, learning and student assessment: Were all necessary
materials for IMCI teaching, learning and student assessment prepared? Are the
materials understandable, affordable and easily available to students and teachers?
Was IMCI incorporated into textbooks? Are additional or different materials
needed? If yes, explain.

e) Placement of teaching: Did teaching start as planned in all relevant academic

units and academic years? Is there a clear link between IMCI and other teaching
on child health? Should IMCI be introduced in additional subjects, years or
academic programmes? If yes, explain.

f) Implementation of teaching: How many hours were spent on IMCI teaching in

each relevant academic unit and year? How many hours of IMCI teaching were
conducted in classroom sessions? How many hours did each student spend in
IMCI clinical practice? Were all three components of the IMCI strategy taught?
Were all essential elements of the IMCI clinical guidelines taught? During clinical
practice, did each student individually manage at least two sick children according
to the IMCI guidelines? Were students able to practise the full IMCI case
management process, including treatment and counselling? What was the average
ratio of students to teachers in classroom and in clinical practice sessions? Were
students assessed for IMCI knowledge and skills? If yes, how were they assessed?
Did each student receive feedback from teachers to improve his or her knowledge
and skills in IMCI? Were questions or problems on IMCI incorporated into
standard examinations? Is each student formally assessed for his or her skills in
IMCI? Are additional or different activities or methods needed for IMCI teaching,
learning and student assessment? If yes, explain.

g) Coordination of teaching: Was an IMCI Working Group created at the school? If

yes, do members of the group represent all academic units that are relevant to
IMCI? How frequently did the IMCI Working Group, or staff from relevant
academic units, meet to discuss achievements and difficulties with IMCI
teaching? Was this enough? If not, please explain. Did students find any
contradictions in teaching between different academic units? Should the IMCI
Working Group be redefined or strengthened? If yes, how?

h) Learning objectives: Were the expected outcomes achieved in terms of student

knowledge and skills? Should any of the learning objectives be revised? Should
some learning objectives be added? For more information about learning
outcomes, see the task in this section called Measure the Outcome of Teaching.

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Additional questions can be found in the IMCI Pre-Service Training: Progress

Report Questionnaire provided in Annex 3.

Suggested Activities and Materials

The persons charged with reviewing the plan of action should refer to the questions
above. The following activities are suggested for conducting the review:

· Individual review. Representatives from relevant academic units can review the
plan of action and prepare a written list of their achievements and difficulties with
its implementation. They should also list actions or resources needed to overcome
difficulties and sustain achievements.

· Review meetings. The IMCI Working Group can call a meeting of representatives
from different academic units to discuss achievements and difficulties with the
implementation of the plan of action. The objective of the meeting should be to
create and agree on a list of achievements and difficulties – and to identify and
agree on activities and resources needed to overcome difficulties and sustain
achievements.

· Review and replanning visit. A teaching institution may request assistance in

reviewing the plan of action. Assistance may be requested from the National
IMCI Focal Person, a member of the National Coordinating Group for IMCI Pre-
Service Training, a WHO staff member, WHO consultant or other qualified
person. Before the visit, representatives from relevant academic units should
review the plan of action individually (see the activity above called Individual
Review). The external reviewer can then conduct interviews and focus group
discussions with teachers and students in order to answer the main questions listed
above. In addition, the review visit can include other tasks described in this phase,
such as Measure the Outcome of Teaching and Revise the Plan of Action. An
outline for the report of a review and replanning visit is provided in Annex 3.

Assess the Methods and Materials Used

It is important to determine if teachers

and students understand, accept and 3.2 TEACHING INSTITUTION(S)
are able to use the methods and
materials used for IMCI teaching, þ Review the plan of action*
learning and student assessment. þ Assess the methods and materials
Teachers can gather feedback from used
students and colleagues as they o Measure the outcome of teaching
conduct and monitor IMCI teaching. o Revise the plan of action*
(See the task called Conduct and
Monitor Teaching in section 2.2 of

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this guide.)

At the time of the review, it is important to re-examine previously collected data and
decide if additional information is needed to revise the teaching institution's plan of
action. To the largest extent possible, the activities recommended below should be
incorporated into pre-existing monitoring and evaluation systems. At the same time,
the activities suggested here present an opportunity to broaden or strengthen existing
monitoring and evaluation systems.

Objectives

The objectives of assessing the methods and materials used for IMCI teaching,
learning and student assessment are to:

· Verify that methods and materials cover all IMCI learning objectives selected for
an academic programme; and

· Determine if students and teachers understand, accept and are able to use the
methods and materials prepared.

Timing

As staff at a teaching institution conduct IMCI teaching, they should simultaneously

request feedback from students and fellow teachers about the methods and materials
used for teaching, learning and student assessment. If additional information is
needed, it can be collected during this phase.

Who Should Collect Information?

The IMCI Working Group within a teaching institution should assist teachers to
collect feedback from students and fellow teachers about the methods and materials
used for IMCI teaching. Students are likely to give more candid responses if a neutral
person conducts interviews or focus group discussions. A neutral facilitator might be
a fellow student, staff member who is not involved with IMCI teaching, or a qualified
person from outside the school. Qualified persons from outside the teaching
institution could be the National IMCI Focal Person, a representative of the National
Coordinating Group for IMCI Pre-Service Training, WHO staff, WHO consultants, or
other persons with good knowledge of IMCI, teaching experience, and knowledge of
the WHO guidelines for IMCI pre-service training.

Description

The purpose of collecting information about methods and materials is to determine if

IMCI teaching, learning and student assessment activities are sufficient, relevant and
useful to both teachers and students. As previously described in the Phase Two task

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called Conduct and Monitor Teaching, information can be collected from teachers,
students and former students through questionnaires, interviews, focus group
discussions and observations. It should be collected during a course as well as after a
course is completed.

Both the technical and educational value of materials should be assessed. Technical
evaluation confirms that the content is technically correct, up to date, written in
appropriate technical terms and comprehensive enough to meet learning objectives. In
addition, it should verify that the content does not contain irrelevant information that
decreases the clarity and usefulness of the materials. Educational evaluation ensures
that materials are properly structured, easy to use and clear, so as to facilitate learning
and enable students to attain the specified objectives for which the materials were
selected or prepared.25

Two main questions should be considered when assessing methods and materials:

· Do the methods and materials reflect essential learning objectives? Are essential
elements of IMCI – typically listed as learning objectives in the plan of action –
included in the materials used for teaching, learning and student assessment? Are
the essential elements actually taught in classroom and clinical practice sessions?
For example, if the plan of action sets an objective that “after IMCI teaching
students should be able to teach mothers correct attachment for breastfeeding,”
then information about correct breastfeeding attachment should be included in
teaching, learning and assessment materials. Moreover, teaching should include
opportunities for students to experience and practise teaching mothers about
breastfeeding attachment.

· Do students and teachers understand, accept and use the methods and
materials? Do teachers and students feel that information in teaching, learning
and assessment materials is presented in a clear and understandable way? Do
teachers feel that the methods or materials are useful and can be applied in their
teaching? Do students report that the methods and materials were effective in
helping them to understand and use IMCI? Are teachers or students confused by
any of the methods or materials used?

Suggested Activities and Materials

The following activities may be used in order to assess the methods and materials
used for IMCI teaching:

· Monitor ongoing teaching. As described in the Phase Two task called Conduct
and Monitor Teaching, feedback can be gathered from students and teachers
through questionnaires, interviews, focus group discussions and observation of

25
Gilbert J. Educational handbook for health personnel, 6th ed. Geneva, World Health Organization,
1998.

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classroom and clinical practice sessions. This feedback should include responses
to the two main questions described above. Staff within teaching institutions
should gather feedback from teachers and students. A person from outside the
teaching institution, who is brought in to conduct a review and replanning visit,
can also collect feedback.

· Review materials used. Materials used for teaching, learning and student
assessment should be reviewed to determine whether essential elements of IMCI
are adequately covered. Teaching staff should check materials to ensure that they
include information that supports the IMCI learning objectives defined in the
teaching institution's plan of action and planning matrices.

· Review and replanning visit. Staff at the teaching institution may request
assistance in assessing the methods and materials used for teaching. Assistance
may be requested from the National IMCI Focal Person, a member of the National
Coordinating Group for IMCI Pre-Service Training, a WHO staff member, WHO
consultant or other qualified person. Before the visit, representatives from
relevant academic units should collect as much feedback as possible from
students and teachers. During the visit, more information may be collected
through interviews, focus group discussions, review of materials and observation
of teaching. It is recommended that review and replanning visits include other
tasks described in this phase, such as Measure the Outcome of Teaching and
Revise the Plan of Action. Annex 3 provides an outline for the report of a review
and replanning visit.

The following materials should be used as references when conducting the above
activities:

- The school’s Plan of Action for Introducing IMCI into an Academic

Programme (see outline in Annex 1)

- For each relevant course, a completed Planning Matrix: Matching Activities

and Materials with Learning Objectives for IMCI (see example in Annex 2)

- The List of Possible Learning Objectives for IMCI (see Annex 1)

The following materials also may be used as a basis for preparing interviews,
focus group discussions and observations:

- Example: Focus Group Interview with Students (see Annex 3)

- Example: Focus Group Interview with Teachers (see Annex 3)
- Example: Observation Form for an IMCI Clinical Practice Session (see
Annex 3)
- Example: Observation Form for an IMCI Classroom Session (see Annex 3)

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Measure the Outcome of Teaching

A review of IMCI teaching should

examine the immediate outcomes of 3.2 TEACHING INSTITUTION(S)
teaching. This means assessing student
abilities after they have participated in þ Review the plan of action*
classroom or clinical sessions that þ Assess the methods and materials
include IMCI teaching. It aims to used
answer the question, “Were the
expected outcomes achieved in terms þ Measure the outcome of teaching
of student knowledge and skills in o Revise the plan of action*
IMCI?”

The immediate outcomes of teaching can be measured at any time after students
complete a rotation, course, term or year that includes IMCI teaching. If students
were assessed for IMCI knowledge and skills during the teaching, the results of those
assessments should be reviewed. In addition, a sample of current students may be
assessed during the review and replanning phase. The results of assessments should
then be analysed to decide if teaching is meeting the expressed learning objectives.

In addition to immediate outcomes, the effectiveness of IMCI teaching can be

evaluated by assessing the performance of graduates in their daily clinical practice.
More detailed information about evaluating teaching is provided in Phase Four of this
guide. If an evaluation of teaching was carried out in a country or region, the results
of that evaluation should be reviewed.

Objectives

The objective of measuring the outcome of teaching is to:

· Determine if students demonstrate expected knowledge and skills after

participating in classroom and clinical practice sessions that include IMCI.

Timing

Students may be assessed for IMCI knowledge and skills anytime during or after they
participate in classroom or clinical practice sessions where IMCI is taught.

Who Should Measure the Outcome of Teaching?

The IMCI Working Group within a teaching institution should assist teachers in
measuring the outcome of IMCI teaching. The teaching staff may also request
assistance from the National IMCI Focal Person, National Coordinating Group for
IMCI Pre-Service Training, WHO staff, WHO consultants, or other persons with

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good knowledge of IMCI, teaching experience, and knowledge of the WHO

guidelines for IMCI pre-service training.

Description

The purpose of measuring the immediate outcome of IMCI teaching is to determine if

students understood what was taught and if they are able to perform specific tasks.
Teachers should review the results of student assessments to identify which areas of
knowledge and skills fall below expected levels. The review should be used to
develop suggestions for modifying teaching, learning and student assessment in order
to improve learning outcomes.

The outcome of teaching can be measured after any amount of IMCI teaching has
taken place. It is not necessary to wait until students complete several rotations,
courses, terms or years of instruction. It is essential, however, to adapt assessment
methods and tools to fit the objectives of the elements of IMCI being taught. For
example, if IMCI has been incorporated into a session on nutrition, the assessment
should include only the elements of IMCI related to nutrition (e.g. assessing a child’s
feeding, and counselling a child’s caretaker about feeding during sickness and
health).

Knowledge and skills of both current and former students can be assessed. In
addition, staff may decide to assess the knowledge and skills of teachers, tutors, or
teacher's assistants to determine if they have received adequate training in IMCI.

Suggested Activities and Materials

The outcome of IMCI teaching can be assessed in the following ways:

· Review the results of previous assessments. Teaching staff, or a qualified person

from outside the school, should review the results of formative and summative
assessments conducted during IMCI teaching. They should decide if the results
satisfy expectations, identify where performance is weak, and suggest how
teaching methods and materials might be modified in order to improve student
performance.

· Assess a sample of current students. If more information is needed in order to

make decisions about future teaching, teachers or other qualified persons should
assess the IMCI knowledge and skills of a sample of current students. This
assessment may be done as part of the review and replanning visit described
earlier in this section. The methods and materials used to assess knowledge and
skills must be adapted to reflect the local IMCI clinical guidelines and the
elements of IMCI that have been taught. Annex 3 contains a Sample Observation
Checklist and a Sample Written Examination. The observation checklist and
written exam are organized to coincide with the steps of the IMCI case

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management process. Computer files of these materials are available from WHO
CAH.

· Evaluate the effectiveness of teaching. Phase Four of this guide gives more
details about how to evaluate if students are able to apply their IMCI knowledge
and skills in their daily clinical practice after graduation.

Revise the Plan of Action

The IMCI Working Group should

identify which elements of the plan of 3.2 TEACHING INSTITUTION(S)
action were achieved and which are
incomplete or delayed. If possible, a þ Review the plan of action*
teaching institution should review the þ Assess the methods and materials
methods and materials used, as well as used
the outcomes of IMCI teaching. This
þ Measure the outcome of teaching
review will allow the teaching
institution to identify actions and þ Revise the plan of action*
resources needed for sustaining and
strengthening IMCI teaching. To
ensure that future actions are taken, it is important to revise the plan of action as well
as the timeline and budget for its implementation.

Objectives

The objectives of revising the plan of action are to:

· Identify actions and resources needed to sustain or strengthen IMCI teaching; and

· Guide the implementation of future activities related to IMCI teaching.

Timing

The plan of action should be reviewed and revised from 6 to 12 months after
beginning its implementation. Before revising the plan, it is useful to collect feedback
from students and teachers about the methods and materials used for teaching,
learning and student assessment. It also is useful to assess the IMCI knowledge and
skills of students after they participate in IMCI teaching.

Who Should Revise the Plan of Action?

The IMCI Working Group should work together with representatives of relevant
academic units and clinical practice sites to revise the plan of action. They may
request assistance from qualified persons outside the teaching institution who have

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good knowledge of IMCI, teaching experience, and knowledge of the WHO

guidelines for IMCI pre-service training. Persons brought in from outside a teaching
institution can contribute by sharing lessons learned from other teaching institutions,
and by helping to identify actions and resources needed.

Description

The purpose of revising the plan of action is to ensure that IMCI teaching is sustained
or strengthened within relevant academic programmes. The outcome should be a
revised plan of action for IMCI teaching that includes a budget and timeline.

When revising the plan of action, administrators and staff should discuss the
achievements and difficulties faced during the implementation of the plan. They
should consider feedback received from teachers and students about the methods and
materials used for IMCI teaching, learning and student assessment. They also should
review the results of any assessments of student knowledge and skills in IMCI.

The persons charged with revising the plan of action may choose to introduce IMCI
into an additional academic programme. They may also decide to revise some of the
learning objectives included in the original plan, or to add more learning objectives.
For example, if the original plan includes only learning objectives related to the
outpatient care of sick children, and these objectives are being met, the IMCI
Working Group may decide, upon review, to add learning objectives related to
breastfeeding counselling, inpatient care or other subjects related to IMCI.

In most teaching institutions, the revision will take place in stages. The first stage
would consist of a meeting of the IMCI Working Group to agree on the actions and
resources needed to overcome difficulties or strengthen teaching. In the second stage,
a smaller group, or an individual, would revise the plan of action and circulated the
revised plan to staff for comments and suggestions. After the comments are
incorporated, the finalized plan should be endorsed by relevant decision-makers.

Suggested Activities and Materials

The following activities are suggested in order to revise the plan of action for IMCI
teaching:

Review and replanning visit. As described in the sections above, staff at the teaching
institution may request assistance to revise the plan of action. Assistance may be
requested from the National IMCI Focal Person, a member of the National
Coordinating Group for IMCI Pre-Service Training, a WHO staff member, WHO
consultant or other qualified person. The person charged with conducting the review
and replanning visit should meet with relevant administrators and staff to reach a
consensus on the activities and resources needed to sustain or improve IMCI
teaching.

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Revise the plan of action. After identifying the actions and resources needed to
sustain or strengthen IMCI teaching, representatives from relevant academic units and
clinical practice sites should draft, review and finalize a revised plan of action. The
revised plan should include a budget and timeline for its implementation. In addition,
it should include suggestions about how to monitor and eventually review the
implementation of the plan (refer to Annex 1 for a sample outline and timeline of a
plan of action).

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4. PHASE FOUR – EVALUATE IMCI TEACHING

Tasks at the teaching institution Page

¨ Evaluate the process and outcomes of IMCI teaching 97

¨ Use the results of evaluations to strengthen teaching* 102

Tasks at national or state level

¨ Evaluate the effectiveness and cost of IMCI teaching 104

¨ Share the results of evaluations* 112

* Critical Task

Phase Two of this guide describes how to monitor the introduction of new teaching in
order to identify shortcomings in the implementation of a plan of action and adapt the
implementation accordingly. Monitoring is defined as a continuous process of gathering
information about teaching for practical judgement and decision-making. It includes
collecting information about the content, context, process and intermediate outcomes of
teaching. Evaluation is concerned with the periodic assessment of the overall process and
final results of IMCI teaching. Many of the same indicators, techniques and tools that are
used for monitoring can also be used for evaluation. Therefore, if monitoring is done
well, evaluation is simplified and in certain cases may not be needed.

The tasks described in this phase aim to:

· Measure to what extent the desired results were achieved;

· Identify gaps between what was expected and the actual results; and

· If needed, prepare for the revision of IMCI teaching.

There are four main types of evaluations. These are the evaluation of the process, final
outcomes, effectiveness and impact of new teaching (see table 1). Process refers to the
changes made in the way an academic programme is taught, the methods and materials
used, and how teachers and students respond to those methods and materials. Outcomes
refer to the final results of teaching, particularly in terms of student knowledge, attitudes
and skills (i.e. competence). Outcomes can be evaluated by testing the students at the end

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 Phase Four – Evaluate IMCI Teaching

of a course or academic programme. The examination, however, must be relevant and

based on defined learning objectives that reflect the job that the students are being trained
to do. Effectiveness assesses the ability of students to apply knowledge, attitudes and
skills to their work after graduation (i.e. performance). It can be evaluated by finding out
how well students are doing after they have left the teaching institution and started work.
Finally, impact concentrates on improvements in the health status of a population that
may – or may not - be related to changes in the quality of care provided by graduates.

Table 1

Evaluating the results of new teaching in terms of the process, student

competence, graduate performance and the quality of care delivered

Attribute: Process Outcomes Effectiveness Impact

(Competence) (Performance) (Quality)
Process of Describing Assessing if Observing service Applying a
evaluation changes made learning delivery by new continuous,
to the teaching objectives were graduates cyclical audit
and learning achieved
process
Basic question How did they Can they do it? Do they do it? How well do they
learn it? do it?
Responsibility Teaching Teaching Licensing Health systems,
for formal institutions, institutions, authorities, organizations,
evaluation national national professional hospitals, services,
academic academic associations, clinics
associations associations societies,
employers
Responsibility Teachers and Teachers and Self (professional), Groupings of
for routine or instructors instructors patients, peers (co- service providers –
informal workers) colleagues, teams,
evaluation managers, planners

A key task in this phase is to evaluate the process and outcomes of new teaching at the
level of the teaching institution. Because evaluating the effectiveness of teaching is
difficult and costly, it is considered an optional task that should only be done as a part of
a larger evaluation effort at state or nation level. No instructions are given in this guide
for evaluating impact, because this type of evaluation is extremely difficult, complicated
and costly to conduct and analyse, and should only be done where evaluation capacity is
high and the results may be used regionally or even globally.

Most teaching institutions have experience in reviewing and evaluating the process and
outcomes of teaching, particularly in relation to student competence at the end of an
academic programme. However, to evaluate the effectiveness of teaching, the
performance of new healthcare professionals must be assessed at their work environment
after graduation. An evaluation of the effectiveness of IMCI teaching determines if

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 Phase Four – Evaluate IMCI Teaching

students are able to correctly apply IMCI after graduation. The results of an effectiveness
evaluation should demonstrate to teaching institutions, funding agencies and national
authorities that the resources invested in IMCI teaching produced the expected effect. In
addition, the results should be used to identify areas where IMCI teaching could be
strengthened.

Because professional performance is much more difficult, complicated and costly to

measure than student competence at the end of an academic programme, an effectiveness
evaluation is typically beyond the capacity and resources of a single teaching institution.
National or state coordinating groups – such as licensing authorities, professional
associations or other societies - should lead the evaluation with the cooperation and
assistance of teaching institutions. Moreover, it is recognized that not all countries have
the need or the resources to conduct this type of evaluation. For this reason, an evaluation
of effectiveness is considered an important but optional task in this phase. In countries
where IMCI health facility surveys are conducted, the results of these surveys might be
used as an alternative means to assess the performance of health professionals who have
completed IMCI pre-service training.

An impact evaluation is not recommended. Impact assesses changes in the quality of care
delivered. It includes many factors such as improved case management, improved
availability of drugs, more rational use of drugs, better referral, better care seeking,
increased service utilization and increased client satisfaction. In the long term, changes in
these factors should contribute to changes in morbidity and mortality. Impact evaluation
is, therefore, concerned with the ultimate goal of introducing IMCI into academic
programmes. However, because impact depends on many factors in addition to the
performance of health care professionals, it is not possible to establish a direct cause and
effect relationship between changes in an academic programme and changes in quality of
care. An impact evaluation can only suggest a probability that revised teaching
contributed to the effect of improved quality of services. In addition, it is difficult and
expensive to accurately measure impact.

Regardless of how, where or what type of evaluation is conducted, it is critical for the
national or state Coordinating Group for IMCI Pre-Service Training to share evaluation
results with all relevant teaching institutions. In addition, it is essential for teaching
institutions to contribute to evaluation efforts, and to use evaluation results to strengthen
their teaching. For this reason, the tasks called Share the Results of Evaluations and Use
the Results of Evaluations to Strengthen Teaching are marked as critical tasks in this
phase.

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 Phase Four – Evaluate IMCI Teaching: Tasks at the Teaching Institution

4.1 Evaluate IMCI Teaching: Tasks at the Teaching Institution

The following tasks can be carried out at
teaching institutions to evaluate IMCI
teaching: 4.1 TASKS AT THE TEACHING
INSTITUTION
· Evaluate the process and outcomes of
IMCI teaching; and o Evaluate the process and
outcomes of IMCI teaching
· Use the results of evaluation to o Use the results of evaluations to
strengthen teaching. strengthen teaching*

Evaluate the Process and Outcomes of IMCI Teaching

An evaluation of process and

outcomes should answer the question, 4.1 AT THE TEACHING INSTITUTION
“If students are taught IMCI in a
particular way within an academic þ Evaluate the process and outcomes
programme, can they do IMCI at the of IMCI teaching
end of the programme?” Process o Use the results of evaluations to
refers to the changes made in the way strengthen teaching
an academic programme is taught, the
methods and materials used, and how
teachers and students respond to those methods and materials. Outcomes are the
results of teaching, particularly in terms of student knowledge, attitudes and skills
(i.e. competence).

In Phase Two and Three of this guide teaching institutions are advised to monitor the
process and intermediate outcomes of new teaching. The task called Conduct and
Monitor Teaching in Phase Two explains how to collect and use information about
the content, context, process and immediate outcomes of new teaching. Phase Three
presents detailed information about how to Assess the Methods and Materials Used
for teaching, learning and student assessment and how to Measure the Outcome of
Teaching.

If staff members at a teaching institution feel that monitoring activities did not collect
enough information about the expected changes in an academic programme, then they
might consider evaluating the process and outcomes of new teaching. In addition, if a
state or national coordinating group plans to evaluate the effectiveness of IMCI
teaching, then teaching institutions should conduct a process and outcome evaluation
in order to confirm that the graduates actually possess the expected knowledge,
attitudes and skills at the end of the academic programme. Outcomes can be evaluated

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 Phase Four – Evaluate IMCI Teaching: Tasks at the Teaching Institution

by testing a group of students who have completed a revised academic programme.

The examination must be based on the revised learning objectives, which in turn
should be based on the job that the students are being prepared to do.

Objectives

The objectives of evaluating the process and outcomes of IMCI teaching are to:

· Describe the changes made to the academic programme;

· Determine if the changes implemented produced the expected results in terms of

student knowledge, attitudes and skills at the end of an academic programme;

· Identify gaps between what was expected and what was achieved; and

· Decide if an evaluation of the effectiveness of teaching would be appropriate.

Timing

Teaching institutions should start to monitor the process and intermediate outcomes
of new teaching as soon as revised learning objectives, methods and materials are
introduced (see Phase Two and Three of this guide).

If staff members at a teaching institution feel that monitoring activities did not collect
enough information about the expected changes in an academic programme, then they
might consider evaluating the process and outcomes of new teaching. In addition, if a
state or national coordinating group plans to evaluate the effectiveness of IMCI
teaching, then teaching institutions should first conduct a process and outcome
evaluation. This evaluation would confirm if graduates actually possessed the
expected knowledge, attitudes and skills needed at the end of the academic
programme.

Who Could Evaluate the Process and Outcomes of IMCI Teaching?

Teachers, with assistance from the institution’s IMCI focal person or working group,
could evaluate the process and outcomes of IMCI teaching. They also may request
assistance from the teaching department within their institution, the Ministry of
Health, Ministry of Education or other organization with experience in evaluation.
The involvement of internal audit committees or external evaluators can add strength
to the evaluation results.

Description

An evaluation of the process and outcomes of new teaching should focus on:

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· The changes made to the academic programme and to the methods and materials
used for teaching, learning and student assessment; and

· The key knowledge, attitudes and skills that students gain from the revised
programme, methods and materials.

An evaluation of process asks the question, “Is teaching being implemented in the
most effective way?” Process evaluation is not concerned with precise measurements
of success or failure. It is concerned with describing the changes made to the teaching
and learning process in order to identify ways to improve the knowledge, attitudes
and skills achieved at the end of an academic programme. If new teaching is
continuously monitored, reviewed and replanned, process problems should be caught
along the way.

An evaluation of outcomes looks at the ability of students to apply knowledge,

attitudes and skills in an ideal setting when tested (i.e. competence). Outcomes are the
direct result of changes in teaching. If students are competent at the end of an
academic programme, it is assumed that this will lead to changes in behaviour in
practice (i.e. performance). An evaluation of students at the end of an academic
programme should measure how much students have learned and to what extent they
have achieved the revised learning objectives (i.e. key performance indicators).

Suggested Activities and Materials

The following activities are needed in order to evaluate the process and outcomes of
new teaching:

· Describe the changes made to the academic programme and assess how teachers
and students reacted to those changes (i.e. process); and

· Assess the ability of students to apply key knowledge, attitudes and skills in an
ideal setting at the end of the academic programme (i.e. outcomes).

In addition to determining if the expected outcomes were achieved, the results of the
above activities are critical for deciding if a larger evaluation of the effectiveness of
new teaching is needed and appropriate (see the task described later in this phase
called Evaluate the effectiveness of IMCI teaching).

Process: Describe and assess the changes made: This activity focuses on describing
the actual changes made to teaching, learning and student assessment. It also assesses
how students and teachers react to those changes. As described in the Phase Two task
called Conduct and Monitor Teaching, process information is best collected through
ongoing monitoring of teaching activities.

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An evaluation of process should answer the following questions (see Phase Two and
Three for suggestions about how to collect this information):

a) In order to achieve the revised learning objectives, what changes were

made in the way the academic programme is taught? The answers should
provide a brief description of the changes made to the content, context and
process of teaching. This includes the organization, flow and relationship
of different courses within the academic programme; the entering abilities
of students; the settings where teaching is conducted; and the resources
and equipment available for teaching. In addition, this activity should try
to determine if teachers and students were informed about and understood:
(a) the aims and objectives of the teaching; (b) the approaches and
procedures used for teaching, learning and student assessment; (c) the
roles and responsibilities of administrators, teachers and students; (d) the
organization of activities and timetable; (e) on-going developments and
changes. Sources of information are: Teachers, administrators, students,
course documents and student records.

b) In order to achieve the revised learning objectives, what changes were

made to the methods and materials used for teaching, learning and student
assessment? The responses should describe the changes made in the way
teaching, learning, and student assessment are implemented, and the
changes made in support materials (e.g. textbooks, handouts, visual aids,
observation checklists, etc.) for both teachers and students. Sources of
information are: Teachers, administrators, students, course documents and
student records.

c) How did teachers and students react to the revised programme, methods
and materials? Feedback should be collected from teachers and students
to identify their reaction to the changes made in the programme, methods
and materials used for teaching, learning and student assessment.
Feedback must be collected in a way that is likely to lead to valid
judgements, rather than basing judgements on what one student says or on
rumour or intuition. Methods for collecting feedback should include more
than handing out a student questionnaire at the end of a session or course.
For suggestions about what types of feedback to collect and how to collect
it, see the task called the task called Conduct and Monitor Teaching in
Phase Two of this guide and the task called Assess the Methods and
Materials Used in Phase Three of this guide.

Outcomes: Assess student competence at the end of the academic programme: This
activity assesses student competence at the end of the academic programme. The
same methods and tools can be used as those described in the task called Measure the
Outcome of Teaching in Phase Three of this guide. It is important to note, however,
that Phase Three focused on monitoring intermediate outcomes of teaching in order to

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guide the review and replanning process. An evaluation of final outcomes should
concentrate on assessing a group of students in a key set of skills at the end of an
academic programme.

In order to evaluate final outcomes, it is important to:

· Assess a group of students who have completed the full academic programme
with the planned changes incorporated into the teaching.

· Conduct a special assessment of this group of students to measure the key

performance indicators (i.e. key knowledge, attitudes and skills). Do not rely on
the results of assessments that were conducted earlier in the course of study.

· Measure key performance indicators that are carefully selected based on the
revised learning objectives of the academic programme. If an evaluation of the
effectiveness of new teaching will be conducted, the same key indicators should
be used.

· Conduct the assessment in an ideal environment with no constraints in equipment,

supplies and other support

Share the Results: Teaching institutions should share the results of process and
outcome evaluations with external groups. These groups can circulate the information
to other teaching institutions, use it to justify the use of resources, or use it to decide
whether or not it would be appropriate to evaluate the effectiveness of new teaching.

WHO CAH is working to develop the following materials to assist teaching

institutions to evaluate the process and outcomes of IMCI teaching:

· Basic process indicators (e.g. indicators of time, place, learning methods, learning
resources, personnel, etc.)

· Guidelines and tools for assessing student skills in IMCI at the end of an
academic programme.

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Use the Results of Evaluations to Strengthen Teaching

Phase Three of this guide suggests

reviewing information collected during 4.1 AT THE TEACHING INSTITUTION
ongoing monitoring activities, as well
as gathering additional information, in þ Evaluate the process and outcomes
order to identify achievements and of IMCI teaching
difficulties with the implementation of þ Use the results of evaluations to
a plan of action. The information strengthen teaching*
collected during the review and
replanning phase, including the results
of any evaluations, should be used to identify activities and resources needed to
sustain or strengthen IMCI teaching, and to revise the plan of action. In addition, the
results of any evaluation should be used to justify resources spent, advocate for
continued or additional resources, and assist with state or national planning for pre-
service training.

Objectives

The objectives of using the results of evaluations are to:

· Identify achievements and difficulties with new teaching;

· Define feasible and affordable actions to overcome difficulties;

· Decide if additional evaluations are needed or appropriate;

· Provide evidence that previous investments produced expected results; and

· Demonstrate a need for additional assistance and resources.

Timing

Whenever results from an evaluation are produced or received by a teaching

institution, staff members should immediately review them to identify strengths and
weaknesses in new teaching. If a teaching institution is in the review and replanning
phase (Phase Three), staff members should actively seek out evaluation results in
order to identify issues that should be addressed in a revised plan of action for
strengthening teaching.

Who Should Use the Results of Evaluations?

The IMCI Working Group within a teaching institution should work together with
representatives of relevant academic units and clinical practice sites to use the results
of evaluations to strengthen teaching. They may request assistance from the National

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IMCI Focal Person, state or national Coordinating Group for IMCI Pre-Service
Training, WHO staff members or consultants, and other persons or organizations with
good knowledge of how to translate the results of evaluations into action at national,
state and teaching institution levels.

Description

Teaching institutions should view evaluation as a learning process – that is as a means

for reflecting and demonstrating a commitment to achieving specific results. The aim
of evaluation is not to produce a report, but to use the findings to identify strengths
and weaknesses in a teaching programme and plan for future action. An evaluation
should show to what extent expected results were achieved and give clear indications
about the elements of an intervention that need to be strengthened or changed in order
to better achieve the expected results. In addition to direct application to planning for
future teaching, evaluation results can also help justify the use of resources and
technical support, and demonstrate a need for additional resources and support.

Suggested Activities and Materials

The following activities are suggested for using the results of evaluations:

· Interpret the results of evaluations. Persons who review the results of evaluations
should compare the expected results of new teaching with the actual results
described in an evaluation report. They should then identify the gaps between
what was expected and what was actually achieved, and try to determine the
causes of those gaps. Finally, they should decide what actions might be needed in
order to reduce those gaps. When identifying what actions are needed, answer the
following questions: What were the successes or strengths? How could they be
extended? What were the problems or limitations? How could they be addressed?

· Plan for future changes in teaching. The actions identified to reduce gaps should
be incorporated into a plan of action for strengthening teaching. This could
happen during the review and replanning phase when a teaching institution
revises their plan of action, or it could happen in phase two as part of the process
of monitoring and refining activities. It is important to recognize that action needs
to be taken and to formalize that action as an addition to or revision of a plan of
action. When planning for future changes, answer the following questions: What
action should be taken? What changes should be implemented? When? By
whom? What is needed (resources, further learning or development, additional
information) to help effect these changes?

· Use results for evidence and advocacy. Share the results of evaluations with
partners, funding organizations and technical agencies to demonstrate what was
achieved and what is still needed.

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4.2 Evaluate IMCI Teaching: Tasks at National Level

The national or state Coordinating

Group for IMCI Pre-Service Training
should decide if an evaluation of the 4.2 TASKS AT NATIONAL LEVEL
effectiveness of IMCI teaching is
needed and feasible in their country. If o Evaluate the effectiveness and
costs of IMCI teaching
opinion leaders and decision-makers o Share the results of evaluations*
have requested evidence that IMCI
teaching is effective, and if appropriate
personnel and resources are available
to conduct an accurate evaluation, the
coordinating group might consider organizing an evaluation. In addition, the coordinating
group should share the results of relevant evaluations conducted both within and outside
the country.

Evaluate the Effectiveness and Costs of IMCI Teaching

An evaluation of the effectiveness of

IMCI teaching is considered an 4.2 AT NATIONAL LEVEL
important but optional task. If
stakeholders have requested evidence þ Evaluate the effectiveness
and costs of IMCI teaching
that the resources invested have o Share the results of
produced the expected results, and if evaluations*
they are not satisfied with the
information collected through
monitoring or through evaluations of the process and outcomes of new teaching,
then an evaluation of the effectiveness of new teaching may be needed. Not all
countries, however, have the capacity and resources to conduct this type of
evaluation. Still an estimate of the costs of new teaching is useful regardless of
whether or not a country conducts an effectiveness evaluation.

Teaching is effective if students are able to apply the knowledge, attitudes and
skills gained during their education to their real work environment after
graduation. It is important to remember that performance in the real work
environment considers the skills of graduates within a service setting, which may
facilitate or hinder their application. In addition, before conducting a complicated
and costly effectiveness evaluation, the outcomes of new teaching must be
assessed in order to verify that students actually gained the expected knowledge,
attitudes and skills before graduation (see figure 4).

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Figure 4
RELATIONSHIP OF OUTCOME TO EFFECTIVENESS AND IMPACT

Teaching

Knowledge Skills Attitudes

Audience:
Implementers

OUTCOME Cost:
Competence When Tested Less difficult
and costly to
Motivation Setting Supplies Other measure

EFFECTIVENESS
Performance in Facilities
Audience:
Implementers
and
Many Other Client Satisfaction, Many Other stakeholders
Factors Service Utilization Factors
Cost:
More difficult
and costly to
IMPACT measure
Quality of Care, Child Morbidity, Mortality

Objectives

The objectives of evaluating the effectiveness and costs of IMCI teaching are to:

· Assess if students are able to do IMCI at their work after graduation.

· Gather evidence for decision-makers, national authorities, funding

organizations, partners and other supporting agencies that the resources
invested produced the expected results in terms of the performance of student
after graduation; and

· Detect strengths and weaknesses in performance in order to identify areas

where further changes to teaching may be needed.

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Timing

Before an evaluation of the effectiveness of IMCI teaching can be conducted:

· Key changes must be made to the academic programme that would lead to
changes in the outcomes; and

· Outcomes must be measured to demonstrate that students actually achieved

expected knowledge, attitudes and skills before graduation.

If IMCI is gradually integrated into different academic years and subjects, it could
take a several years and several revisions of a plan of action before enough
changes are made to an academic programme to produce measurable changes in
the performance of graduates. Until then, it is highly recommended to focus on
monitoring the process and outcomes of new teaching. Once the major elements
of IMCI teaching are in place, and a group of students has achieved the expected
outcomes, then the effectiveness of teaching can be evaluated.

Who Could Evaluate the Effectiveness and Costs of IMCI Teaching?

Any state, national or international group that has interest and capacity in
evaluation could lead an evaluation of the effectiveness of IMCI teaching.
Possible groups are the national or state Coordinating Group for IMCI Pre-
Service Training, licensing authorities, academic associations, professional
associations, non-governmental organizations, technical agencies, international
organizations, funding organizations, other teaching institutions or WHO.

In addition, teaching institutions - particularly the IMCI working group within a

teaching institution - should cooperate with and assist the evaluation group. They
should share process information such as the learning objectives, what teaching
methods and materials were used and how students responded to those methods
and materials. And they should report the outcome of teaching in terms of student
competency at the end of the academic programme.

Description

An evaluation of the effectiveness and cost of new teaching should answer the
questions:

· Are students able to apply their IMCI knowledge and skills to their work after
graduation?

· How much did it cost to introduce new teaching?

· How much will it cost to sustain new teaching?

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The purpose of this task is to determine if students are able to apply what they
have learned to their work after graduation. As shown in figure 4, evaluation can
assess a continuum of results ranging from outcome to effectiveness to impact.
The farther down the list, the more valid the evaluation. Outcome or learning is
easiest and least costly to evaluate. However, the results may not be robust
enough to convince stakeholders that a change actually occurred in the practices
of healthcare providers. Impact or results is complicated, expensive and can only
suggest a probability that new teaching led to changes in the quality of care. An
evaluation of effectiveness - or graduate performance - is one of the most valid,
reliable and feasible ways to identify strengths and weakness in a teaching
programme, and to justify or advocate for the use of resources for strengthening
teaching.

Still it is difficult to achieve a rigorous evaluation of effectiveness. A robust

evaluation requires the definition and use of key performance indicators –
measures you can see. In addition, it must show change in comparison to
something – usually to another group of students who did not receive the
intervention. The comparison group could be one that completed the academic
programme at the same teaching institution before IMCI teaching was introduced,
or a group that completed a similar academic programme at a different teaching
institution without IMCI.

Suggested Activities and Materials

The following questions must be answered when evaluating the effectiveness and
costs of teaching:

· Who will conduct the evaluation? Do they have the necessary capacity and
experience in evaluation?
· What is the purpose of the evaluation? Who is the evaluation for?
· What is expected to change? What are the key performance indicators?
· How will the change be measured? How will we know that it changed because
of IMCI teaching?
· How will relevant information be collected and analysed (by whom, when and
where, using what methods)?
· How much did it cost?
· How will the results be used?

Who will evaluate? As previously explained, any state, national or international

group that has interest and capacity in evaluation could take the lead in evaluating
the effectiveness of IMCI teaching. If a group is interested, but does not have
evaluation capacity, they may request an NGO or international organization to
assist them to strengthen their evaluation capacity.

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What is the purpose? The primary purpose of the evaluation should be to

establish whether the changes made in teaching produced the expected results,
and to help teaching institutions alter what they are doing if certain results were
not achieved. It should help teaching institutions as well as their partners and
funding agencies decide whether to carry on with a particular intervention, modify
it, or test an alternative strategy. An evaluation could also help to clarify what the
problem really is.

What should change? It is critical to carefully define key performance indicators

to measure during the evaluation. An indicator is a marker that shows whether or
not you are making progress. It identifies what you expect to change either in
quality or quantity. For example, expected changes after IMCI is incorporated
into an academic programme might include: graduates check all sick children who
come to an outpatient clinic for common serious childhood illnesses, regardless of
the presenting complaint; or graduates assess the feeding of all sick children under
two years of age who do not need urgent referral. The indicators used for the
evaluation must be based on the defined learning objectives, and they should be
confirmed as key knowledge, attitudes and skills (i.e. outcomes) at the end of the
course or academic programme.

How will change be measured? Strong evaluation designs (i.e. valid, accurate
and reliable) with clear results, which include an assessment of costs, are essential
in order to satisfy the needs of decision-makers, partners and funding
organizations. However, the evaluation approach also should be feasible, practical
and relevant, using simple, key performance indicators to show that the behaviour
of graduates has changed.

Any evaluation of effectiveness must address the question, “performance

compared to what?” Some possibilities for the evaluation of teaching are:

· Comparing graduates who have completed an academic programme where

IMCI was incorporated versus graduates who have not (i.e. case-control
design);

· Conducting a baseline of graduate performance before the intervention and

comparing the performance of graduates after the introduction of IMCI
teaching (i.e. longitudinal design); and

· Comparing the performance of graduates against a standard.

These possible evaluation designs are described in more detail below:

Case intervention and control: This design should satisfy both

implementers and donors. It compares the outcome of two different groups
of graduates. One that received revised teaching and one that did not. The

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control group must be very carefully selected to ensure that all aspects of
the group’s experience (e.g. type and length of academic programme, time
of graduation, learning environment, etc.) were similar in every way
except for the absence of IMCI teaching. The null hypothesis is that
performance is the same between the two different groups. However, the
evaluation is expected show a difference in the performance of graduates
with and without IMCI teaching. This design is useful for advocacy, but is
difficult and expensive to carry out. The advantage: no baseline is needed.
The difficulty: identifying an appropriate control group.

Longitudinal (i.e. before and after): This design also should satisfy both
implementers and donors. It compares the performance of a group of
graduates before IMCI is incorporated into a teaching programme versus
the performance of a group of graduates after IMCI is incorporated. In
order to document change in performance, comparable information should
be collected as a baseline before a teaching institution begins to revise its
teaching. Phase One of this guide encourages the national coordinating
group to analyse the situation. If possible, a baseline assessment may be
included as part of the situation analysis. The advantage: no need to
identify a control group. The challenge: must have comparable baseline
information.

Against a standard: This design is more useful for implementers than for
funding organizations. It can be used to make a plausible argument that
the skills measured against the standard are due to the change in the
academic programme. In the case of IMCI, graduate performance would
be measured against the standard of the IMCI clinical guidelines.
Normally, this is sufficient for self-evaluation in order to check if teaching
is achieving its expected results. However, it may not be sufficient to
convince national officials, partners and donors to keep investing in the
process.

How will information be collected and analysed? Performance can be measured

by observing graduates on the job, by interviewing them, by interviewing their
managers or supervisors and - in certain situations - by analysing health statistics.
Performance evaluations should occur after graduates have had sufficient
opportunity to apply their knowledge, attitudes and skills on the job (e.g., 2 to 12
months after graduation).

Regardless of how information is collected, the evaluation should always

determine if a graduate has had the opportunity to practice new skills. Has the
graduate been working in a position that allows him or her to use the skills? For
how long? The key factor of practice can greatly enhance performance if it is
present, and can significantly hinder performance if it is not.

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The following are possible methods for collecting information about performance:

Observation of performance on the job – Direct observation is the most valid

method for measuring performance. However, it is also the most time
consuming and costly. It answers the question, “are graduates able to perform
the skills they developed during the academic programme?” Both graduates
and supervisors should be notified in advance of an observation. During the
observation, evaluators should watch graduates as they perform specific tasks,
and record their observations using a tool that collects targeted information on
key skills (i.e. key performance indicators). The data collected should indicate
areas where the course or academic programme should be modified. When
compared with the observations of a baseline or control group, the data should
demonstrate differences or changes in the performance of the two groups.

Graduate self-reports or interviews – New graduates can provide information

on the usefulness of the course to their current job functions as well as their
ability to apply specific knowledge, attitudes and skills in the workplace.
Questions should focus on the key skills (i.e. key performance indicators) that
were incorporated into the academic programme as well as any constraints
that graduates face in applying those skills. Evaluators should ask graduates
how confident and capable they feel to perform key behaviours/skills. When
asking these questions, it is best to use a Likert rating scale that provides a 5-
point range such as from very confident to very unconfident or from very
capable to very incapable. It is also useful to collect some limited information
about the activities conducted in the facility where the graduate works, in
order to provide a context in which to assess the graduate’s performance. In
addition, critical incident studies or interviews can ask recent graduates to
describe five or six recent events related to specific behaviours/skills that they
felt unable to handle (i.e. critical incidents). Some of the critical incidents may
be very unusual or rare. However, if several graduates report difficulty with
similar situations, then clearly the objectives, methods and materials used for
teaching the subject should be reviewed.

Supervisor reports or interviews – The aim of questioning mangers or

supervisors is to determine if they observed a change in the performance of
new graduates with regard to key behaviours/skills. If they did perceive a
change, further questions should be asked to find out if the change solved any
problems or filled previously unmet needs for service provision. In some areas
supervision is carried out almost continuously. In other areas supervision is
very restricted – for example when healthcare professionals work alone in
remote villages. Therefore, the value of supervisors’ reports or interviews will
vary from one situation to another. However, any report can be made more
useful if supervisors are asked to comment on specific points. Supervisors can
look for changes in the way healthcare professionals do a particular job, and
they can identify tasks that new graduates do well or badly.

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Analysis of health statistics – Health statistics are usually available for details
such as the number of children immunized, number of live births, number of
infant deaths, and number of cases of disease. If statistics are available, they
can help to identify problems and possible areas where academic programmes
could be strengthened.

How much did it cost? Regardless of whether or not effectiveness is assessed, it

is always helpful to estimate the cost of introducing and sustaining new teaching.
The resources used should be estimated for all tasks that were carried out to
introduce and sustain new teaching. It is difficult to estimate a cost per graduate,
because many of the costs incurred should produce results for many cycles of
teaching to come. For this reason, it is useful to estimate the one time
“introduction costs” and the “recurrent costs” that will continue in order to sustain
new teaching. Costs can be estimated for activities at national or state level, and
activities at the level of individual teaching institutions. In addition to monetary or
financial resources, costs may also include other resources such as materials,
facilities, supplies and staff time.

Introduction costs at the level of the teaching institution might include

estimates for:
· Conducting a situation analysis
· Orientation meetings with decision makers
· Training of planners, teachers, clinical instructors and relevant staff at
clinical practice sites
· Planning meetings (where learning objectives are defined and a plan of
action is developed)
· Preparing clinical practice sites
· Developing or revising materials for teaching, learning and student
assessment
· Coordination meetings with relevant departments
· Monitoring and review of teaching methods and materials
· Evaluation of the process and outcome of new teaching

Recurrent costs at the level of the teaching institution might include estimates
for:
· Training of teachers, clinical instructors and relevant staff at clinical
practice sites
· Review and replanning meetings (where implementation of a plan is
reviewed, learning objectives are refined and the plan of action is revised)
· Procuring supplies and equipment needed for teaching
· Procuring of supplies and equipment needed for clinical practice
· Periodic updating or revision of materials for teaching, learning and
student assessment
· Coordination meetings with relevant departments

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· Monitoring and review of teaching

How will the results be used? Typically the results should be used to determine to
what extent the desired effect has been achieved, identify discrepancies that still
exist in job performance, and – if needed - plan for additional revision of
teaching.

Materials that can be adapted for use in evaluating the effectiveness of IMCI
teaching include:

· WHO CAH Guidelines and tools for evaluating IMCI in-service training
(currently under development), and guidelines and tools for follow-up after
IMCI training. Although these tools must be adapted to the context of pre-
service training, they can help countries define key performance indicators
and appropriate methods for collecting and analysing information about
performance.

· IMCI health facility survey tool. The tool and methods must be adapted to the
context of pre-service training.

· Tool for estimating the costs related to introducing and sustaining IMCI
teaching

Share the Results of Evaluations

The national or state Coordinating

4.2 AT NATIONAL LEVEL
Group for IMCI Pre-Service Training
should share the results of relevant
þ Evaluate the effectiveness
evaluations with all teaching and costs of IMCI teaching
institutions. Evaluations or reviews that þ Share the results of
measure healthcare provider skills or evaluations*
performance after IMCI training either
within the country, or in a similar
country, are particularly relevant. This includes results from follow-up after IMCI
training visits, results from IMCI health facility surveys, and results from the
evaluation of the outcomes and effectiveness of IMCI pre-service training.

Objectives

The objectives of sharing the results of evaluations are to:

· Inform teaching institutions of different approaches that can be taken to

strengthen the teaching of child health;

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· Identify gaps – if any - between what was expected from changes in teaching
and the actual results;

· Provide evidence to partners and funding agencies that previous investments

produced the expected results; and

· Demonstrate the need for additional activities and resources.

Timing

When the results of evaluations are produced or received, they should be shared
as quickly and as widely as possible.

Who Could Share the Results of Evaluations?

Any state, national or international group that has interest and capacity in
evaluation could collect and share the results of relevant evaluations. These
groups may include the national or state Coordinating Group for IMCI Pre-
Service Training, licensing authorities, academic associations, professional
associations, non-governmental organizations, technical agencies, international
organizations, funding organizations, other teaching institutions or WHO.

Description

The results of evaluations should be shared as widely as possible to teaching

institutions as well as to partners and funding agencies. Whenever possible,
assistance should be given to help others interpret the results of an evaluation.
This might involve activities such as writing a detailed description of the
intervention and a summary of the findings.

Suggested Activities and Materials

There are two main ways that the results of evaluations can be shared:

· Written. The results of an evaluation accompanied by a description of the

intervention can be distributed to teaching institutions, partners and funding
agencies in written format such as letters, reports, journal articles and web
pages.

· Verbal Presentations. The results of evaluations can be presented at meetings

or conferences both within and outside teaching institutions, such as at
paediatric conferences, meetings of academic associations, etc. These
presentations should include an opportunity for discussion of the results and
the actions that have been, or should be, taken as a consequence of the
evaluation.

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 Annex 1
PHASE ONE - ORIENT AND PLAN

Tools and Materials in this Annex:

PRE-SERVICE MATERIALS:

List of Possible Materials for IMCI Teaching, Learning and

Student Assessment .....................................................................................................1-4

ANALYZE THE SITUATION:

Questions to Consider at National Level to Plan for the Introduction

of IMCI Pre-Service Training .......................................................................................1-6

ORIENT OPINION LEADERS AND DECISION MAKERS:

Suggested People and Materials for:

Disseminating Information About IMCI ......................................................................1-9
Leading Presentations or Discussions at Meetings or Congresses .............................1-10
Conducting an Orientation Workshop ........................................................................1-11

SAMPLE AGENDA: National Orientation Workshop for IMCI

Pre-Service Training ...................................................................................................1-12

SAMPLE AGENDA: Expanded Orientation on IMCI............................................. 1-13*

TRAIN PLANNERS AND TEACHERS:

SAMPLE AGENDA: Five-Day IMCI Training Course for University

Staff ...........................................................................................................................1-16*

PLAN FOR THE INTRODUCTION OF NEW TEACHING:

SAMPLE AGENDA: Planning Workshop for IMCI Pre-Service Training ...............1-17

List of Possible Learning Objectives for IMCI...........................................................1-19

OUTLINE: Plan of Action for Introducing IMCI into an Academic Programme ......1-23

TIMELINE: Steps Needed to Implement the Plan of Action for Introducing

IMCI into an Academic Programme ...........................................................................1-25

*
Other agendas for orientation (i.e. 2-day orientation seminars for decision-makers at
teaching institutions - Egypt) and training are available on request from WHO CAH.
Phase One - Orient and Plan Annex 1

PRESENTATIONS: .........................................................................................................1-28

Overview of the IMCI Strategy

Introduction to the IMCI Clinical Guidelines
Academic Rationale for IMCI
Summary of Experience Related to IMCI Pre-Service Training
IMCI Training Methods and Materials
IMCI Learning Objectives

Other Useful Tools and Materials

IMCI Information (unpublished document WHO/CHS/CAH/98.1A-M; available on request

from the Department of Child and Adolescent Health and Development, World Health
Organization, 1211 Geneva 27, Switzerland (Fax: +41 22 791 4853, email: [email protected])

IMCI Model Chapter for Textbooks (unpublished document WHO/FCH/CAH/01.01;

available on request from the Department of Child and Adolescent Health and Development,
World Health Organization, 1211 Geneva 27, Switzerland (Fax: +41 22 791 4853, email:
[email protected])

IMCI Model Handbook (unpublished document WHO/FCH/CAH/00.12; available on request

from the Department of Child and Adolescent Health and Development, World Health
Organization, 1211 Geneva 27, Switzerland (Fax: +41 22 791 4853, email: [email protected])

Improving Child Health: IMCI the Integrated Approach (unpublished document

WHO/CHD/97.12 Rev.1; available on request from the Department of Child and Adolescent
Health and Development, World Health Organization, 1211 Geneva 27, Switzerland (Fax:
+41 22 791 4853, email: [email protected])

Improving Family and Community Practices: A Component of the IMCI Strategy

(unpublished document WHO/CAH/98.2; available on request from the Department of Child
and Adolescent Health and Development, World Health Organization, 1211 Geneva 27,
Switzerland (Fax: +41 22 791 4853, email: [email protected])

“Integrated Approach to Child Health in Developing Countries.” Tulloch J., The Lancet,
1999, 354 (supplement II): 16-20.

“Integrated Management of Childhood Illness (IMCI): A Challenge for Both Health

Professionals and Teaching Institutions.” Lejnev I. and Bailey R., Towards Unity for Health,
2000, 1:18-19.

Management of the Child with a Serious Infection or Severe Malnutrition: Guidelines for
Care at the First-referral Level in Developing Countries (unpublished document
WHO/FCH/CAH/00.1; available on request from the Department of Child and Adolescent
Health and Development, World Health Organization, 1211 Geneva 27, Switzerland (Fax:
+41 22 791 4853, email: [email protected])

1-2 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

“Rationale for Introducing IMCI into Medical and Paramedical Education,” IMCI:
Guidelines for Planning, Implementing and Evaluating Pre-Service Training, Part A.
(unpublished document WHO/FCH/CAH01.09; available on request from the Department of
Child and Adolescent Health and Development, World Health Organization, 1211 Geneva
27, Switzerland (Fax: +41 22 791 4853, email: [email protected])

Report of an Iintercountry Workshop on IMCI Pre-service Training: Geneva, 2-5 November

1999 (unpublished document WHO/FCH/CAH/00.11; available on request from the
Department of Child and Adolescent Health and Development, World Health Organization,
1211 Geneva 27, Switzerland (Fax: +41 22 791 4853, email: [email protected])

“Selected Exercises from the IMCI Training Course for First-Level Health Workers,” IMCI
Planning Guide: Gaining Experience with the IMCI Strategy in a Country, Annex J, pp. 211-
267 (unpublished document WHO/CHS/CAH/99.1; available on request from the
Department of Child and Adolescent Health and Development, World Health Organization,
1211 Geneva 27, Switzerland (Fax: +41 22 791 4853, email: [email protected])

1-3 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

PRE-SERVICE MATERIALS:

List of Possible Materials for IMCI Teaching, Learning and

Student Assessment

IMCI Materials for Teachers

IMCI Model Chapter for Textbooks (WHO/FCH/CAH/01.01)

IMCI Handbook (WHO/FCH/CAH/00.12)
Photograph Booklet
Wall Charts (adapted version)
Videotapes
Checklist of Clinical Signs Observed
IMCI Reference Library of Selected Materials
IMCI Technical Seminars
Improving Family and Community Practices: A Component of the IMCI Strategy
(WHO/CAH/98.2)
Management of the Child with a Serious Infection or Severe Malnutrition: Guidelines for
Care at the First-Referral Level in Developing Countries (WHO/FCH/CAH/00.1)
Breastfeeding Counselling: A Training Course (WHO/CDR/93.4)

Materials from the IMCI in-service course that could be adapted or used as references:
Facilitator Guide for Modules
Facilitator Guide for Outpatient Clinical Practice
Guide for Clinical Practice in the Inpatient Ward
Course Director's Guide

IMCI Materials for Students

IMCI Chapter for Textbooks ((WHO/FCH/CAH/01.01 adapted and incorporated into a

local textbook)
IMCI Handbook (WHO/FCH/CAH/00.12 adapted version of the IMCI Model Handbook)
IMCI Chart Booklet (adapted version)
Mother's Card (adapted version)
Case Recording Forms
Photograph Booklet
Management of the Child with a Serious Infection or Severe Malnutrition: Guidelines for
Care at the First-Referral Level in Developing Countries (WHO/FCH/CAH/00.1)

Materials for Student Assessment

Sample Written Test

Sample Clinical Skills Observation Checklist
Guide for IMCI Assessment In Pre-Service Training Institutions
(WHO/FCH/CAH/DRAFT MARCH 2001)

1-4 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

Other Useful IMCI Materials

Report of an Intercountry Workshop on IMCI Pre-Service Training: Geneva, 2-5

November 1999 (WHO/FCH/CAH/00.11)
OUTLINE: Plan of Action for Introducing Integrated Management of Childhood Illness
(IMCI) into an Academic Programme
List of Possible Learning Objectives for Integrated Management of Childhood Illness
(IMCI)
IMCI Pre-Service Training: Progress Report Questionnaire

1-5 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

ANALYZE THE SITUATION:

Questions to Consider at the National Level to Plan for the

Introduction of IMCI Pre-Service Training

A. Has IMCI been introduced in the country?

1. Have the IMCI clinical guidelines been adapted to the local circumstances?

2. Has the ministry of health endorsed IMCI?

3. Have some persons in the country been trained as IMCI course facilitators?

4. Is there a national policy on IMCI?

B. Who provides care to sick children at first-level health facilities?

1. What types/categories of health care professionals manage sick children at first-level

health facilities?

2. Do the job descriptions of those health care professionals include the clinical
management of sick children?

3. What type of formal training does each type/category of health care professional
receive?

4. Do first-level health care providers attend refresher training or continuing education

courses?

C. Where do first-level health care providers, in both the public and private sectors,
receive their basic training?

1. Which teaching institutions, both public and private, are responsible for training
first-level health care providers?

2. What programmes of study at these institutions do first-level health care providers

attend?

3. Do the programmes attended by future first-level health professionals include

teaching about paediatrics and/or child health?

4. Do the programmes attended by future first-level health professionals include

clinical practice with sick children in outpatient clinics? If yes, where (i.e. health
centres, outpatient wards of teaching hospitals, etc.)?

1-6 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

5. For each teaching programme, what level of education is needed to enter the
programme? How many years are required to complete the programme? And how
many students graduate each year from the programme?

6. Have any staff at these teaching institutions attended an IMCI in-service training
course?

7. Approximately how many staff from teaching institutions and clinics used for
outpatient clinical practice need training in IMCI?

8. How often is the formal written curriculum revised at these teaching institutions?

9. If first-level health workers attend refresher training or continuing education courses,

are pre-service teaching institutions responsible for conducting these courses?

D. Who influences what is taught to first-level health care professionals during their
basic education?

1. Which government bodies have an interest in and influence on the education of health
care professionals?

2. Which professional societies and associations influence the education of health care
professionals, particularly in child health?

3. Which academic associations influence the education of health care professionals,

particularly in child health?

4. What is the relationship between teaching institutions and national authorities,

professional associations and academic associations?

5. Who reviews and approves academic programmes and written curricula for teaching
institutions attended by first-level health care professionals?

6. Who is the licensing authority for each type of first-level health care professional?

7. Who is responsible for preparing and conducting certification examinations?

8. Is there a continuing education system in the country? If yes, who is responsible for
organizing and conducting continuing education courses?

E. How are curricula set and revised in the country?

1. Where is the curriculum prepared for each type of teaching institution (i.e. by a
national curriculum body or by individual teaching institutions)?

2. How frequently are curricula normally revised?

3. What is the standard process for curriculum revision?

1-7 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

4. What groups are normally responsible for submitting and approving curriculum
revision?

F. Who can help plan and implement IMCI pre-service training?

1. Which professional and academic organizations can help?

2. Which non-governmental, donor or technical organizations can help?

G. How are human resources for health managed?

1. Who decides where health staff will be stationed or deployed?

1-8 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

ORIENT OPINION LEADERS AND DECISION MAKERS:

Orient National Authorities, the Academic Community and

Members of Professional Associations

Activity A: Suggested People and Materials

Activity A: Disseminate information about IMCI through channels such as local journals,
newsletters of professional societies and associations, brochures, leaflets, and displays at meetings
and conferences.

People Materials

Possible Implementers and/or Authors Existing Brochures and Leaflets

· Members of the national IMCI task force · IMCI brochure: Improving Child Health: IMCI
and/or staff of the Ministry of Health (MOH) the Integrated Approach (WHO/CHD/97.12
· Staff of universities and training institutions Rev.1)
who have been trained in IMCI · IMCI information package: IMCI Information
· Members of professional societies or (WHO/CHS/CAH/98.1A-M)
associations who have been trained in IMCI
· WHO staff or consultants

Target Audiences Background Materials for Authors

· National authorities that influence teaching · Rationale for Introducing IMCI into Medical and
curricula Paramedical Education, IMCI Pre-Service
· Representatives of the academic community Training: Guidelines for Planning,
· Members of professional societies or Implementing and Evaluating IMCI Teaching in
associations Medical, Nursing and Other Health Professional
Schools, Part A. (WHO/FCH/CAH…..)
· Report of an Intercountry Workshop on IMCI
Pre-Service Training: Geneva, 2-5 November
1999 (WHO/FCH/CAH/00.11)
· Article: “IMCI - A Challenge for Both Health
Professionals and Teaching Institutions,” by
Lejnev I. and Bailey R., Towards Unity for
Health, April 2000.
· Article: “Integrated Approach to Child Health in
Developing Countries,” by Tulloch J., Lancet,
Sept. 1999.
· The country's adapted IMCI chart booklet and
mother's card

1-9 Working Draft: April 2001

 Phase One - Orient and Plan Annex 1

Orient National Authorities, the Academic Community and

Members of Professional Associations

Activity B: Suggested People and Materials

Activity B: Lead presentations or discussions at meetings or congresses of academic associations,
professional societies or government authorities.

People Materials

Possible Presenters Materials for Presenters

· Members of the national IMCI task force · Presentations: Overview of the IMCI Strategy,
and/or staff of the Ministry of Health Introduction to the IMCI Clinical Guidelines, and
(MOH) Academic Rationale for IMCI
· Staff of universities and training · Country's adapted IMCI wall charts
institutions who have been trained in · Report of an Intercountry Workshop on IMCI Pre-Service
IMCI Training: Geneva, 2-5 November 1999
· Members of professional societies or (WHO/FCH/CAH/00.11)
associations who have been trained in · Article: “IMCI - A Challenge for Both Health
IMCI Professionals and Teaching Institutions,” by Lejnev I. and
· WHO staff or consultants Bailey R., Towards Unity for Health, April 2000.
· Article: “Integrated Approach to Child Health in
Developing Countries,” by Tulloch J., Lancet, Sept. 1999.

Possible Participants Materials for Participants

· National authorities that influence · IMCI brochure: Improving Child Health: IMCI the

teaching curricula Integrated Approach (WHO/CHD/97.12 Rev.1)

· Representatives of the academic · IMCI information package: IMCI Information

community (WHO/CHS/CAH/98.1A-M)
· Members of professional societies or · Model chapter for textbooks: Integrated Management of

associations Childhood Illness (WHO/FCH/CAH/01.01)

· The country's adapted IMCI chart booklet and mother's
card
· List of possible learning objectives for IMCI

Two copies of each of the following for display:

· Model IMCI Handbook (WHO/FCH/CAH/00.12)
· IMCI reference library
· IMCI technical seminars
· Guidelines for the Management of a Child with a Serious
Infection or Severe Malnutrition: Guidelines for Care at
the First-Referral Level
· Improving Family and Community Practices: A
Component of the IMCI Strategy (WHO/CAH/98.2)

One copy of each of the following for display:

· The country's adapted IMCI in-service training modules
and mother's card (one set)
· IMCI photograph booklet
· Director's guide for IMCI in-service training
· Facilitator's guides for IMCI in-service training modules
and clinical practice
· Technical basis section of the IMCI adaptation guide

1-10 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

Orient National Authorities, the Academic Community and

Members of Professional Associations

Activity C: Suggested People and Materials

Activity C: Conduct an orientation workshop with representatives from national authorities, the
academic community and members of professional associations.

People Materials

Possible Implementers Materials for Implementers

· Members of the national IMCI task force Same materials as those suggested for presenters of
and/or staff of the Ministry of Health IMCI at meetings or congresses (Activity B), plus:
(MOH) · Example agenda of a national orientation workshop
· Staff of universities and training for IMCI pre-service training
institutions who have been trained in IMCI · Presentation: Introduction to the IMCI clinical
· Members of professional societies or guidelines combined with one or two video
associations who have been trained in exercises from the IMCI training course for first-
IMCI level health workers (see IMCI Planning Guide:
· WHO staff or consultants Gaining Experience with the IMCI Strategy in a
Country, Annex J, pp. 211-267
(WHO/CHS/CAH/99.1))
· Presentation: Summary of WHO experience related
to IMCI pre-service training
· Presentation: Introduction to possible IMCI teaching
materials and methods

If appropriate and time permits:

· Selected exercises from the IMCI training course for
first-level health workers, IMCI Planning Guide:
Gaining Experience with the IMCI Strategy in a
Country, Annex J, pp. 211-267
(WHO/CHS/CAH/99.1)
· IMCI video
· IMCI photograph booklets
· Presentation: Possible learning objectives for IMCI

Possible Participants Materials for Participants

· National authorities that influence teaching Same materials as those suggested for participants of
curricula IMCI presentations at meetings or congresses, plus:
· Representatives of the academic · IMCI photograph booklet (one for each participant

community for selected exercises)

· Members of professional societies or · IMCI case recording forms

associations

1-11 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

SAMPLE AGENDA

National Orientation Workshop for IMCI Pre-Service Training

Day 1

Name of Session Suggested Session Leader

Welcome Remarks MOH Representative

Introduction of Participants
Review of Agenda and Administrative Issues MOH Representative

Overview of the IMCI Strategy MOH and/or WHO

Status of IMCI Implementation in the Country Representative

Lunch Break

Introduction to the IMCI Clinical Guidelines Experienced Facilitator for IMCI

and Selected Exercises In-Service Training

Day 2

Name of Session Suggested Session Leader

Introduction to the IMCI Clinical Guidelines Experienced Facilitator of IMCI

and Selected Exercises (continued) In-Service Training

Possible Learning Objectives for IMCI MOH and/or WHO

Representative

Summary of Experience with IMCI WHO Representative

Pre-Service Training

Lunch Break

Academic Rationale for IMCI and Discussion of MOH and/or WHO

Relevant Academic Programs for IMCI Teaching Representative

Introduction to Possible IMCI Teaching

Materials and Methods WHO Representative

Discussion of the Next Steps for IMCI MOH and/or Representative

Pre-Service Training of a Teaching Institution

Conclusions and Recommendations MOH Representative

1-12 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

SAMPLE AGENDA

Expanded Orientation on
Integrated Management of Childhood Illness (IMCI)

DAY 1

08:30 - 08:45 Welcome and opening remarks

08:45 - 09:00 Presentation and adoption of objectives and proposed agenda for the meeting

09:00 - 09:30 Rationale for the IMCI strategy

Major causes of childhood mortality
Components of IMCI
Relationship of IMCI to existing technical programmes
IMCI and health system reform

09:30 - 09:45 Discussion

09:45 - 10:00 Coffee break

10:00 - 10:20 IMCI: Global strategy and Regional experience

Introduction, Early implementation and Expansion
Implementation in other countries

10:20 - 10:30 Discussion

10:30 - 11:45 Current situation of child health in China

Child health activities and status of CDD, ARI, Nutrition, EPI and
Communicable Disease programmes

11:45 - 12:00 Discussion

12:00 - 13:00 Lunch

13:00 - 13:45 Components of the IMCI strategy

Improvements in case management skills of health staff
Improvements in the health system
Improvements in family and community practices

13:45 - 14:00 Discussion

14:00 - 15:00 IMCI case management guidelines for first-level health workers
Review of guidelines
Examples of how they work

15:00 - 15:15 Discussion

15:15 - 15:30 Coffee break

15:30 - 16:00 Summary and closing

1-13 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

DAY 2

08:30 - 09:00 Welcome and introduction

Case management process
Structure of expanded orientation
Teaching methods we will use/not use

09:00 - 10:00 Assess and Classify the Sick Child Age 2 Months Up to 5 Years
pages 1-7, 11-24 (danger signs, cough and difficult breathing)

10:00 - 10:15 Coffee break

10:15 - 11:30 Complete pages 11-24

11:30 - 12:00 Video Exercise C page 30

12:00 - 13:00 Lunch

13:00 - 14:00 pages 32-36, 38-41,45-46 (diarrhoea)

14:00 - 15:00 pages 54-59, 62, 64-65 (fever)

Drill determining fast breathing

15:00 - 15:15 Coffee break

15:15 - 17:30 pages 68-73, (fever-continued))

pages 91-95 (ear problem)
pages 98-102 (malnutrition and anaemia)
Photograph Exercise N, pages 103-104
pages 105, 108-111 (malnutrition and anaemia-continued)

DAY 3

08:30 - 09:00 Assess and Classify the Sick Child Age 2 Months Up to 5 Years
pages 120-122 (immunization), page 126 (other problems)
Exercise R, case 3, page 132
Group A
09:00 - 11:00 Outpatient session
11:00 - 12:00 Inpatient session

Group B
09:00 - 10:00 Inpatient session
10:00 - 12:00 Outpatient session

12:00 - 13:00 Lunch

13:00 - 15:00 Identify Treatment

pages 1-8, 11-15, 26-27, 31-32, 41-45

15:00 - 15:15 Coffee break

15:15 - 15:45 Exercise F, page 51

1-14 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

15:45 - 17:30 Treat the Child

pages 1-4, 8-10, 13-18, 22-26

DAY 4

08:30 - 09:00 Treat the Child

Role play, Exercise E, page 29-30

09:00 - 09:30 pages 39, 45-49, 79-80

09:30 - 12:00 Outpatient session

12:00 - 13:00 Lunch

13:00 - 15:00 Counsel the Mother

pages 1-10, 13, 15-17, 19-24

15:00 - 15:15 Coffee break

15:15 - 17:30 pages 31, 34-35

Role play, Exercise D, Case 1, pages 37-39
pages 41-45

DAY 5

08:30 - 10:30 Outpatient session (Assess, Classify, Treat, Counsel the Mother)

10:30 - 12:00 Management of the Sick Young Infant Age 1 Week Up to 2 Months
Pages 1-3, 19-26
Video Exercise D, part 1, page 29

12:00 - 13:00 Lunch

13:00 - 13:30 pages 47-50

13:30 - 14:30 Follow-Up

pages 1-3, 27-30
Exercise D, 1, page 31-32

15:00 - 15:15 Coffee break

15:15 - 16:00 Discussion focused on perceived needs for adaptation

The process of adaptation
Major area of adaptation

16:00 - 16:45 Discussion focused on implementation and follow-up after training

Implementation, Follow-Up

16:45 - 17:15 Conclusions and closing

1-15 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

TRAIN PLANNERS AND TEACHERS:

SAMPLE AGENDA
Five-Day IMCI Training Course for University Staff

TIME CONTENTS OPTIONAL

08:00-09:00 Registration
09:00-10:00 Opening Ceremony
DAY 1 10:00-10:30 Opening presentation
10:30-11:15 Module 1: Introduction (page 1-6)
11:15-11:30 BREAK
11:30-12.45 Module II pages 7-16 (Assess & Classify: Exercise 2A, 2B, 2D, 2E, 2F
Danger signs, Cough, Diarrhea)
12:45-13:15 Video pres.: Danger signs, Cough, Diarrhea Video exercise 2C, 2G
13:15-14:00 Technical Seminar: ARI, Diarrhea

08:00-09:45 Module II pages 17-23 (Assess & Classify: Photo exercise 2J, 2K, 2L
Sore throat, Ear problems, Fever) Exercise 2H, 2I, 2M
09:45-11:00 INPATIENT: demonstration: Assess and
DAY 2
Classify danger signs, Cough, Diarrhea.
11:00-11:15 BREAK
11:15-12:45 Module II pages 24-30 (Assess & Classify: Photo exercise 2O, 2P
Malnutrition and anemia, Vit. A, Exercise 2Q, 2R, 2S
Immunization, Other problems)
12:45-13:30 Video presentation: Malnutrition and anemia Video exercise 2T, 2U
13:30-14:00 Technical Seminar: Malnutrition,
Immunization
08:00- 09:30 Module III page 31-36: Identify treatment Exercise 2A, 2B, 2C, 2D, 2F
09:30-11:00 OUTPT: Demonstration: Identify treatment
DAY 3
Participants: Assess, classify, Identify, treat.
11:00-11:15 BREAK
11:15-13:00 Module IV (Treat) pages 37-65 Exercise 4A, 4B, 4C, 4D, 4F
13:00-14:00 Module IV (Treat) pages 66-79 Exercise 4H, 4I

08:00-10:00 Module V (Counsel) page 81-106 Exercise 5A, 5C, 5F

10:00-11:30 OUTPT: Demonstration: Counsel
DAY 4 Participants: Assess, classify, Identify,
Counsel
11:30-11:45 BREAK
11:45-14:00 Module V (Follow-up) page 107-121 Exercise 6A, 6B, 6C, 6D

08:00-10:00 Module VII (Sick young infant) page 123- Exercise 7B, 7D, 7E, 7F, 7H
150
10:00-11:30 INPATIENT: Demonstration and Practice:
Assess and classify sick young infant,
DAY 5
Counsel for breast-feeding (attachment and
positioning)
11:30-11:45 BREAK
11:45-12:30 Video presentation: Breast-feeding (position Video exercise 7A, 7C, 7G
and attach.)
12:30-13:15 Technical Seminar: Sick young infant /
Breast-feeding
13:15-14:00 General Discussion and Closing

1-16 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

PLAN FOR THE INTRODUCTION OF NEW TEACHING:

SAMPLE AGENDA
Planning Workshop for IMCI Pre-Service Training

[Name of Teaching Institution, School, Department]

[Dates of the Workshop]

Opening

- Welcome, Workshop Objectives and Agenda

- Introduction of the Participants

Session 1: Overview of IMCI (Global and Local)

- Global IMCI Strategy and Status of Implementation

- Current Status of IMCI Implementation in the Country

- Country, Regional and Global Experience with IMCI Pre-Service Training

Session 2: Placing IMCI within an Identified Programme(s)

- Overview of the Certificate, Diploma and Degree Programmes at the Faculty

or School that Include a Paediatrics or Child Health Component. Rationale for
Selecting the Programme(s) where IMCI will First be Introduced.

- Presentation of How Paediatrics or Child Health is Taught in the Selected

Programme(s) and Why it is Taught that Way

- Possible IMCI Teaching/Learning Objectives

- Minimum Criteria for Quality IMCI Training

- Discussion of How IMCI Can be Taught Within the Identified Programme(s)

Session 3: Teaching, Learning and Assessment Methods and Materials

- Summary of Methods and Materials Currently Used by the Faculty or School

to Teach Paediatrics or Child Health

- Presentation of Materials and Methods Used for IMCI In-Service Training

and Available for IMCI Pre-Service Training

- Discussion of the Teaching, Learning and Assessment Materials Needed by

the Faculty or School in order to Teach IMCI and to Assess the IMCI
Knowledge and Skills of Students.

1-17 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

Session 4: Planning and Monitoring

- Introduction to the "Outline of a Plan for Introducing Teaching on Integrated

Management of Childhood Illness (IMCI)"

- Discussion of the main areas of work within the plan (including training of
faculty, preparation of teaching, learning and assessment materials,
preparation of clinical practice sites, etc.)

- Identification of Next Steps for Planning and Preparing for the Introduction of
IMCI Teaching. Who will do what, when and how? What support or
assistance will be needed?

1-18 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

List of Possible Learning Objectives for Integrated

Management of Childhood Illness (IMCI)

The broad objective is to:

Prepare health professionals to prevent and manage major childhood illnesses

and conditions in an effective and integrated manner.

Below are possible specific objectives related to the IMCI strategy:

A. Clinical management of sick children at outpatient health facilities

1) Students should learn and demonstrate knowledge of the following topics as a basis
for good clinical practice in outpatient clinics:

a) Combined etiology and epidemiology of major childhood conditions: ARI

(including pneumonia), diarrhoea, malaria, measles, ear infections, malnutrition
b) Assessment, in an integrated manner, of the signs and symptoms of the above
illnesses, and of nutritional and immunization status
c) Classification of the child’s illnesses according to the IMCI case management
charts
d) Identification of treatments for the child's classifications, and of children in need
of referral based on the IMCI case management charts
e) Administration of important pre-referral treatments (such as a first dose of an
antibiotic, vitamin A, quinine injection, and treatment to prevent low blood sugar)
f) Treatment in the clinic, including oral rehydration therapy, oral antibiotics, oral
antimalarial, vitamin A, and immunization
g) The signs of correct breastfeeding positioning and attachment, and steps for
assessing and improving them if needed
h) Methods for counselling the mother about treatment, feeding (including age-
appropriate feeding recommendations), and when to return
i) For children who return for a scheduled follow-up, reassessment of the problem
and provision of appropriate care.

2) Based on the knowledge of the topics listed above and after appropriate clinical
practice, students should be able to demonstrate the following skills necessary for
effective case management in outpatient health facilities:

a) Assessing and classifying the sick child age 2 months up to 5 years according
to the IMCI clinical guidelines:

i) Ask the mother about the child's problem

ii) Check for general danger signs
iii) Ask the mother about the four main symptoms (cough or difficult breathing,
diarrhoea, fever, ear problem)
iv) When a main symptom is present, assess the child further for signs related
to that symptom
v) Classify the illness according to the signs which are present or absent

1-19 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

vi) Check for signs of malnutrition and anaemia and classify the child's
nutritional status
vii) Check the child's immunization status and decide if the child needs any
immunizations today
viii) Assess the child's feeding and identify feeding problems
ix) Assess any other problems

b) Identifying actions needed for case management according to the IMCI clinical
guidelines:

i) Determine if urgent referral is needed

ii) Identify treatments needed for children who are not referred
iii) For children who need urgent referral, identify urgent pre-referral treatments
needed, explain the need for referral to the child’s caretaker, write a referral
note

c) Treating the sick child according to IMCI clinical guidelines:

i) Determine oral drugs needed and their appropriate dosage and schedule for
a sick child
ii) Give the first dose of oral drugs (including antibiotics, antimalarials,
paracetamol, vitamin A, iron and mebendazole), and teach the child’s
caretaker how and when to give oral drugs at home
iii) Treat local infections (such as eye infections, ear drainage, mouth ulcers,
sore throat and cough), and teach the child’s caretaker how and when to
give the treatments at home
iv) Give pre-referral drugs administered in the clinic only (intramuscular
injections of chloramphenicol and/or quinine)
v) Prevent low blood sugar
vi) Treat different classifications of dehydration, and teach the child’s caretaker
about giving extra fluids at home
vii) Immunize children

d) Advising and counselling the caretaker(s) of a sick child according to the IMCI
guidelines:

i) Counsel the child’s caretaker about feeding problems

ii) Advise the child’s caretaker to increase fluid during illness
iii)Advise the child’s caretaker on when to return for follow-up visits, when to
return immediately for further care, and when to return for immunizations
iv) Give relevant advice to each caretaker using good communication skills and
using a Mother's Card as a communication tool
v) Ask open-ended questions of a child’s caretaker to check his/her
understanding

e) Assessing, classifying and treating the sick young infant up to 2 months of age
according to the IMCI clinical guidelines:

i) Assess and classify a young infant for possible bacterial infection

ii) Assess and classify a young infant with diarrhoea

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Phase One - Orient and Plan Annex 1

iii) Check for feeding problem or low weight, assess breastfeeding and classify
feeding
iv) Treat a young infant with oral or intramuscular antibiotics
v) Give fluid for treatment of diarrhoea
vi) Teach the young infant’s caretaker to treat local infections at home
vii) Teach correct positioning and attachment for breastfeeding
viii) Advise the child’s caretaker on how to care for the young infant at home

f) Conducting a follow-up visit according to the IMCI clinical guidelines:

i) Decide if a child has been brought for a first visit or a follow-up visit for the
illness
ii) If the child has been brought for follow-up, assess the signs specified in the
follow-up box for the child's previous classification
iii) Select further treatment based on the child's signs
iv) If the child has any new problems, reassess and classify the child’s illnesses
as in an initial visit

B. Clinical management of sick children at first level referral health facilities

1) Students should learn and demonstrate knowledge of the following topics as a basis
for good clinical practice in first-level referral hospitals:

a) Steps of the triage process at the referral level based on IMCI classifications at
first-level outpatient facilities

i) Triage assessment for all sick children to detect emergency conditions

ii) Emergency treatment for emergency conditions
iii) Assessment for further treatment

b) Steps of problem-based assessment and diagnosis of children with lethargy,

unconsciousness, convulsions, diarrhoea, cough or difficult breathing, and fever

c) Hospital management of children with diarrhoea, including dysentery and

persistent diarrhoea

d) Hospital management of children with respiratory problems

e) Hospital management of children with fever

f) Management of children from high risk groups (young infants, severe

malnutrition, children with HIV/AIDS)

g) Items to monitor the progress of the child

h) Criteria and procedures for discharge from the facility when improved

2) Based on the knowledge of the topics listed above and after appropriate clinical
practice, students should be able to demonstrate the following skills necessary for
effective case management in first-level referral hospitals:

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Phase One - Orient and Plan Annex 1

a) Perform triage at referral level based on IMCI classifications at first-level

outpatient facilities

b) Give emergency treatment(s) for emergency conditions

c) Assess for further treatment

d) Make problem-based assessment and diagnosis of children with lethargy,

unconsciousness, convulsions, diarrhoea, cough or difficult breathing, and fever

e) Treat sick children at the first-level referral hospital using IMCI principles of:

i) Fluid management
ii) Antibiotic/antimalarial therapy
iii) Oxygen therapy
iv) Management of wheezing
v) Management of fever
vi) Nutritional management
vii) Management of high risk groups (young infant, severe malnutrition, children
with HIV/AIDS)

f) Counsel mothers about breastfeeding

g) Provide emotional and psychological support to sick children and their families

h) Ensure that essential practical clinical procedures are available and safe: blood
transfusion, IV administration, intraosseous infusion, insertion of a nasogastric
tube, lumbar puncture, insertion of a chest drain.

C. Strengthening health system support for the effective prevention and

management of childhood illnesses1

1) Students should learn and demonstrate knowledge and skills to advocate for and
implement IMCI at health facilities.

D. Strengthening practices within families and communities to support the

prevention and management of childhood illnesses1

1
Contact WHO CAH for information about additional learning objectives related for this component .

1-22 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

OUTLINE

Plan of Action for Introducing IMCI into an Academic

Programme

[Name of the Teaching Institution, School, Department]

Draft: [date]

1. Introduction

Background information about the faculty or school, its students, its methods of teaching and
its teaching programmes, including paediatrics or child health components.

2. Description of the …[insert name of the certificate, diploma or degree programme where
IMCI will first be introduced]

Briefly describe the mission and objectives of the overall programme. Total number of years
of study to complete the programme. Total number of students who enter the programme
each year. Briefly describe how paediatrics or child health is taught within the programme.
For each year of study, give the total number of hours in paediatric or child health rotations.
For each year, indicate the number of hours of theory and the number of hours of clinical
practice in paediatrics or child health.

3. IMCI Teaching/Learning Objectives

Give a broad description of what students will know and be able to do after learning IMCI
(attach detailed list of learning objectives as an annex).

4. Placement of IMCI Teaching within the … [insert name of the certificate, diploma or
degree programme where IMCI will first be introduced]

Describe how IMCI will be taught within the selected academic programme. Within each
section or term of teaching activities, describe the main IMCI teaching/learning objectives
that will be achieved.

List the teaching departments, sub-departments and clinical practice sites where IMCI
teaching will be introduced.

5. Teaching, Learning and Assessment Materials Needed for IMCI

List the primary materials used by teachers and students (including the major textbook and
reference books used) to teach and learn paediatrics or child health. Indicate which of the
existing materials need to be revised in order to include, or be made compatible with, IMCI.
Identify what types of new materials should be developed or adapted. Estimate the cost of
revising and/or developing materials, and of reproducing and distributing the materials.
Identify possible sources of funding and technical support. Describe how materials will be
supplied in a sustainable way.

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Phase One - Orient and Plan Annex 1

5.1 Teaching and Learning Methods and Materials

For each year or term of teaching (e.g. theory, clinical practice, etc.), list the types
of teaching and learning methods that might be used, and the types of teaching and
learning materials that would be needed IMCI.

5.2 Student Assessment Methods and Materials

For each year or term of teaching, list the types of methods that might be used for
student assessment (e.g. assignments, exercises, written examinations, observation
of clinical skills, etc.), and the types of materials that would be needed to assess
student knowledge and skills in IMCI.

6. Training of Administrators, Teachers and Staff at Clinical Practice Sites

Describe what types of staff members will need training in IMCI, and how they would be
trained. Remember to include relevant staff from clinical practice sites as well as teachers
and administrators from relevant departments and sub-departments such as community or
social medicine, infectious diseases, epidemiology and nutrition. Describe how new
administrators, teachers and relevant clinical staff, who join the school after IMCI teaching
has been introduced, would be trained in IMCI.

7. Preparation of Clinical Training Sites

Describe what will be needed to prepare clinical practice sites for IMCI teaching.

8. Monitoring and Evaluation

Explain how the teaching institution will monitor the implementation of the plan for
introducing IMCI teaching. Will staff hold regular meetings to discuss achievements and
difficulties with the implementation of the plan of action? When will the meetings be held
and who will attend? Will the plan of action be reviewed and revised based on initial
experience with IMCI teaching? If yes, who will review and revise the plan and when? Will
IMCI teaching be evaluated? If yes, how and when?

9. Budget

Estimate the cost for:

· Orienting decision makers and staff;

· Training administrators, teachers and clinical staff;
· Planning and coordination;
· Developing and supplying materials for teaching, learning and student assessment;
and
· Preparing clinical practice sites.

10. Timeline

See attached.

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Phase One - Orient and Plan Annex 1

Timeline: Steps Needed to Implement the Plan of Action for Introducing IMCI into an Academic Programme
Months 1-3 Months 4-6 Months 7-9 Months 10-12
EXAMPLE AREAS OF
ACTIVITY Dates: _________________ Dates: _________________ Dates: _________________ Dates: _________________

Orientation of Senior
Staff

Training of Teachers and

of Relevant Clinical Staff

Identification and
Preparation of Clinical
Practice Sites

Preparation of Teaching,
Learning and
Assessment Materials

Coordination of
Teaching (both
classroom and clinical)
Between Departments
and Sub-Departments

Other:

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Phase One - Orient and Plan Annex 1

Timeline: Steps Needed to Implement the Plan of Action for Introducing IMCI into an Academic Programme
Name of University: ____________________________________ City: ____________________ Country: ______________________

Months 1-3 Months 4-6 Months 7-9 Months 10-12

AREA OF ACTIVITY
Dates: _________________ Dates: _________________ Dates: _________________ Dates: _________________

1-26 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

1-27 Working Draft: April 2001

Phase One - Orient and Plan Annex 1

PRESENTATIONS

Overview of the IMCI Strategy

Introduction to the IMCI Clinical Guidelines (request from WHO CAH)
Academic Rationale for IMCI
Summary of Experience Related to IMCI Pre-Service Training (request from WHO CAH)
IMCI Training Methods and Materials
IMCI Learning Objectives

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

Annex 2

PHASE TWO – PREPARE AND CONDUCT THE

FIRST ROUND OF IMCI TEACHING

Tools and Materials in this Annex

Planning Matrix: Matching Activities and Materials with Learning

Objectives for IMCI............................................................................................................ 2-3

Training Teachers and Clinical Staff: Sample Topics for Sessions on Pedagogy.............2-5*

List of Drugs and Supplies Needed for IMCI Practice in Outpatient Clinics .................... 2-7

Description of Possible Materials for IMCI Teaching, Learning and

Student Assessment ............................................................................................................ 2-9

Sample Group Checklist of Clinical Signs ....................................................................... 2-13

Other Recommended Tools and Materials

IMCI Facilitator Guide for Modules (unpublished document WHO/CHD/97.3.I;

available on request from the Department of Child and Adolescent Health and
Development, World Health Organization, 1211 Geneva 27, Switzerland (Fax: +41
22 791 4853, email: [email protected])

IMCI Facilitator Guide for Outpatient Clinical Practice (unpublished document

WHO/CHD/97.3.H; available on request from the Department of Child and
Adolescent Health and Development, World Health Organization, 1211 Geneva 27,
Switzerland (Fax: +41 22 791 4853, email: [email protected])

IMCI Guide for Clinical Practice in the Inpatient Ward (unpublished document
WHO/CHD/97.3.J; available on request from the Department of Child and
Adolescent Health and Development, World Health Organization, 1211 Geneva 27,
Switzerland (Fax: +41 22 791 4853, email: [email protected])

IMCI Guidelines for the Assessment of Students (unpublished document, Draft

March 2001; available on request from the Department of Child and Adolescent
Health and Development, World Health Organization, 1211 Geneva 27, Switzerland
(Fax: +41 22 791 4853, email: [email protected])

*
WHO is developing a self-instructional course on the skills needed to teach maternal and child health.
Contact WHO CAH (email: [email protected]) for more information.

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

IMCI Model Chapter for Textbooks (unpublished document WHO/FCH/CAH/01.01;

available on request from the Department of Child and Adolescent Health and
Development, World Health Organization, 1211 Geneva 27, Switzerland (Fax: +41
22 791 4853, email: [email protected])

IMCI Model Handbook (unpublished document WHO/FCH/CAH/00.12; available

on request from the Department of Child and Adolescent Health and Development,
World Health Organization, 1211 Geneva 27, Switzerland (Fax: +41 22 791 4853,
email: [email protected])

IMCI Photograph Booklet (unpublished document WHO/CHD/97.3.L; available on

request from the Department of Child and Adolescent Health and Development,
World Health Organization, 1211 Geneva 27, Switzerland (Fax: +41 22 791 4853,
email: [email protected])

IMCI Reference Library of Selected Materials (unpublished document,

WHO/FCH/CAH/01.08; available on request from the Department of Child and
Adolescent Health and Development, World Health Organization, 1211 Geneva 27,
Switzerland (Fax: +41 22 791 4853, email: [email protected])

IMCI Technical Seminars (unpublished document WHO/FCH/CAH/01.10; available

on request from the Department of Child and Adolescent Health and Development,
World Health Organization, 1211 Geneva 27, Switzerland (Fax: +41 22 791 4853,
email: [email protected])

Management of the Child with a Serious Infection or Severe Malnutrition:

Guidelines for Care at the First-referral Level in Developing Countries
(unpublished document WHO/FCH/CAH/00.1; available on request from the
Department of Child and Adolescent Health and Development, World Health
Organization, 1211 Geneva 27, Switzerland (Fax: +41 22 791 4853, email:
[email protected])

Breastfeeding Counselling: A Training Course - Trainer’s Guide (unpublished

document WHO/CDR/93.4; available on request from the Department of Child and
Adolescent Health and Development, World Health Organization, 1211 Geneva 27,
Switzerland (Fax: +41 22 791 4853, email: [email protected])

Breastfeeding Counselling: A Training Course - Overhead Figures (unpublished

document WHO/CDR/93.6; available on request from the Department of Child and
Adolescent Health and Development, World Health Organization, 1211 Geneva 27,
Switzerland (Fax: +41 22 791 4853, email: [email protected])

Breastfeeding Counselling: A Training Course - Participant’s Manual (unpublished

document WHO/CDR/93.5; available on request from the Department of Child and
Adolescent Health and Development, World Health Organization, 1211 Geneva 27,
Switzerland (Fax: +41 22 791 4853, email: [email protected])

Video Exercises on Integrated Management of Childhood Illness (IMCI)

(unpublished document 2001; available on request from the Department of Child

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

and Adolescent Health and Development, World Health Organization, 1211 Geneva
27, Switzerland (Fax: +41 22 791 4853, email: [email protected])

2-3
Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

Planning Matrix: Matching Activities and Materials with Learning Objectives for IMCI
NAME OF ACADEMIC PROGRAMME: LENGTH OF PROGRAMME:

NAME OF DEPARTMENT and SUB-DEPARTMENT: YEAR/TERM:

Time and Place of IMCI Teaching Teaching Teaching/Learning Assessment Assessment
1
Learning Outcomes Expected Methods/Activities Materials Methods/Activities Materials

1
See List of Possible IMCI Learning Objectives in Annex 1 and the task called Plan for the Introduction of IMCI Teaching in Phase 1, section 1.2, of this guide.

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

EXAMPLE
Planning Matrix: Matching Activities and Materials with Learning Objectives for IMCI
NAME OF ACADEMIC PROGRAMME: Bachelor of Medicine and Surgery (MBBS) LENGTH OF PROGRAMME: 5 Years

NAME OF DEPARTMENT and SUB-DEPARTMENT: Department of Child Health, Infectious Diseases Unit YEAR/TERM: Year 4, Term 1
Time and Place of IMCI Teaching Teaching Teaching/Learning Assessment Assessment
1
Learning Outcomes Expected Methods/Activities Materials Methods/Activities Materials
Year 4, Term 1: One-Week Rotation in
Paediatric Infectious Diseases.
IMCI Classroom Sessions (5 hours):
After completion, students should show
knowledge of: Lectures Materials for Teachers Written Exercises Exercise Book
· Danger signs of severe disease Discussions IMCI Technical Seminars Video Exercises Written Case Studies
· Simple clinical signs to assess ARI, Video Sessions IMCI Video Case Studies IMCI Video
diarrhoea, malaria, measles, other fever, Role Plays
and ear infections Materials for Students
· IMCI classifications of illness severity IMCI Handbook
· Appropriate treatments for different IMCI IMCI Chart Booklet
disease classifications IMCI Photograph Booklet
IMCI Practical Sessions in the Outpatient Clinic
(10 hours):
Demonstration of Patients Materials for Teachers
After completion, students should show
Supervised Clinical Practice Guidelines for Conducting Observation of Students Observation Checklist
ability or skills to:
Supervised Clinical Practice
· Assess a child or young infant according
to the IMCI guidelines,
Materials for Students
· Classify a child’s conditions
Those listed above, plus:
· Identify appropriate treatments
IMCI Case Recording Form
· Choose treatment priorities
IMCI Mother’s Card
· Advise a child’s caretaker about feeding
and fluids during illness and about when
to return

1
See List of Possible IMCI Learning Objectives in Annex 1 and the task called Plan for the Introduction of IMCI Teaching in Phase 1, section 1.2, of this guide.

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

Training Teachers and Clinical Staff:

Sample Topics for Sessions on Pedagogy*

Preparing for Learning

· Identify the learning needs of students

· Identify learning objectives
· Develop a learning schedule
· Determine appropriate teaching and learning methods
· Select effective teaching and learning materials
· Determine appropriate methods for student assessment
· Select effective assessment materials
· Prepare the classroom and clinical practice environment
· Organize and manage student learning and assessment

Communication and Group Work

· Create an atmosphere of communication

· Introduce a subject
· Summarize a subject
· Use effective presentation skills
· Effectively lead and work in groups
· Facilitate a small group activity
· Facilitate the use of role-playing
· Facilitate the use of a case study
· Facilitate the problem-solving process
· Facilitate a discussion
· Facilitate clinical practice
· Conduct a brainstorming session
· Use questioning techniques

Prepare and Use Audiovisuals

· Present information using a writing board, flipchart, computer projector,

transparencies, slides and videotapes

Student Assessment

· Develop and administer written knowledge examinations

· Develop and administer skill assessments
· Use examination results to improve student performance

*
Based on the Time Schedule of Pedagogic Course in Medicine, University of Medicine and
Pharmacy, Ho Chi Minh City, Vietnam, December 2000. Contact WHO CAH for more information
about a training course specifically designed to strengthen teaching skills needed for experience-
based learning.

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

Monitor and Improve Teaching

· Coordinate teaching between different teaching units

· Select, collect and analyze information from students and colleagues for self-
evaluation
· Identify personal strengths and weaknesses
· Plan for self-improvement
· Evaluate the curriculum to reveal weaknesses and to identify means of improvement
· Contribute to the improvement of the curriculum

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

List of Drugs and Supplies Needed for IMCI Practice in

Outpatient Clinics

Drugs: ORS packets - a least eight per participant

First-line oral antibiotic for pneumonia
First-line antimalarial
First-line oral antibiotic for dysentery
Mebendazole
Vitamin A capsules
Paracetamol
Iron (tablet and syrup if possible)

Supplies: Plastic cups (one for each participant - to

offer drinks to child with diarrhoea)
Clean water supply (for mixing ORS; for
offering fluid to a child when assessing signs of
dehydration; and for making crushed drugs)
Enough watches or other timing devices
(participants will usually use their own
watches)
Mother’s cards
Banana or other acceptable food to use when
mixing crushed tablets. (Banana is handy,
portable and children like it.)

Other Essential Containers for demonstrating how to

Supplies for ORT mix ORS (and to mix ORS for Plan B
Corner: administration)
Spoons
Oral Rehydration Salts (premixed packets)

Other Essential Thermometer

Clinic Supplies: Wash basin, towel, soap
Functional scale for weighing children and
young infants accurately

Desirable for Use in Tetracycline eye ointment* - 1 tube per group

Clinical Practice: Gentian violet* - small bottle of 0.5%
Soft cloths for applying gentian violet and
washing eyes with pus
(*These are unlikely to be used during the session.
However, facilitators can keep a small supply on
hand for demonstrating treatments of local
infections.)

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

Desirable for ORT Ringer’s Lactate solution for IV administration

Corner if IV Fluids Beds or tables with wires above for hanging
to be Given: bottles of IV fluid
IV supplies such as scalp vein (butterfly)
needles

* * *
Note: It is ideal for clinics where outpatient sessions are held to be stocked with all the drugs
listed on the country’s adapted case management charts, and with the necessary equipment
for administering them. The types of drugs, which are needed for all the steps described on
all of the case management charts, include the following:

Antibiotics See the adapted IMCI case management guidelines for your
country or region (e.g. Cotrimoxazole, Amoxycillin,
Chloramphenicol Intramuscular, Gentamicin Intramuscular,
Benzylpenicillin, Nalidixic Acid Tablets, Tetracycline
Tablets, Furazolidone Tablets, Erythromycin Tablets)

Antimalarials See the adapted IMCI case management guidelines for your
country or region (e.g. Chloroquine Tablets, Sulfadoxine
and Pyrimethamine Tablets, Quinine Intramuscular)

Antipyretic Paracetamol
-- Tablet (500 mg) OR
-- Tablet (100 mg)

Other drugs Small bottles of safe, soothing cough remedy (optional)

Vaccines Adequate supplies of BCG, OPV, DPT and Measles

vaccines

Other Supplies Sugar

Cloth for wicking draining ears
Large drum (5, 10, or 15 litre size) with cover and side
tap for holding large quantities of ORS in ORT corner
Food to give patients on Plan B
Nasogastric tube
Sterile syringes and sterile needles:
-- 5 cc sterile syringes and sterile needles
-- 10 cc sterile syringes and sterile needles
Sterile water for diluting IM antibiotics and IM
antimalarials
Cotton swabs and alcohol or spirits
All appropriate cold chain supplies, including a reliable
refrigerator or cold box, sterilizers, sterile syringes, sterile
needles, immunization cards.

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

Description of Possible Materials for IMCI Teaching,

Learning and Student Assessment

Many of the materials developed for the IMCI in-service training course may be used to teach,
learn and assess IMCI in pre-service training settings. For example, the IMCI chart booklet,
mother’s card, case recording forms, videotapes and photograph booklet are all applicable to pre-
service training. Additionally, WHO has developed several generic materials for IMCI pre-
service training. These generic materials can be adapted and used in their existing format, or they
can be incorporated into materials already used by a teaching institution. The following materials
for IMCI teaching, learning and student assessment may be requested from the Ministry of
Health in a country or from WHO.*

Materials for Teachers

List of Possible IMCI Learning Objectives (see Annex 1). The list is designed to help
teaching staff define learning objectives for IMCI. It describes expected learning
outcomes in terms of student knowledge and skills in both the outpatient and inpatient
care of sick children.

Planning Matrix: Matching Activities and Materials with Learning Objectives for
IMCI (see Annex 2). Teaching staff can use the planning matrix to identify teaching,
learning and assessment materials needed to achieve specific learning objectives for
IMCI.

IMCI Reference Library of Selected Materials. The reference library includes an

annotated bibliography of selected materials that constitute the evidence base for the
generic IMCI clinical guidelines. The library includes full-text versions of key articles,
documents and publications on CD-ROM. Teachers can use the library as a reference
source. They also can instruct students to read different materials from the library to gain
a better understanding of the rationale and technical basis for the IMCI strategy and
clinical guidelines.

IMCI Technical Seminars. A set of speakers’ notes and overhead transparencies that
present technical justifications for the IMCI clinical guidelines. The seminars cover
topics such as acute respiratory infections, diarrhoea, malaria, other causes of fever,
malnutrition and the sick young infant. All seminars are available in hard copy and on
CD-ROM. Teaching staff can adapt or revise the seminars to include local or regional
data and/or information about national adaptations made to the IMCI clinical guidelines.

IMCI Photograph Booklet. A book of 82 photographs illustrating children from age two
months up to five years with clinical signs of dehydration, measles, measles

*
Materials may be requested from the WHO representative in a country, the WHO regional office, or the Department of
Child and Adolescent Health and Development (CAH), World Health Organization, Avenue Appia 20, 1211 Geneva 27,
Switzerland (Fax: +41 22 791 4853, e-mail: [email protected]).

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

complications, anaemia, wasting and oedema. The book also contains photographs of
young infants with local infections, and signs of good and poor breastfeeding attachment
and positioning. The booklet can be used to teach students to identify clinical signs and
to assess their ability to recognize signs. It is used to complete written and oral exercises
in the IMCI in-service training course, and does not need to be adapted.

IMCI Videotapes. Two videotapes that provide examples of clinical signs, case studies
and exercises to assess sick children and classify their illnesses according to the IMCI
clinical guidelines. The first video is entitled, “Assess and Classify the Sick Child.” The
second is called, “Assess and Classify the Sick Young Infant.” The videotapes may be
adapted and/or translated at the national level.

IMCI Wall Charts. A set of four wall charts that present the nationally adapted IMCI
clinical guidelines. The wall charts are entitled, “Assess and Classify the Sick Child,”
“Treat the Child,” “Counsel the Mother,” “Assess, Classify and Treat the Sick Young
Infant” and “Treat the Young Infant and Counsel the Mother.” The charts should be
displayed in classrooms and at health facilities where students will participate in IMCI
clinical practice. Because these charts should correspond to the nationally adapted IMCI
clinical guidelines, they should be requested from the Ministry of Health or WHO
country office.

IMCI Facilitator Guides for Outpatient and Inpatient Clinical Practice. Two guides
(WHH/CHD/97.3.H and WHO/CHD/97.3.J) that describe the techniques for supervised
clinical practice in IMCI. The guides describe how to prepare for, conduct and monitor
practical sessions in outpatient clinics and inpatient wards. Computer files of the guides
may be requested from WHO. Teaching staff can adapt or revise the guides to fit their
own objectives and schedules for clinical practice. Or they may incorporate elements of
the guides into existing course descriptions or lesson plans.

Checklists for Monitoring IMCI Outpatient and Inpatient Clinical Sessions. Checklists
for monitoring outpatient and inpatient clinical sessions are presented and described in
the IMCI Facilitator Guides for Outpatient and Inpatient Clinical Practice
(WHH/CHD/97.3.H and WHO/CHD/97.3.J). The checklists are designed to monitor
progress in learning the IMCI case management process. There are four types of
checklists for each of the two IMCI age groups (i.e., 1 week up to 2 months, and 2
months up to 5 years). They are entitled: Checklist for Monitoring Outpatient Sessions;
Checklist for Monitoring Inpatient Sessions; Group Checklist of Clinical Signs; and
Additional Signs in Young Infants. The process and clinical signs presented in these
checklists should be adapted to correspond to the national IMCI clinical guidelines.

Materials for Students

IMCI Model Chapter for Textbooks. The model chapter for textbooks was created to
help authors and editors incorporate IMCI content into local and international
textbooks and reference books. Before incorporating the chapter into local textbooks,
writers should first make the content of the model chapter consistent with the
nationally adapted IMCI clinical guidelines. The model chapter also may be used to
orient key persons to the IMCI strategy and clinical guidelines.

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

IMCI Model Handbook. The IMCI model handbook provides a detailed explanation
of the IMCI case management guidelines. It is organized into seven main parts: (1)
overview of the IMCI process; (2) assess and classify the sick child age 2 months up
to 5 years; (3) assess and classify the sick young infant age 1 week up to 2 months;
(4) identify treatment; (5) treat the sick child or the sick young infant; (6)
communicate and counsel; (7) and give follow-up care. Teaching institutions are
advised to adapt the handbook in two ways: (a) to ensure that all text, charts and
illustrations are consistent with nationally-adapted IMCI clinical guidelines; and (b)
to ensure that its content and format correspond to the teaching approach used by the
institution.

IMCI Chart Booklet. The IMCI chart booklet is a critical teaching and learning tool that
summarizes the process and content of the nationally adapted IMCI clinical guidelines.
The booklet is designed as a job aid, or memory aid, to assist students in learning how
to: assess a sick child; classify the child’s illnesses; assess feeding problems; identify
treatment; treat; counsel; and give follow-up care according to the IMCI guidelines. The
chart booklet includes the same information contained in the IMCI wall charts and, like
the IMCI wall charts, is adapted in each country. Staff from teaching institutions may
request copies of the nationally adapted IMCI chart booklet from the Ministry of Health
or WHO country office.

IMCI Mother’s Card. In most countries that have adapted IMCI guidelines, caretakers
of children are given a counselling card specifying feeding recommendations, by age,
and the signs for when to return to a health facility. The mother’s card is designed to
improve the effectiveness of messages regarding home care. The card provides
reminders, in words and pictures, of the key messages that health care providers should
be teaching caretakers about how to care for a sick child at home. Teaching institutions
may request copies of the adapted mother’s card from the Ministry of Health or WHO
country office.

IMCI Case Recording Form. The case recording form is designed to record information
about a child’s symptoms, clinical signs, classifications, treatment and key counselling
messages. Like the wall chart and chart booklet, the case recording form should be
adapted in each country. Teaching institutions may request copies of the adapted
mother’s card from the Ministry of Health or WHO country office.

Management of the Child with a Serious Infection or Severe Malnutrition: Guidelines

for Care at the First-referral Level in Developing Countries. This manual aims to
strengthen the management of children who present at small hospitals with severe
infections or severe malnutrition. The guidelines in the manual are consistent with the
IMCI guidelines for outpatient care of sick children. The manual includes information
about: triage and emergency care (i.e., Emergency Triage and Treatment); appropriate
laboratory investigations; correct diagnosis; treatment; supportive care; monitoring
patient progress in the hospital; discharge procedures and counselling caretakers.

Breastfeeding Counselling: A Training Course. The IMCI guidelines incorporate basic

elements of breastfeeding counselling. Per the guidelines, mothers with more serious
problems should be referred. The breastfeeding counselling training course aims to

2-13
Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

strengthen health professionals’ ability to provide comprehensive and effective

counselling to mothers with breastfeeding problems.

Materials for Assessing Student Knowledge and Skills

IMCI Guidelines for the Assessment of Students. An overview of the guiding principles
for IMCI assessment, including information to help teaching staff plan for the assessment
of students. The guidelines offer suggestions as to which competencies to assess and
possible methods for assessment, including the advantages, disadvantages and use of
each method in relation to IMCI. Annexes contain sample tools for formative and
summative assessment of student knowledge and skills. Although the guidelines were
developed for IMCI assessment, the concepts and methods also apply to other topics.

Video Exercises on IMCI. The video contains 15 case studies designed to assess the
students’ ability to correctly identify clinical signs and to classify the severity of a child’s
condition in accordance with IMCI clinical guidelines.

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

Sample Group Checklist of Clinical Signs

Students and teachers can monitor clinical practice experience by completing individual or
group checklists of clinical signs observed.

Sample group checklists are shown on the next two pages. The first page lists signs to
observe in children age two months up to five years. The second page lists additional signs
usually seen in young infants age one week up to two months.

To use the group checklist:

1. Obtain or make an enlarged version of each page of the checklist and hang it on the
wall of the classroom. (You can copy it onto flipchart paper.)

2. When students return to the classroom after clinical practice, they should indicate
the signs they have seen that day by writing their initials in the box for each sign.
Indicating whether signs were seen in outpatient or inpatient practice.

3. Each day students should add to the same checklist.

4. Teachers should monitor the Group Checklist to make sure students are seeing all
of the signs.

-- If you notice that students have not seen many examples of a particular sign,
take every opportunity to point out this sign to students when a child with
the sign presents during an outpatient session.

-- Or, talk with the inpatient instructor about locating, in the inpatient ward, a
child or young infant with the sign the students need to observe.

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

GROUP CHECKLIST OF CLINICAL SIGNS

Sick Child Age Two Months Up To Five Years

Unable to drink or Vomits everything History of convulsions Lethargic or

breastfeed (with this illness) unconscious

Fast breathing Chest indrawing Stridor in calm child Restless and irritable

Sunken eyes Drinking poorly Drinking eagerly, Very slow skin pinch
thirsty

Slow skin pinch Stiff neck Runny nose Generalized rash of

measles

Red eyes Mouth ulcers Deep and extensive Pus draining from eye
mouth ulcers

Clouding of the cornea Pus draining from ear Tender swelling behind Visible severe wasting
the ear

Severe palmar pallor Some palmar pallor Oedema of both feet

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Phase Two – Prepare and Conduct the First Round of IMCI Teaching Annex 2

ADDITIONAL SIGNS IN YOUNG INFANTS

Age One Week up to Two Months

Note: These signs may also be observed in older infants and children age two months up to
five years.

Mild chest indrawing in Fast breathing in young Severe chest indrawing Nasal flaring
young infant (normal) infant in young infant

Grunting Bulging fontanelle Umbilical redness Red umbilicus or

extending to the skin draining pus

Many or severe skin Skin pustules Lethargic or Less than normal

pustules unconscious young movement
infant

No attachment at all Not well attached to Good attachment Not suckling at all
breast

Not suckling effectively Suckling effectively Thrush

2-17
 Annex 3

PHASE THREE - REVIEW AND REPLAN

IMCI TEACHING

Tools and Materials in this Annex

Report of a Review and Replanning Visit: Outline................................................. 3-2

Progress Report Questionnaire: IMCI Pre-Service Training .................................. 3-4

EXAMPLE: Focus Group Interview with Students .............................................. 3-12

EXAMPLE: Focus Group Interview with Teachers ............................................. 3-18

EXAMPLE: Observation form for an IMCI Clinical Practice Session ................ 3-24

EXAMPLE: Observation form for an IMCI Classroom Session .......................... 3-29

IMCI Sample Observation Checklist .................................................................... 3-34

IMCI Sample Written Examination ...................................................................... 3-36

3-1
Phase Three – Review and Replan IMCI Teaching Annex 3

Report of a Review and Replanning Visit:

Outline

1. Background

Tell when IMCI was introduced in the country; when the teaching institution became
interested in IMCI; and the name(s) of the academic programme(s) selected for IMCI
teaching. Give a brief overview (3-6 paragraphs) of the process followed at national or
state level, and at teaching institution level, to introduce IMCI into the academic
programme(s).

2. Objectives

List the objectives of the review and replanning visit (i.e. What was the purpose of the
vist? What results were expected from the visit?)

3. Activities

Briefly describe the activities carried out during each day of the review and replanning
visit.

4. Findings

This section should describe the achievements and difficulties experienced by the
teaching institution in the following areas:

4.1. Planning for IMCI Teaching (i.e. developing a plan of action and selecting
learning objectives)

4.2. Orienting Administrators and Teaching Staff to IMCI

4.3. Placement of IMCI Teaching (i.e. In which academic programme(s), in which

years of the programme(s) and in which teaching units? Which teaching unit is
responsible for coordinating IMCI teaching?)

4.4. Materials for IMCI Teaching, Learning and Student Assessment

4.5. Selection and Preparation of Clinical Practice Sites

4.6. Training of Teachers and Relevant Staff at Clinical Practice Site(s)

4.7. Coordination (i.e. between different teaching units and with clinical practice
sites) and Implementation of IMCI Teaching

If students were assessed, teaching sessions were observed, or focus group interviews
were conducted, this section should also provide information about:

3-2
Phase Three – Review and Replan IMCI Teaching Annex 3

4.8. Results of the Assessment of Student Knowledge and Skills in IMCI (i.e.
Review of exam results and/or assessment of a sample of students during the
review and replanning visit)

4.9. Results of the Observation of Teaching

4.10. Results of Focus Group Discussions (i.e. With teachers and with students)

5. Conclusions and Recommendations

This section should list general conclusions regarding each of the topic areas described in
the findings section above.

It should also provide a few broad recommendations for:

· The teaching institution

· The national coordinating group for IMCI pre-service training

· WHO at country, regional and global levels

ANNEXES

This section may included items such as:

An Agenda of Activities
Results of Assessments of Student Knowledge and Skills
Results of Focused Interviews with Teachers
Results of Focused Interviews with Students
Results of Observations of Classroom or Clinical Teaching
Etc.

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Phase Three – Review and Replan IMCI Teaching Annex 3

Progress Report Questionnaire:

IMCI Pre-Service Training

The WHO and UNICEF strategy for Integrated Management of Childhood Illness (IMCI)
aims to reduce death and the frequency and severity of illness and disability, and contribute to
improved growth and development in children under 5 years of age. When applied correctly,
the IMCI clinical guidelines promote the accurate identification of major childhood illnesses
in outpatient settings, ensure appropriate combined treatment, strengthen the counselling of
caretakers and the provision of preventive services, speed up the referral of severely ill
children, and aim to improve the quality of care of sick children at the first referral level.

We understand that your faculty has made efforts to incorporate IMCI into one or more
academic programmes. We recognize that the approach taken to IMCI teaching depends on
the capacity of a teaching institution, the responsibilities of students after graduation and the
needs of a country's health system. Consequently, we expect that there is no single way to
introduce IMCI into an academic programme, but rather a variety of ways. For this reason,
the experience and lessons learned by your faculty would be very useful in our search for
effective ways to introduce IMCI teaching. In addition, information provided about your
achievements and difficulties would assist WHO in preparing global recommendations on the
subject.

We, therefore, ask you to prepare a Progress Report that answers the questions on the
following pages. If your faculty previously submitted a similar report to WHO, we ask you to
answer only the questions in Section H, experience to date with IMCI teaching and
assessment of students.

It is recommended that you designate one person in your faculty, preferably the school's focal
person for IMCI, as responsible for writing the report and returning a copy to us. When
gathering information for the report, the designated person should collaborate closely with
other departments and staff who are responsible for IMCI teaching. In addition, please attach
a description of the certificate, diploma or degree programme(s) where IMCI is being
introduced. This information can be photo copied from the faculty's annual catalogue or
bulletin.

We hope that your faculty will have no difficulty preparing a Progress Report and returning
it to WHO within the next few weeks.1

Thank you in advance for your valuable assistance.

1
The report should be returned to the WHO representative in your country, to the WHO Regional Office, or to
the Department of Child and Adolescent Health and Development (CAH), World Health Organization,
Avenue Appia 20, 1211 Geneva 27, Switzerland (Facsimile: +41 22 791 4853, e-mail: [email protected])

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Phase Three – Review and Replan IMCI Teaching Annex 3

Recommended Content of the Progress Report

In the Progress Report, please provide the following information about your faculty and the
academic programme(s) where IMCI is being introduced; the activities carried out to orient
staff and plan for IMCI teaching; the placement of IMCI teaching within the academic
programme(s) and the teaching methods used; the approach used to train teachers and
relevant clinical staff in the IMCI guidelines; the preparation of clinical practice sites and of
teaching, learning and assessment materials; and the experience to date with IMCI teaching
and assessment.

A. Information About the Teaching Institution

· Name of the teaching institution

· Address
· Country
· Name of the person preparing this report
· Department of the person preparing this report
· Date (month and year)

B. Information About the Academic Programme(s)

· Name of the certificate, diploma or degree programme(s) where IMCI is being

introduced 2
· Number of years needed for a student to complete the selected certificate,
diploma or degree programme(s)
· Number of students enrolled in the selected programme(s)
· Name of the department(s) responsible for planning and implementing IMCI
teaching
· Number of teaching staff within those department(s)
· Briefly describe how paediatrics or child health is taught within the certificate,
diploma or degree programme(s) selected for IMCI introduction, including in
what years, the length of paediatric rotations, the main subjects taught during
each paediatric rotation, and the proportion of time dedicated to classroom
sessions and to clinical practice

C. Orientation and Planning

Achievements
· How and when were the members of your faculty first introduced to the
IMCI strategy?
· How did your faculty plan for the introduction of IMCI teaching? Briefly
describe the main activities.
· Did the faculty develop or adopt learning objectives for IMCI teaching?
· Does the faculty plan to incorporate IMCI into the formal written
curriculum?
2
Please attach a description of the certificate, diploma or degree programme(s) where IMCI is being
introduced. This information can be photo copied from the faculty's annual catalogue or bulletin.

3-5
Phase Three – Review and Replan IMCI Teaching Annex 3

· In your opinion, why did the faculty decide to introduce IMCI teaching?
· Approximately how much do you estimate it cost to plan for the
introduction of IMCI teaching (i.e. time and/or money)?

Challenges
· Describe the main challenges or difficulties experienced with the
orientation and planning for IMCI teaching.

D. Placement of IMCI and Teaching Methods Used

Achievements
· How is IMCI incorporated into the selected certificate, diploma or degree
programme(s)? For each year of a programme, describe what elements of
IMCI will be taught, for how many hours or days, and in what setting (e.g.
classroom, outpatient clinic, inpatient clinic, homework, etc.). (see Annex
A for a list of IMCI topic areas)
· Are all three components of the IMCI strategy taught (i.e. 1. Improving the
skills of health staff, 2. Improving the health system to support IMCI,
3. Improving family and community practices)? If yes, how?
· What is the average ratio of teachers to students in IMCI classroom
sessions and in IMCI clinical practice sessions?
· What proportion of IMCI clinical practice is supervised by a trained
instructor who demonstrates cases, observes students as they practise and
provides feedback to students on their performance?
· Are aspects of IMCI taught within related subjects such as pulmonology,
gastroenterology, haematology, paediatric infectious diseases, infant and
child nutrition, etc.? If yes, name the subjects in which IMCI is taught.
· List the primary teaching methods used for IMCI. (see Annex A for a list
of possible teaching and assessment methods)
· Does IMCI classroom and clinical instruction include ways to regularly
check how much and how well students are learning? If yes, how is this
done?
· Are IMCI questions or problems included in oral, written or practical
exams? If yes, please explain.
· Is each student formally assessed for his or her skills related to IMCI? If
yes, how is this done?

Challenges
· Describe the main challenges or difficulties experienced with the
placement of IMCI teaching.
· Describe the main challenges or difficulties with the methods used to teach
IMCI and to assess student knowledge and skills.
· After some experience with IMCI teaching, does your faculty plan to
change the way they teach IMCI? If yes, briefly explain the possible
changes.

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Phase Three – Review and Replan IMCI Teaching Annex 3

E. Training of Teachers and Relevant Clinical Staff

Achievements
· How many staff, if trained, would be available to teach IMCI? Indicate
how many are mainly classroom teachers, how many are clinical teachers,
and how many are both.
· How many teaching staff have attended an IMCI training course?
Indicated how many of the trained staff are mainly classroom teachers,
how many are primarily clinical teachers, and how many are both.
· What types of IMCI courses were used to train the teaching staff (e.g.
standard in-service course, shortened 5-day course, others - please
describe)?
· How many teaching staff have facilitated an IMCI in-service training
course?
· How many clinical staff at the practice site(s), who are available to assist
IMCI teaching, have attended an IMCI training course?
· What types of IMCI courses were used to train staff at the clinical practice
site(s) (e.g. standard in-service course, shortened 5-day course, others -
please describe)?
· Approximately how much do you estimate it cost to train teachers and
relevant clinical staff in IMCI (i.e. time and/or money)?
Challenges
· Describe the main challenges or difficulties experienced with training
teachers and relevant clinical staff in the IMCI guidelines.

F. Clinical Practice
Achievements
· Where do students practise IMCI clinical skills?
· What elements of IMCI do students practise during each year of the
selected certificate, diploma or degree programme(s) (see list of possible
IMCI topics for clinical practice in Annex A)?
· During IMCI clinical practice, does each student manage both outpatient
and inpatient cases of childhood illness?
· Does each student see many children with a variety of signs related to
cough, diarrhoea, fever, measles, ear problem, malnutrition and anaemia?
· Does each student see children with severe illnesses such as pneumonia,
meningitis and severe malaria?
· Does each student manage at least 20 sick children throughout IMCI
clinical practice?
· Does each student receive feedback on his/her performance?
· Are students allowed, under supervision, to dispense oral drugs?
· Are the administration and staff at the clinical practice site(s) informed
about IMCI?
· Is at least one staff member at each clinical practice site available to help
the IMCI clinical instructor to select cases?

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Phase Three – Review and Replan IMCI Teaching Annex 3

· Do clinical staff at the practice site(s) regularly manage cases of childhood

illness according to the IMCI guidelines?
· Approximately how much do you estimate it cost to identify and prepare
sites for IMCI clinical practice (i.e. time and/or money)?
Challenges
· Describe the main challenges or difficulties experienced with clinical
practice for IMCI.

G. Teaching, Learning and Assessment Materials3

Achievements
· Which WHO materials does the faculty use to teach IMCI? (see Annex A
for a list of WHO materials)
· What WHO materials does the faculty use to assess IMCI knowledge and
skills? (see Annex A for a list of WHO materials)
· Which teaching and assessment materials did (or will) the faculty adapt or
develop?
· Does your faculty use other materials to teach or assess IMCI? If yes,
briefly describe those materials.
· Who finances or supplies the materials used?
· Which materials do students keep after IMCI teaching is finished?
· What paediatric textbook do teachers commonly use? What paediatric
textbook do students use?
· Approximately how much do you estimate it cost to identify, develop and
create a supply of teaching and assessment materials for IMCI (i.e. time
and/or money)?
Challenges
· Describe the main challenges or difficulties experienced with the
identification, development and supply of teaching and assessment
materials for IMCI.

H. Experience to Date with IMCI Teaching and Assessment of Students

Please summarize your faculty's experience since starting to teach IMCI to

students. Include the main achievements and difficulties experienced with the:
· placement of IMCI teaching,
· methods used to teach IMCI,
· methods used to assess student knowledge and skills in IMCI,
· training of teachers and relevant clinical staff in IMCI,
· IMCI clinical practice, and the
· teaching, learning and assessment materials used.

3
Please enclose with your report examples of materials that the faculty adapted or developed.

3-8
Phase Three – Review and Replan IMCI Teaching Annex 3

Annex A: Progress Report Questionnaire

Possible Topics, Methods and Materials for IMCI Teaching

1. Possible IMCI topics for classroom sessions

The IMCI case management process

The age groups included in the IMCI charts
General danger signs
Breastfeeding attachment and suckling
Principles of assessing and classifying:
· cough or difficult breathing
· possible bacterial infection (young infant)
· diarrhoea
· fever
· ear problem
· nutritional status
· feeding problem or low weight
Immunization
Referral
Urgent pre-referral treatments
Appropriate outpatient treatments
Follow-up care
Principles of good communication to:
· assess sick children
· teach caretakers to give treatments at home
Principles of counselling:
· to assess and solve feeding problems
· about feeding during sickness and health
· about when to return to a health professional
· about the mother's own health
Technical basis for the general danger signs
Technical basis for the assessment and classification of:
· cough or difficult breathing
· possible bacterial infection
· diarrhoea
· fever
· ear problem
· malnutrition
· anaemia
· feeding problem or low weight
Principles of referral level:
· triage
· emergency care
· monitoring of patient progress

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Phase Three – Review and Replan IMCI Teaching Annex 3

2. Possible IMCI topics for clinical practice sessions

How to use:
· the IMCI charts
· the IMCI case recording form
How to assess:
· general danger signs
· breastfeeding attachment and suckling
How to assess and classify:
· cough or difficult breathing
· possible bacterial infection (young infant)
· diarrhoea
· fever
· ear problem
· nutritional status
· feeding
How to check immunization status
How to identify appropriate treatments
How to give:
· pre-referral treatments
· outpatient treatments
· follow-up care
How to communicate with caretakers
How to advise caretakers about referral
How to teach caretaker's to give treatment(s) at home
How to counsel:
· about feeding and fluids
· about when to return
How to perform referral level:
· triage
· emergency care
· monitoring of patient progress

3. Possible teaching and assessment methods

Classroom methods
lecture student presentation
debate brainstorming
seminar distance/self learning
question and answer (oral drill) role play
case study simulation
written exercise individual reading
video exercise games
photograph booklet exercise individual feedback
assignment/project computer based learning

3-10
Phase Three – Review and Replan IMCI Teaching Annex 3

Clinical practice methods

demonstration case presentation
individual student practice case conference
group practice individual feedback
group discussion group feedback
clinical rounds ward report
patient simulation case write-up/report
work based (on-the-job) learning video reviews of consultations
supervised clinical practice

Assessment methods
observed practice and feedback
written examination
oral examination
practical examination

4. WHO teaching and assessment materials

IMCI course director's guide Guide for clinical practice in the inpatient ward
IMCI facilitator guide for modules Case recording forms
Set of IMCI modules Checklist of clinical signs observed
IMCI chart booklet IMCI pre-service training references
Adapted mother's card Guidelines for Management of the child with
Photograph booklet a serious infection or severe malnutrition
IMCI video tape Breastfeeding counselling course
IMCI wall charts IMCI observation checklist
Facilitator guide for outpatient clinical IMCI written examination
practice

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Phase Three – Review and Replan IMCI Teaching Annex 3

EXAMPLE:
Focus Group Interview with Students

Note for interviewer:

It is recommended to conduct the focus group interview with a small group of

students (from 5 to 10). Try to conduct interview outside of normal teaching hours.

Make sure that you explain the purpose of the interview:

q To collect information about the process of introducing IMCI into an

academic programme; and

q To use the information to improve teaching, learning and assessment

methods and materials used for IMCI.

Try to create a friendly and relaxing atmosphere. Avoid being an “examiner” or

“evaluator.” If possible, organize the interview without the presence of teaching
staff. The presence of teachers may affect the answers to some of the questions.

Try to involve all students in the group in the discussion. However, it is not
necessary to record every answer, or reach a consensus. Make your own
judgement about the answers based of responses from the majority of students. If
you feel that certain individual comments or suggestions are interesting, you may
record them separately as an example.

If you have an opportunity to conduct the interview with more than one group of
students (i.e. in different years or terms of study), try to do it. This will give you an
opportunity to make a more objective decision about the overall process of IMCI
teaching.

3-12
Phase Three – Review and Replan IMCI Teaching Annex 3

1. RECORD INFORMATION ABOUT THE GROUP

a) Number of students interviewed.

b) Year of study in the academic programme.

c) How much training in IMCI was received (tick Ö all relevant topics)?

Introduction ( ) Assess & Classify ( ), Identify Treatment ( )

Treat ( ) Follow-up ( ), Counsel mother ( ), All ( )

2. RELEVANCE OF IMCI TO ACADEMIC PROGRAMME

a) Ask students “Is the IMCI concept relevant to their academic

programme?" Ask them to rate the relevance on a scale of 1 to 5 (1= not
relevant at all to 5 = fully relevant).

b) Ask why a particular score was given

___________________________________________________________
___________________________________________________________
___________________________________________________________

3. THE PROCESS OF TEACHING

a) About how much time has been given to IMCI teaching?

In classroom? _____ hours. Is this: too short ( ), adequate ( ) too long ( )

In the clinic? _____ hours. Is this: too short ( ), adequate ( ) too long ( )

If not adequate, ask why. Then ask for suggestion for improvement.

___________________________________________________________
___________________________________________________________
___________________________________________________________

b) Time of introduction. Was IMCI introduced at appropriate time in the

academic programme?

Use the following categories: not at all appropriate ( ), neutral ( ), fully

appropriate ( )

Then ask: Why?

___________________________________________________________
___________________________________________________________
___________________________________________________________

3-13
Phase Three – Review and Replan IMCI Teaching Annex 3

If not appropriate, ask for suggestions for improvement.

___________________________________________________________
___________________________________________________________
___________________________________________________________

c) Suitability for inpatient and/or outpatient case management. Ask

students: “Where should someone use the IMCI clinical guidelines?”

Only in outpatient department ( )

Only in inpatient department ( )

Both in outpatient and inpatient department ( )

Ask why:

___________________________________________________________
___________________________________________________________
___________________________________________________________

d) Teaching methodology. Ask what main teaching methods were used to

teach IMCI in the school.

In classroom?
___________________________________________________________
___________________________________________________________
___________________________________________________________

In the clinic?
___________________________________________________________
___________________________________________________________
___________________________________________________________

Ask which methods were used most frequently

___________________________________________________________
___________________________________________________________

Ask which methods were most useful

___________________________________________________________
___________________________________________________________

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Phase Three – Review and Replan IMCI Teaching Annex 3

Ask for any suggestion for improving teaching methodology

___________________________________________________________
___________________________________________________________

e) Opportunities for clinical practice using IMCI. If students participated in

clinical practice, ask if they managed patients individually or in groups.

f) If in groups, ask about the size of the group ________ (number of

students)

g) Ask on average how many patients each student managed using IMCI
guidelines. _____________ (number of patients)

h) Ask students “Was the amount of time scheduled/allowed for clinical

practice in IMCI: not enough ( ), enough ( ), too much ( )?

Ask "why" they gave this answer. And ask for any other comments related
to IMCI clinical practice.

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

4. LEARNING MATERIALS

a) Availability of learning materials. Ask what types of materials were

available students used to learn about IMCI:

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Ask how students obtained materials. Was it difficult?

___________________________________________________________
___________________________________________________________
___________________________________________________________

Ask about cost of materials (if appropriate):

too expensive ( ), reasonable ( ) no cost ( )

3-15
Phase Three – Review and Replan IMCI Teaching Annex 3

b) Usefulness of learning materials. Ask which materials they found most

useful? Why?

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Ask for any suggestions to improve the content, presentation and

availability of learning materials?

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

5. ASSESSING STUDENT PROGRESS.

a) Ask “Did teachers informally check how well you were learning and give
information to help you improve?”
___________________________________________________________

If yes, how?

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

b) Ask “Was IMCI included in a formal examination (written, oral, practical

etc.)?

___________________________________________________________
___________________________________________________________

If yes, what kind of examination was it?

___________________________________________________________
___________________________________________________________
___________________________________________________________

Ask "Do you feel that the examinations used, accurately measured your
knowledge and skills in IMCI?"

___________________________________________________________
___________________________________________________________
___________________________________________________________

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Phase Three – Review and Replan IMCI Teaching Annex 3

Ask for any suggestions for improving the methods of assessing student
knowledge and skills.

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

6. STUDENT CONFIDENCE TO USE IMCI

a) Ask students if they feel confident that they can use IMCI to manage sick
children. Ask them to rate their level of confidence on a scale from 1 to 5
(1= not confident at all to 5 = very confident).
___________________________________________________________
___________________________________________________________

b) If confidence rate is low ask for suggestions on what should be done to

increase it.

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

7. OTHER COMMENTS OR SUGGESTIONS

If time permits, ask for any comments or suggestions students may have, for
example:

a) “What do you not understand about IMCI?”

b) “What do you like or not like about IMCI?”
c) “Will IMCI be useful for your future work?”.
d) “Is teaching of IMCI different from other subjects, if yes, how?”

Interviewer _______________________ Date _____________________

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Phase Three – Review and Replan IMCI Teaching

EXAMPLE:
Focus Group Interview with Teachers

Note for interviewer:

It is recommended to conduct the focus group interview with a small group of

teachers who are involved with IMCI teaching.

Make sure that you explain the purpose of the interview:

q To collect information about the process of introducing IMCI into an

academic programme; and

q To use the information to improve teaching, learning and assessment

methods and materials used for IMCI.

Try to conduct interview outside of normal teaching hours. Try to involve all
teachers in the group in the discussion. However, it is not necessary to record
every answer, or reach a consensus. Make your own judgement about the answers
based of responses from the majority of teachers. If you feel that certain individual
comments or suggestions are interesting, you may record them separately as an
example.

If different teaching units are involved in IMCI teaching, try to conduct the
interview with more than one group of teachers. This will give you an opportunity
to make a more objective decision about the overall process of IMCI teaching

Try to create friendly relaxing atmosphere during group interview. Avoid being an
“examiner” or “evaluator”.

3-18
Phase Three – Review and Replan IMCI Teaching

1. RECORD INFORMATION ABOUT THE GROUP

a) Number of teachers interviewed.

b) Department in the teaching institution.

c) Positions and teaching responsibilities/specialities within the department.

d) Formal training received in IMCI: 11-day course ( ), training in facilitator

skills ( ), none ( ), other (specify) ______________________________
_________________________________________________________

2. RELEVANCE OF IMCI TO THE ACADEMIC PROGRAMME

a) Ask teachers “Is the IMCI concept relevant to the selected academic
programme?" Ask them to rate the relevance on a scale of 1 to 5 (1= not
relevant at all to 5 = fully relevant).

c) Ask why a particular score was given

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

3. THE PROCESS OF TEACHING

a) Ask about how much time was spent on IMCI teaching?

In classroom? ____ hours. Is this: too short ( ), adequate ( ) too long ( )

In the clinic? _____ hours. Is this: too short ( ), adequate ( ) too long ( )

If not adequate, ask why. Then ask for suggestion for improvement.

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

b) Time of introduction. Ask if teachers think that IMCI was introduced at

appropriate time in the course of study. Use the following categories:
not appropriate at all ( ), neutral ( ), fully appropriate ( )

Then ask: Why?

______________________________________________________________
______________________________________________________________
______________________________________________________________

3-19
Phase Three – Review and Replan IMCI Teaching

If not appropriate, ask for suggestions for improvement.

______________________________________________________________
______________________________________________________________
______________________________________________________________

c) Suitability for inpatient and/or outpatient case management. Ask

teachers: “When the IMCI clinical guidelines should be used?”

Only in outpatient department ( )

Only in inpatient department ( )

Both in outpatient and inpatient department ( )

Ask why:

______________________________________________________________
______________________________________________________________
_____________________________________________________

d) Teaching methodology. Ask what main teaching methods were used to

teach IMCI in the school.

In classroom?
______________________________________________________________
______________________________________________________________
______________________________________________________________

In the clinic?
______________________________________________________________
______________________________________________________________
______________________________________________________________

Ask which methods were used most frequently

______________________________________________________________
______________________________________________________________

Ask which methods were most useful

______________________________________________________________
______________________________________________________________

Ask for any suggestion for improving teaching methodology

______________________________________________________________
______________________________________________________________
______________________________________________________________

3-20
Phase Three – Review and Replan IMCI Teaching

e) Opportunities for clinical practice using IMCI. Ask if students managed

patients individually or in groups.

f) If in groups ask about the average size of the group. _________ (students)

g) Ask on average how many patients each student manage using the IMCI
guidelines. _____________ (number of patients)

h) Ask teachers “Was the amount of time scheduled/allowed for clinical

practice in IMCI: too little ( ), enough ( ), too much ( )?

Ask why. Ask for any other comments related to IMCI clinical practice, if any

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

4. LEARNING MATERIALS

a) Availability of learning materials. Ask what types of IMCI learning materials

students were asked to use:

______________________________________________________________
______________________________________________________________
______________________________________________________________

Ask how students obtained materials?

______________________________________________________________
______________________________________________________________
______________________________________________________________

Ask about cost of those materials (if appropriate):

too expensive ( ), reasonable ( ) no cost ( )

b) Usefulness of learning materials. Ask which student materials were more

useful? And why?

______________________________________________________________
______________________________________________________________
______________________________________________________________

Ask for any suggestions to improve the content, presentation and availability
of student materials?

______________________________________________________________
______________________________________________________________
______________________________________________________________

3-21
Phase Three – Review and Replan IMCI Teaching

5. TEACHING MATERIALS

a) Availability of teaching materials. Ask what types of IMCI materials were

used by teachers:

______________________________________________________________
______________________________________________________________
______________________________________________________________

Ask how did teachers obtain materials?

______________________________________________________________
______________________________________________________________
______________________________________________________________

Ask about cost of those materials (if appropriate):

too expensive ( ), reasonable ( ) no cost ( )

b) Usefulness of teaching materials. Ask which teaching materials they found

more useful? And why?

______________________________________________________________
______________________________________________________________
______________________________________________________________

Ask for any suggestions to improve the content, presentation and availability
of IMCI teaching materials?

______________________________________________________________
______________________________________________________________
______________________________________________________________

6. ASSESSING STUDENT PROGRESS.

a) Ask “Did you check how well students were learning and give information to
help students improve their performance?”

______________________________________________________________
______________________________________________________________
______________________________________________________________

If yes, how?

______________________________________________________________
______________________________________________________________
______________________________________________________________

b) Ask “Was IMCI included in a formal examination (written, oral, practical etc.)?
______________________________________________________________

3-22
Phase Three – Review and Replan IMCI Teaching

______________________________________________________________
______________________________________________________________

If yes, what kind of examination was it?

______________________________________________________________
______________________________________________________________
______________________________________________________________

Ask about appropriateness of the method(s) used for assessing student

knowledge and skills in IMCI

______________________________________________________________
______________________________________________________________

Ask for any suggestions for improving the method of assessing student IMCI
knowledge and skills.

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

7. STUDENT CONFIDENCE TO USE IMCI

a) Ask teachers if they feel confident that their students could use IMCI to
manage sick children. Ask them to rate the confidence on a scale of 1 to 5
(1= not confident at all to 5 = very confident).

If the confidence rating is low, ask for suggestions about what should be done
to increase it.

______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________

8. OTHER COMMENTS OR SUGGESTIONS

If time permits, ask for any comments or suggestions teachers may have, for
example:

a) “What do their students not understand about IMCI?”

b) “What do they like, or not like about IMCI?”
c) “Will IMCI be useful for your students in their future work?”.
d) “Is teaching of IMCI different from other subjects, if yes, how?”

3-23
Phase Three – Review and Replan IMCI Teaching

Interviewer _______________________ Date ______________

3-24
Phase Three – Review and Replan IMCI Teaching

EXAMPLE:
Observation Form for an IMCI Clinical
Practice Session

Notes for the observer:

Discuss with the unit chief or a responsible teacher the possibility of observing
a typical IMCI clinical training session for students. If possible select a training
session in the outpatient department rather that in an inpatient hospital ward.

Before the session, try to obtain the following (if they exist):

i. objectives of the session (written or orally from a teacher)

ii. written guidelines for the session (If not available, ask the teacher in
advance about his/her plans for conducting the session)

During the session try not to interrupt with questions or other activities
such as interviews with students or student assessment.

3-25
Phase Three – Review and Replan IMCI Teaching Annex 3

1. INFORMATION ABOUT THE TEACHING INSTITUTION/UNIT

Name of the teaching institution ___________________________________

Name of the teaching unit ________________________________________

2. INFORMATION ABOUT SESSION OBSERVED

a. Topic of the session observed (according to written materials or based

on information from the teacher):

b. Objectives of the session observed (according to written materials or

based on information from the teacher):

c. Duration of the session and opportunities for clinical practice

Number of
students in a
Length of the
group. AND
session (minutes).
Teacher/student
ratio.

Did students
practice with Average number
patients individually of cases that each
or in groups? If in student managed
groups, how many individually.
students per group?

Average number
Average number of
of inpatients
outpatients seen by
seen by each
each student:
student:

Working Draft: April 2001

Phase Three – Review and Replan IMCI Teaching

d. Use of teaching guidelines. Note if IMCI teaching guidelines were

followed by the teacher (obtain written guidelines for the session before
the session starts. If not available, ask the teacher before the session
what will be the main elements of the session). Were there deviations
from the guidelines? If yes, explain what was added or removed.

e. Approximate time spent (% or min) for different session components

Explanations
Clinical Demonstrations
Discussions
Questions/answers
Student evaluation/monitoring/feedback
Supervised clinical practice by students
(individual or in small groups)
Summary
Others (describe)

f. Types of IMCI signs and symptoms demonstrated/practised:

 Danger signs  feel hot/fever

 Fast breathing  stiff neck
 Chest indrawing  runny nose
 Stridor  generalized rash
 Clouding cornea  Lethargic
 deep mouth ulcers  Sunken eyes
 pus draining of the eye  Not able to drink
 Skin pinch (S/VS)  ear pain/discharge
 Restless  pus draining from the ear
 Drink eagerly/thirsty  tender swelling behind the ear
 Blood in the stool  Severe wasting visible
 Palmar pallor  signs of local bacterial infection
 Oedema on feet  assessment of attachment
 Weight for age  assessment of positioning
 signs of possible serious
bacterial infection

3-27
Phase Three – Review and Replan IMCI Teaching

g. IMCI classifications demonstrated/practised:

 Cough or difficult breathing  Fever

 Possible bacterial infection  Nutritional status
 Feeding problem  Diarrhoea

h. Treatment and counselling practised

Treatment
o Always o Frequently o Sometimes o Never
identified
Treatment
o Always o Frequently o Sometimes o Never
practised
Follow-up
o Always o Frequently o Sometimes o Never
practised
Counselling
o Always o Frequently o Sometimes o Never
practised

i. Variety of teaching methods used during the session (tick all

methods used)

o question and answer (oral drill)

o demonstration
o individual student practice o individual feedback
o group practice o group feedback
o observation of student practice
o clinical rounds o group discussion
o ward report o case write-up/report
o case studies
o patient simulation o work based (on-the-job) learning
o supervised clinical practice o video reviews of consultations
o case presentation
o case conference o others (describe):

j. Teaching/learning material and equipment used

Materials used by
teachers

Materials used by
students

Clinical supplies and

equipment used

3-28
Phase Three – Review and Replan IMCI Teaching

k. Specific questions asked by students during the session

l. Overall comments about the session

Observer: _________________________ Date : _________________

3-29
Phase Three – Review and Replan IMCI Teaching

EXAMPLE:
Observation Form for an IMCI Classroom Session

Notes for the observer:

Discuss with the unit chief or a responsible teacher the possibility of observing
a typical IMCI classroom session for students.

Before the session, try to obtain the following (if they exist):

iii. objectives of the session (written or orally from a teacher)

iv. written guidelines for the session (If not available, ask a teacher in
advance about how he/she plans to conduct the session)

During the session try not to interrupt with questions or other activities
such as interviews with students or student assessment.

3-30
Phase Three – Review and Replan IMCI Teaching

1. INFORMATION ABOUT SCHOOL/DEPARTMENT

Name of the teaching institution ______________________________________

Name of the teaching unit ___________________________________________

2. INFORMATION ABOUT SESSION OBSERVED

a. Topic of the session observed (according to written materials or based on

information from the teacher):

b. Objectives of the session observed (according to written materials or

based on information from the teacher):

c. Duration of the session and opportunities for clinical practice

Number of
students in a
Length of the
group. AND
session (minutes).
Teacher/student
ratio.

Did students
practice with Average number
patients individually of cases that each
or in groups? If in student managed
groups, how many individually.
students per group?

Average number
Average number of
of inpatients
outpatients seen by
seen by each
each student:
student:

3-31
Phase Three – Review and Replan IMCI Teaching

d. Use of teaching guidelines. Note if IMCI teaching guidelines were followed

by the teacher (Obtain written guidelines for the session before the session
starts. If not available, ask the teacher what will be the main elements of the
session). Were there deviations from the guidelines? If yes, explain what
was added or removed.

e. Approximate time spent (% or min) for different session components

Lecture/explanations
Reading/written exercises
Discussions
Questions/answers
Student
assessment/monitoring/feedback
Demonstrations
Summary
Others (describe)

f. IMCI content presented during the session

 The IMCI case management process  Principles of counselling:

 The age groups included in the IMCI  to assess/solve feeding problems
charts  feeding during sickness and
 The general danger signs health
 Breastfeeding attachment and  when to return to a health facility
suckling  about the mother's own health
 Principles of assessing and  Tech basis for general danger
classifying: signs
 cough or difficult breathing  Tech basis for assessment / class of:
 possible bacterial infection  cough or difficult breathing
(infant)  possible bacterial infection
 diarrhoea  diarrhoea
 fever  fever
 ear problem  ear problem
 nutritional status  malnutrition
 anaemia
 feeding problem or low weight
 feeding problem or low weight
 Immunization
 Principles of referral level:
 Referral  triage
 Urgent pre-referral treatments  emergency care
 Appropriate outpatient treatments  monitoring of patient progress
 Follow-up care  Other (describe):
 Principles of good communication to:
 assess sick children

3-32
Phase Three – Review and Replan IMCI Teaching

 teach to give treatments at home

g. Variety of teaching methods used during the session(tick all methods

used)

 lecture  student presentation  demonstration

 debate  group discussion  brainstorming
 seminar  distance/self learning  oral drill
 case study  role play  simulation
 Individual reading  games  written exercise
 Individual feedback  video exercise  computer learning
 Photograph booklet  assignment/project  Others (describe):

h. Teaching/learning material and equipment used

By teachers

By students

Classroom
equipment

i. List specific questions asked by students during the session:

j. Overall comments on the session

3-33
Phase Three – Review and Replan IMCI Teaching

Observer: ________________________________ Date : ___________

3-34
Phase Three – Review and Replan IMCI Teaching Annex 3

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Sample Observation Checklist - Sick Child Age 2 Months up to 5 Years

Student's Name: _______________ Student Type: _________ Examiner: _______________ Date: _______
Child's Name: __________________________ Age: ______ Weight: _______ kg Temperature: ________°C
Presenting Complaint: ____________________________________________________________________________
A. Assessment
Assessment Student Percent
KEY ASSESSMENT TASKS
needed? Score* of gold Notes
(Tasks in bold are needed for all children) 2 = Needed (0, 1, or 2) standard**
1. CHECKS all danger signs
(ASKS if child is able to drink or breastfeed, if child vomits The total of
everything, if child had convulsions during this illness. student
CHECKS if child is lethargic or unconscious, or convulsing now) score
The total of
2. ASKS if child has cough or difficult
assess-
breathing ment
2.a. If YES, asks for how long, counts breathing rate, looks for needed
chest indrawing and listens for stridor.
3. ASKS if child has diarrhoea
3.a. If YES, asks for how long, asks if there is blood in stool,
observes drinking or breastfeeding, pinches skin of abdomen,
looks for sunken eyes.
4. ASKS if child has sore throat
4.a. If YES, feels for enlarged lymph node on the neck, look for
white exudate on the throat
5. ASKS if child has an ear problem
5.a. If YES, asks about ear pain and discharge, looks for pus and
feels for swelling
6. ASKS if child has fever
4.a. If YES, asks for how long, asks about measles, looks for stiff
neck, and signs of measles
4.b. If MEASLES, looks for mouth ulcers, pus draining from eye
and clouding of cornea.
7. CHECKS for malnutrition and anemia
(looks for visible severe wasting, palmar pallor, oedema of both
feet and determines weight for age)
8. CHECKS immunization status
9. CHECKS vitamin A status
10. ASKS about other problems
Totals: %
* (0 = Not done; 1 = Done, but not correctly; 2 = Done correctly) ** Per cent of examiner's assessment
B. Classification
KEY CLASSIFICATION WRITE THE CLASSIFICATION Classification Student Percent of
needed? Score* gold Notes
AREAS
by EXAMINER by STUDENT 2 = Needed (0, 1 or 2) standard**
1. General danger sign?(Y/N)
The total of
2. Cough or difficult breathing student
score
3. Diarrhoea
The total of
Dehydration classifica-
Persistent Diarrhoea tion needed
Dysentery
4. Sore throat
5. Ear problem
6. Fever (including Measles)
7. Malnutrition and anemia
Totals: %

* (0 = Not done; 1 = Done, but not correctly; 2 = Done correctly) ** Per cent of examiner's classification

3-35
Phase Three – Review and Replan IMCI Teaching Annex 3
Observation Checklist - Sick Child Age 2 Months up to 5 Years

C. Identification of Feeding Problems (if anaemia, very low weight, or less than 2 years)
Steps Student Percent of
KEY TASKS needed? Score* gold Notes
2=Needed (0, 1, or 2) standard**

1. ASKS about breastfeeding, other food or fluids, if feeding The total of

student
changed during illness
score
The total of
steps
2. IDENTIFIES feeding problems needed
Totals: %
* (0 = Not done; 1 = Done, but not correctly; 2 = Done correctly) ** Per cent of examiner's conclusion

D. Treatment (given or identified)

TREATMENT IDENTIFIED Treatment Student Percent of
KEY TREATMENT TASKS needed? Score* gold Notes
by EXAMINER by STUDENT 2 = Needed or (0, 1, or 2) standard**
(Y or N) (Y or N) Done
1. IDENTIFIES pre-referral
The total of
treatment/s
student
2. PRESCRIBES/IDENTIFIES score
2.a. Antibiotic tablets/syrup The total of
treatment
2.b. Rehydration Plan A, B or C
needed
2.c. Paracetamol/aspirin
2.d. Vitamin A
2.e. Tetracycline eye ointment
2.f. Gentian violet
2.g. Iron
2.h. Other (specify):
2.i. Other (specify):
Totals: %
* (0 = Not done; 1 = Done, but not correctly; 2 = Done correctly) ** Per cent of examiner's treatment

E. Counselling
Counselling Student Percent of
KEY COUNSELLING TASKS needed? Score* gold Notes
(Tasks in bold are needed for all children) 2=Needed (0, 1, or 2) standard**

1. Gives mother feeding counseling relevant to the child's age The total of
2. Advises to give child extra fluid and continue feeding during student
score
illness
The total of
3. Explains when to return immediately counselling
needed
4. Explains reason for referral and gives a referral note
5. Gives mother feeding counselling relevant to the child's age
6. Teaches mother to give oral drugs
7. Teaches mother to treat local infection
Totals: %
* (0 = Not done; 1 = Done, but not correctly; 2 = Done correctly) ** Per cent of examiner's conclusion

GRAND TOTAL: %

Egypt Adaptation: 16-Jan-01

3-36
Phase Three – Review and Replan IMCI Teaching Annex 3

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)

Sample Written Examination

March 2001

Instructions: Select or write the correct answer. Remember that for some questions
there may be more than one correct answer.

Note: If needed, you may refer to the IMCI Chart Booklet and Mother's Card. You may
also use the IMCI case recording form.

A. The IMCI Guidelines

A.1. What are the five major killers of children?

a. ___________________________
b. ___________________________
c. ___________________________
d. ___________________________
e. ___________________________

A.2. Where should the IMCI guidelines be used?

a. in the inpatient ward of a hospital

b. in the outpatient ward of a hospital
c. at first-level health facilities
d. in specialized hospitals

A.3. The IMCI clinical guidelines describe how to manage a child:

a. with a chronic problem

b. with an acute illness
c. with injuries
d. during a follow-up visit
e. with trauma

A.4. The IMCI clinical guidelines are designed for use with which of the following
age group(s)?

a. Birth – 5 years
b. 2 months – 2 years
c. 1 week up to 5 years
d. 2 months up to 9 years
e. 6 months up to 10 years

3-37
Phase Three – Review and Replan IMCI Teaching Annex 3

B. Assessment and Classification

B.1. When a child is brought to a health facility you should always check for general
danger signs. The general danger signs are:

a. child is restless or nervous

b. child is lethargic or unconscious
c. child cries loudly or too long
d. child is not able to drink or breastfeed
e. child vomits frequently
f. child has convulsions
g. child vomits everything

B.2. List the main symptoms for which every sick child should be checked:

______________________________________________________________
______________________________________________________________
______________________________________________________________

B.3. What is the cut-off rate for fast breathing in a child who is exactly 12 months
old:

a. 60 breaths per minute or more

b. 50 breaths per minute or more
c. 40 breaths per minute or more
d. 30 breaths per minute or more

B.4. Read the description of the following case and write the correct classification:

Pemba is 18 months old. He weighs 9 kg, and his temperature is 37ºC. His
mother says he has had a cough for 3 days.

Pemba's mother said that he is able to drink and has not vomited anything. He
has not had convulsions. Pemba was not lethargic or unconscious.

You counted 40 breaths per minute. The mother lifted the child's shirt and you
did not see chest indrawing. You did not hear stridor or wheeze when you
listened to the child's breathing.

Write down Pemba’s classification(s):

_________________________________________________________

B.5. To classify the dehydration status of a child with diarrhoea you should LOOK
and FEEL for:
a. ____________________________
b. ____________________________
c. ____________________________
d. ____________________________

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Phase Three – Review and Replan IMCI Teaching Annex 3

B.6. In addition to assessing dehydration status, the mothers of ALL children with
diarrhoea should be asked:

a. For how long has the child had diarrhoea?

b. How many times did the child have watery stool?
c. What did the child eat before the diarrhoea started?
d. Is there blood in the stool?
e. Do other family members have diarrhoea?

B.7. Read the description of the following case and write the correct
classification(s):

Heera is 3 years old. She weighs 10 kg. Her temperature is 37ºC. Her mother
came today because Heera has diarrhoea.

She does not have any general danger signs. She does not have cough or
difficult breathing.

When you asked how long Heera has had diarrhoea, the mother said, "For more
than 2 weeks." There is blood in the stool. Heera is irritable during the visit, but
her eyes are not sunken. She is able to drink, but she is not thirsty. A skin pinch
goes back slowly.

Write down Heera’s classification(s):

__________________________________________________________
__________________________________________________________

B.8. To be classified as having STREPTOCOCCAL SORE THROAT a child must

have fever or sore throat and TWO of the following signs:

a. severe pain in the throat

b. not able to drink
c. have enlarged tender lymph node(s) on the throat or tonsils
d. redness seen in the throat
e. white or yellow exudate on the throat or tonsils
f. red (congested) throat

B.9. To be classified as having MASTOIDITIS a child must have the following

signs:

a. severe ear pain and redness behind the ear

b. swelling behind the ear
c. pus draining from one of child’s ear
d. pus draining from both child’s ears
e. tender swelling behind the ear

3-39
Phase Three – Review and Replan IMCI Teaching Annex 3

B.10. Read the description of the following case and write the correct
classification(s):

Dana is 18 months old. She weighs 9 kg. Her temperature is 37ºC. Her mother
said that Dana had discharge coming from her ear for the last 3 days.

Dana does not have any general danger signs. She does not have cough or
difficult breathing. She does not have diarrhoea and she does not have fever.

You asked about Dana's ear problem. The mother said that Dana does not
have ear pain, but the discharge has been coming from the ear for 3 or 4 days.
You can see pus draining from the child's right ear. You do not feel any tender
swelling behind either ear.

Write down Dana’s classification(s):

__________________________________________________________

B.11. A child should be assessed for the main symptom of FEVER if the child:

a. has a history of fever

b. does not feel well
c. feels hot
d. has temperature 37º
e. has temperature 37.5º or above
f. has generalised rash

B.12. Read the description of the following case and write the correct
classification(s):

Anders is 3 years old. He weighs 9.4 kg. His temperature is 37,5ºC. His mother
says he feels hot. He also has a cough, she says.

Anders was able to drink, had not vomited, did not have convulsions, and was
not lethargic or unconscious.

The mother said Anders had been coughing for 3 days. You counted 51 breaths
a minute. You did not see chest indrawing. There was no stridor when Anders
was calm, and there is no wheezing.

Anders does not have diarrhoea.

Because Anders’ temperature was 37,5ºC you assessed the child further for
signs of fever. The child has felt hot for 5 days, the mother said. The child did
not have a stiff neck, but there was runny nose, and generalized rash. There is
no clouding of cornea, pus draining from the eye, or moths ulcers.

Write down Anders’s classification(s):

___________________________________________________________

3-40
Phase Three – Review and Replan IMCI Teaching Annex 3

___________________________________________________________

B.13. Which children should be checked for malnutrition and anaemia?

a. all children with feeding problem(s)

b. all children who are less than 12 months of age
c. all children brought to the clinic
d. all children who are not breastfeed

B.14. Read the description of the following case and write the correct
classification(s):

Kalisa is 11 months old. He weighs 8 kg. His temperature is 37ºC. His mother
says he has had a dry cough for the last 3 weeks.

Kalisa does not have any general danger signs. You assessed his cough. It has
been present for 21 days. You counted 41 breaths per minute. You do not see
chest indrawing, but you can hear wheezing noise when the child breathing out.
There is no stridor when the child is calm. Kalisa does not have diarrhoea. He
has not had a fever during this illness. He does not have an ear problem.

You checked Kalisa for malnutrition and anaemia. Kalisa does not have visible
severe wasting. His palms are very pale and appear almost white. There is no
oedema of both feet. Look at the weight for age chart in your chart booklet and
determine Kalisa's weight for age.

Write down Kalisa’s classification(s):

_________________________________________________________
_________________________________________________________
B.15. Review the information below and decide if a contraindication to immunization
is present for each of the following children (tick ¥ appropriate box):

Immunize this Do not

If the child: child today immunize today
if due for
immunization
a. will be treated at home with
antibiotics
b. has a local skin infection

c. has a chronic heart problem

d. is being referred for severe

classification
e. is exclusively breastfed

f. was jaundiced at birth

g. Is classified as VERY LOW WEIGHT

3-41
Phase Three – Review and Replan IMCI Teaching Annex 3

Immunize this Do not

If the child: child today immunize today
if due for
immunization
h. Is classified as NO PNEUMONIA:
COUGH OR COLD

C. Feeding problems

C.1. You should assess the feeding of children who:

a. are classified as having VERY SEVERE DISEASE

b. are less then 2 years old and any classification
c. are classified as having ANAEMIA OR VERY LOW WEIGHT
d. are classified as having PERSISTENT DIARRHOEA

C.2. Write a "T" by the statements that are True. Write an "F" by the statements
that are False.

a. ____ children should be given fewer feedings during illness.

b. ____ a 3-month-old child should be exclusively breastfed.

c. ____ a very thin cereal gruel is a nutritious complementary food.

d. ____ a 3-year-old child needs 5 feedings each day of family foods or

other nutritious foods.

e. ____ a 5-month-old child should be breastfed as often as he wants, day

and night.

C.3. Read the description of the following case and answer the questions.

Rena is 5 months old and weighs 4 kilograms. She is classified as VERY

LOW WEIGHT. When you assess Rena's feeding, her mother tells you that
she breastfeeds 4 times in 24 hours and also gives Rena cow's milk by
feeding bottle 2 times per day. The mother explains that she gives no other
foods to Rena and her feeding did not change during this illness.

a. What are Rena's feeding problems?

___________________________________________________________
___________________________________________________________
___________________________________________________________

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b. What is the mother doing correctly to feed Rena?

___________________________________________________________
___________________________________________________________

c. What feeding advice is needed?

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
__________________________________________________________

C.4. You just counseled the mother of a 5 month old about starting complementary
foods. The first and second columns below show your first checking questions
and the mother's responses. In the third column, write another checking
question to clarify that the mother knows how to feed the child correctly.

First Checking Question Mother's Second Checking

Response Question
C.4.a. What are some good Thick, nutritious
foods to give? foods

C.4.b. When will you begin When he is ready

giving these foods?

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D. Treatment

D.1. Review information about the sick children below and decide if they need
urgent referral.
Urgent No need
referral for urgent
needed referral

a. Sara is an 11-month-old girl. She has no general

danger signs. She is classified with:

PNEUMONIA
ACUTE EAR INFECTION
NO ANAEMIA AND NOT VERY LOW WEIGHT
no other classifications

b. Neema is a 6-month-old girl. She has no general

danger signs. She is classified with:

NO PNEUMONIA: COUGH OR COLD

Diarrhoea with NO DEHYDRATION
PERSISTENT DIARRHOEA
NO ANAEMIA AND NOT VERY LOW WEIGHT
no other classifications

c. David is a 7-month-old boy. He has no general danger

signs. He is classified with:

MASTOIDITIS
NO ANAEMIA AND NOT VERY LOW WEIGHT
no other classifications

d. Habib is a 9-month-old boy. He is lethargic. He is

classified with:

Diarrhoea with SEVERE DEHYDRATION

NO ANAEMIA AND NOT VERY LOW WEIGHT
no other classifications

The clinic can provide IV therapy

e. Isoke is 2 years old. She has no general danger signs.

She is classified with:

Diarrhoea with SEVERE DEHYDRATION

SEVERE MALNUTRITION OR SEVERE ANAEMIA
no other classifications

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D.2. Read the steps used to teach mother how to give oral drugs au home. Write
down missing steps:

1. Determine the appropriate drugs and dosage for the child's age or weight.

2. Tell the mother the reason for giving the drug to the child

3. _____________________________________________

4. _____________________________________________

5. Ask the mother to give the first dose to her child

6. Explain carefully how to give the drug, then label and package the drug

7. Explain that all the oral drug tablets or syrups must be used to finish the
course of treatment, even if the child gets better.

8. _______________________________________________

D.3. For the cases given below identify the correct antibiotic(s) and the amount of
the first dose.

Type of Amount
antibiotic(s) of 1st
dose

D.3.a. A 6-month-old (7 kg) child has PNEUMONIA

D.3.b. A 36-month-old child (15 kg) needs an

antibiotic for SEVERE DEHYDRATION
because there is cholera in the area

D.4. What are the three rules for home treatment of diarrhoea?

a. _______________________________________________________
b. _______________________________________________________
c. _______________________________________________________

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E. Counselling

E.1. According to the IMCI guidelines, the mother of a sick child should be
counselled about four topics. What are the four topics for counselling?

a. _______________________________________________________
b. _______________________________________________________
c. _______________________________________________________
d. _______________________________________________________

E.2. For the cases given below list the signs that indicate when to return
immediately (you will teach the mother to watch for these signs).

Signs when to return immediately

E.2.a. A child has: -

no general danger signs -

ACUTE EAR INFECTION
NO ANAEMIA AND NOT -
VERY LOW WEIGHT
no other classifications

E.2.b. A child has: -

no general danger signs -

Diarrhoea with NO
DEHYDRATION -
PERSISTENT DIARRHOEA
NO ANAEMIA AND NOT -
VERY LOW WEIGHT
no other classifications -

E.3. It is important to ask good checking questions to ensure that a mother

understood well your treatment instructions. The questions below can be
answered with “yes” or “no.”

Rewrite the questions as good checking questions.

E.3.a. Do you remember when to give

the antibiotic?

E.3.b. Do you understand how much

syrup to give your child?

E.3.c. Do you know how to get to the

hospital?

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F. Follow-Up

F.1. Read the following case and answer the questions.

Ahmed has been brought in the outpatient clinic for a follow-up visit for
pneumonia. He is three years old and weighs 12.5 kg. His axillary temperature
is 37ºC. He has been taking amoxycillin. His mother says he is still sick and has
vomited twice today.

a. How would you reassess Ahmed today? List the signs you would look at
and the questions you would ask his mother.

When you reassess Ahmed, you find that he is able to drink and does not always
vomit after drinking. He has not had convulsions. He is not lethargic or
unconscious. He is still coughing, so he has been coughing now for about 2
weeks. He is breathing 55 breaths per minute. He has chest indrawing. He
does not have wheezing or stridor. His mother says that sometimes he feels hot.
She is very worried because he is not better. He has hardly eaten for two days.

b. Is Ahmed getting worse, the same, or better?

c. How should you treat Ahmed?

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INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)

ANSWER SHEET FOR THE WRITTEN EXAMINATION

A. The IMCI Guidelines

A.1 It is expected that a student should list the five major killers in his/her own
country.

A.2. “b”, “c”

A.3. “b”, “d”

A.4. “c”

B. Assessment and Classification

B.1. “b”, “d”, “f”, ‘”g”

B.2 In generic materials the list includes cough and difficult breathing, diarrhoea,
fever, ear infection, malnutrition and anemia (in some countries it may include
additional symptoms depending on local adaptation)

B.3 “c”

B.4 “PNEUMONIA”

B.5 “Look at the child’s general condition”, “Look for sunken eyes”, “Offer the child
fluid (look how the child drinks)”, “Pinch the skin of the abdomen”

B.6 “a”, “d”

B.7 “SOME DEHYDRATION”, SEVERE PERSISTENT DIARRHOEA”,

“DYSENTERY”

B.8 “c”, ”e”, “f”

B.9 “e”

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B.10 “ACUTE EAR INFECTION”

B.11 “a”, “c”, “e”

B.12 “PNEUMONIA”, “MEASLES”

B.13 “c”

B.14 “NO PNEUMONIA: COUGH OR COLD”, “SEVERE ANAEMIA”

B.15 ”d” – do not immunize, all others - immunize

C. Feeding problems

C.1 “b”, “c”

C.2. “a” = F, “b” = T, “c” = F, “d” = T, “e” = T

C.3.a. Not breastfed often enough. Giving cows milk. Using feeding bottle.

C.3.b. She is breastfeeding.

C.3.c. Breastfeed at least 8 times in 24 hours (day and night). If you cannot
breastfeed 8 times in 24 hours, use a cup instead of a bottle to give the
cow's milk. Give complementary foods 1 or 2 times per day after
breastfeeding.

C.4.a. What kind of thick, nutritious food will you give? What are some examples
of food you will give?

C.4.b. How will you know when your baby is ready for these foods? What signs
you will look for?

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D. Treatment

D.1.a. - NO

D.1.b. - NO

D.1.c. - YES

D.1.d. - NO

D.1.e. - YES

D.2 3. – determine how to measure a dose, 4 – Watch the mother practice

measuring a dose by herself, 8 – Check the mother’s understanding before she
leaves the clinic

D.3.a. first line antibiotic before referral

D.3.b. cotrimoxazole to treat cholera. Dosage = 1 adult tablet, two times daily or 3
paediatric tablets two times daily, or 7.5 ml of syrup, two times daily

D.4 Three rules of home treatment are: 1. Give more fluids, 2. Continue
feeding, 3. Counsel when to return

E. Counseling

E.1. Four main items to counsel the mother are: 1. About food and feeding
problems, 2. About fluid, 3. When to return, 4. About her own health.

E.2.a. Not able to drink or breastfeed, Becomes sicker, Develops fever

E.2.b. Not able to drink or breastfeed, Becomes sicker, Develops fever, Blood in
stool, Drinking poorly

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E.3.a. When you will give antimalarial? For how many days?

E.3.b. How much syrup will you give your child? Show me

E.3.c. How will you get to the hospital?

F. Follow-up

F.1.a. Is he is able to drink? Does he vomits everything? Has he had convulsions?

See if he is lethargic or unconscious. Is he still coughing? How long has he
been coughing? Count the breaths in one minute. Look for chest indrawing.
Look and listen for stridor. Is he breathing slower? Is there fever? Is it less?
Is he eating better?

F.1.b. He is worse. He has chest indrawing.

F.1.c. Refer urgently. Before departure give him a dose of amoxycillin (the second
line antibiotic), one 250 mg tablet.

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