ICRC Almanach

Enhancing PHC quality diagnostic and treatment for the under 5 children in ICRC supported health centres; The ALMANACH project

A SwissTPH - PMU - ICRC project (2015-2018)

Report author(s): Enrica Leresche, Valérie D'Acremont, Alexandre Vanobberghen, Stéphane Du Mortier

Summary

All over the world, ICRC is supporting Primary Health Services - Primary Health Care Centres (PHCC) or Mobile Health Units (MHU) - in conflict areas, by supporting national health authorities in their duty to deliver quality health care to the civilian population.

Most of the countries are implementing the Integrated Management of Childhood Illnesses (IMCI) protocols promoted by WHO since the year 2000 but few have updated the organigrams with the latest rapid diagnostic tests (RDT) as urine dipsticks or malaria rapid tests.

In line with the ICRC health strategy 2014-2018, especially its 4th objective “The ICRC ensures the highest possible quality of health care in line with appropriate standards that are adapted to the specific contexts. The health impact of these activities is monitored and evaluated”, the PHC Services encountered the Swiss Tropical and Public Health Institute (SwissTPH) and the Policlinique Médicale Universitaire (PMU) teams to develop an innovative project in common (Partner innovation and technological innovation projects) to respond to the needs of the less than 5 year old children in these remote health services. The Swiss TPH has developed the ALAMANACH, an electronic ALgorithm for the MAnagement of CHildhood illnesses running on mobile devices with proven successes and published results.

This project paper documents the strategic objectives, logical framework and corresponding budget to guarantee that in Lebanon and Mexico, children under 5 year, consulting ICRC supported PHC centres, receive up to date evidence based quality diagnostic, treatment and care. The long-term vision is that all supported PHCC worldwide would have this technology in the ICRC support package and algorithms will be enlarged to all populations.

 

  • Assess & Analyse
    • General situation of the country and/or intervention area(s)
  • ICRC supports hundreds of PHC centres in conflict setting where thousands of children are consulted yearly. Due to turmoil and insecurity, the - mainly MOH- health workers in charge of these consultations are still applying old protocols, generally with a low level of adherence.
  • The Integrated management of Childhood Illnesses (IMCI) promoted by WHO in 2000 (A syndromic based approach with generous antimicrobial medicine deliveries in order to save children lives by all means) is targeting only a limited number of the various causes of acute illness in children. Since then, malaria incidence has reduced drastically, and several validated Rapid Diagnostic Test (RDT) are now available for different infectious diseases, making this approach based on presumptive treatment obsolete.
  • ICRC is working in agreement with national MOH protocols, supporting recognised health centres critically situated in the conflict zone. Logistic or epidemiological support is always in respect of national system avoiding parallel standards.
  • ICRC is working in conflict-affected settings where security and access are issues: remote-control can be a way of working with its issues in terms of supervision and feedback on quality of care.

 

  • Health needs and existing response
  • The children consulted in ICRC PHC supported centres are not diagnosed and treated according to the latest evidence based protocols.
  • In most of the countries, IMCI is recognised but applied with few supervision, no local adaptation and no update. RDT (for malaria or urinary tract infection e.g.) are irregularly available and not integrated in a systematic diagnostic approach.
  • In conflict-affected settings ICRC is collecting epidemiological data with the MAD but there is a delay (update of tools and feedback) both at national and periphery level leading to poor quality of care.
  • Swiss TPH has developed an electronic ALgorithm for the MANAgement of CHildhood illnesses (ALMANACH) for primary health care facilities, running on mobile device (android tablets). ALMANACH is aimed at improving health workers’ performance by providing evidence-based standardized procedures for the management of common conditions. Relying on simple point-of-care diagnostic tests and procedures, ALMANACH has demonstrated to be an essential tool to ensure good clinical outcome for children and rational use of antimalarial (AM) and antibiotics (AB)1. ALMANACH is a dynamic tool, which can be enhanced by “sensors”, such as electronic thermometers, automated respiratory rate calculators, oximeters e.g.
  • PMU has expertise and a long experience in primary care and community medicine, in particular regarding the use of clinical algorithms and point-of-care tests for the patients who attend their clinics. They have clinical teams (doctors and nurses) able to go in the field to implement this project. The Swiss TPH and the PMU are working together for many years on projects in resource-limited countries, under a memorandum of understanding agreement.
    • Rationale for ICRC intervention
  • By working with the SwissTPH/PMU, the ICRC will provide updated and scientifically proven protocols to the field level through the deployment of mobile devices.
    • It will rationalize the use of AM and AB for the under 5 in respect of local criteria of emergency/ need to transfer.
    • It respects patient's privacy (it is not a medical file, there is no patient identification).
    • It is compatible to any PfR health general objective by its desire to guarantee access to quality health services for the under 5.
    • It will allow to providing PHC centers health workers, as well as their corresponding authorities, with regular epidemiological feed-back (through 3G connection between HC, district, provincial or national level)
    • It is an ongoing process where new updates, scientifically recognized, will be inserted "by a click"

Strengths

Opportunities

·       Up to date support to decentralized health workers

·       Scientifically proven by competent institutions (Swiss TPH and PMU)

·       Adaptability: mobile devices, easy update and follow up from a distance by 3G

·       Easy epidemiological follow up from PHC centre level to authorities in respect of patient's privacy

·       Clearly defined with SwissTPH and PMU; it is not a research program. However, as per agreement, research components could be added at a later stage with the aim of improving ALMANACH

·       Tool introducing quality management on existing epidemiological information captured by the MAD.

 

·       Updating and reinforcing scientific dialogue with MOH and health authorities

·       Long term interest and involvement of MOH

·       Regular analysis with SwissTPH/PMU

·       Distance quality monitoring and feedback to health staff working in remote settings

 

Weaknesses

Threats

 

·       Need to determine how to capture U5Y consultations in their epidemiological records at PHC centre level while using the ALMANACH.

·       To be deployed in 3G areas only

·       Possible Out-of-country server with clinical data (before hand-over to the country)

 

 

·       Misunderstanding by authorities (MOH but also arm carriers) if not well explained

·       Possible theft

 

 

 

  • Formulate objectives & Plan activities
    • The target population group(s)

Civilian Resident Population already considered in existing health programs (CV_RES), more specifically the children under 5 years (U5)

  • General and specific objectives of the intervention

In respect of PfR health CV_RES GO and SOs, we could describe the ALMANACH project

GO Children under 5 year, consulting ICRC supported PHC centres, receive up to date evidence based quality diagnostic, treatment and care.

  • The ICRC mode of action and strategies

The project is done in support to the national / provincial / district / PHC centres authorities.

By working in pair with the SwissTPH/PMU, the ICRC will reinforce local knowledge / competences/ tools in order to deliver adequate management of children under 5 in the centres supported.

All countries concerned by ICRC PHC services were reviewed and analysed (Number of PHCC, MHU, mode of action, security access, security restriction (nationalities e.g.) but also 3G or 4G technology). Most of the PHCC being in frontline, the 3G/4G technology criteria was the most restricting one. Out of DRC, CAR, Syria, Lebanon, Afghanistan, Mexico, Honduras, Panama and Guatemala, Lebanon and Afghanistan were primarily selected.

 

Strategic objective 1: Adapt ALMANACH to identified conflict-affected context and requirements

1.1 Adapt content                     Agree on content: content should be agreed on by Swiss TPH/PMU, ICRC and MoH in each context, and procurement of needed tools (diagnostic tests, treatments) should be warranted by either ICRC or local MoH, and content adapted to available tools

1.2 Define the system architecture

Requirements analysis

Design technical architecture

Procure the server, the decision support software, and the monitoring and reporting software (incl. licensing and contracting)

1.3 Configure ALMANACH in software

Specify requirements

Program the algorithm

Translate languages

Application test and validation

Strategic objective 2: Develop an implementation plan, monitoring plan and related tools

2.1 Implementation plan

Initial Field assessment on feasibility (combined to pre project evaluation). Timeframes, phases of implementation, roles and responsibilities, training sessions, resources (funding and human resources), risk management, identification of potential barriers to implementation to be dealt with, monitoring and reporting requirements, role of third parties, plan for adaptation to particular settings, in collaboration with MoH national and local authorities

2.2 Human resources                 Interview and recruit the required staff

2.3 Required tools Define HW’s training tools, supervision tools

Formulate the information and communication methods

Create M&E indicators

2.4 Support procedures

Define contacts and access to system support

 

Strategic objective 3: Implement ALMANACH in ICRC context(s)

Phase 1:            Information /sensitization of all involved partners (Head of delegation, Health coordinator, Health delegates and field officers, Central key MOH responsible, Provincial and district level)

Develop culturally adapted sensitization material to present the tool and project to the patients and population

Phase 2:            Implementation preparation (In collaboration with MoH supervision chain)

Identify field specific barriers and facilitators to implementation,

Settle the electronic device implementation plan, including planning for material safety, power charge, access and maintenance, and internet connections

Plan for procurement and follow up of needed medicines, material, and diagnostic tools

Adapt the supervision, report and monitoring plans

Inform population and patients

Phase 3:            Implementation

Train involved HWs in ALMANACH rationale, content and use,

Set up all material in the health facilities

Begin utilization, supervision and monitoring of ALMANACH by trained HWs

Phase 4:            Monitoring & Evaluation of ongoing activities

Including follow up of drugs and diagnostic tools management

Hand-over of the whole system to local authorities

 

Strategic objective 4: Analyze and document the results of ALMANACH implementation on HWs management of children illness and rational use of drugs

Discuss the methodology needed to document outcomes and results of the intervention:

Pre/ post evaluation of health workers performance

Pre/ post evaluation of diagnoses and treatment prescribed at the health facilities involved

And adapt it to ICRC requirements and pragmatic constraints

2.5 The main activities and resources

Activities are defined in the Log Frame, with estimated resources and budget for country 1 (Afghanistan e.g.) and country 2 (Lebanon e.g.)

  • Sorting the budget allows us to a first prevision of the following budget for 3 years
    • Project supervision and support 180’000 CHF
    • Project implementation 1’200’000 CHF
    • Administrated project fund 130’000 CHF
  • Contracts will specify responsibilities between Swiss TPH and ICRC under a general convention

 

2.5 The estimated duration of the project.

  • The project is for three years and covers 2 countries
  • The following phases will be respected 1) Preparation of the evaluation mission by collecting data and info from National level to health centre level 2) Evaluation / Feasibility mission of 2 to 3 weeks to meet all stakeholders from national to health centres level in respect of delegation rules 3) Transitory phase while the field and the TPH process findings of the mission (e.g. adaptation of ALMANACH algorithm, translation, recruitment of local FO…) 4) Implementation phase in sequence.
  • The evaluation phase of country nr2 is not foreseen before the transitory phase of country nr1.
  • Main activities are lengthy described in the logical framework in annex considering month 1 as the official beginning of the project as soon as validated by the direction.

 

  • Formulate & plan the monitoring

Select indicators of ALMANACH activities and outputs for monitoring & evaluation

Indicators

Definition

Source / Method

Training activities

 

 

# supervisors trained

 

Project register / report

# training sessions organized

 

Project register / report

% of targeted HWs trained and supervised on site on ALMANACH tool

Numerator: # of HWs trained on ALMANACH

Denominator total # of HWs involved in OPD U5 management

1. Training and F2F supervision register (to be developed)

2. HFs list of HWs

Output: use of ALMANACH

 

 

% of consultations of children U5 managed using the electronic device

1. Numerator: # of cases sent to the server from the involved HFs

2.: Total # of U5 consultations performed in the involved HFs

1. Server data (automated) report

2. HFs activities data collection tools (HIS)

Diagnoses distribution in children attended using the electronic device

1. Distribution of disease classifications in cases sent to the server

Server data (automated) report

% children prescribed AB

1. Numerator: # of children prescribed AB among cases sent to the server

2. Denominator: # of cases sent to the server

Server data (automated) report

% children prescribed AM

1. Numerator: # of children prescribed AM among cases sent to the server

2. Denominator: # of cases sent to the server

Server data (automated) report

Outcome: HWs performance indicators

 

 

Indicators of appropriateness of treatment

 

 

% of children in need for AB/AM prescribed it correctly

1. Numerator: # of observed children needing AB/AM prescribed AB/AM correctly (ALMANACH recommended drug prescribed with right dosage in accordance with child’s presentation, age/weight)

2. Denominator: total # of observed children having a disease classification requiring AB/AM

Consultation observation during a cross sectional survey +/- expert reassessment of the observed children if possible during the initial field assessment.

% of children not in need for AB/AM leave without AB/AM

1. Numerator: # of children not needing AB/AM (no classifications requiring AB/AM according to ALMANACH)

2. Denominator: # of children having no disease classification requiring AB/AM

 

Indicators of completeness of assessment

 

 

% of children checked for danger signs

1. Numerator: # of observed children checked for each danger sign

2. Denominator: total # of observed children

 

% of children assessed for main symptoms

1. Numerator: # of observed children checked for each main symptom

2. Denominator: total # of observed children

 

 

 

  • Formulate & plan the evaluation

It is too early at this stage to propose indicators before the first Evaluation phase of country Nr 1. As written in specific objectives 1 & 2 and specifically in strategic objective 4, precise indicators related to the “results of ALMANACH implementation on HWs management of children illness and rational use of drugs” will be chosen.