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 Table of Contents  
Year : 2014  |  Volume : 3  |  Issue : 2  |  Page : 161-170

Challenges to the implementation of the integrated management of childhood illness (IMCI) at community health centres in West Java province, Indonesia

1 Center for Health Research Universitas Indonesia, Faculty of Public Health Universitas Indonesia, West Java, Indonesia
2 World Health Organization, country office, Dr Adhyatma Building, Ministry of Health, Jakarta 12950, Indonesia
3 World Health Organization, Indonesia country office, Dr Adhyatma Building, Ministry of Health, Jakarta 12950, Indonesia; World Health Organization Regional Office for South-East Asia, New Delhi, India

Date of Web Publication22-May-2017

Correspondence Address:
C R Titaley
Center for Health Research Universitas Indonesia, Building G, 2nd Floor, Room 211, Faculty of Public Health Universitas Indonesia, UI Campus Depok, West Java, 16424, Indonesia

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2224-3151.206732

Rights and Permissions

Background: The integrated management of childhood illness (IMCI) is a comprehensive approach to child health, which has been adopted in Indonesia since 1997. This study aims to provide an overview of IMCI implementation at community health centres (puskesmas) in West Java province, Indonesia.
Methods: Data were derived from a cross-sectional study conducted in 10 districts of West Java province, from November to December 2012. Semi-structured interviews were used to obtain information from staff at 80 puskesmas, including the heads (80 informants), pharmacy staff (79 informants) and midwives/nurses trained in IMCI (148 informants), using semi-structured interviews. Quantitative data were analysed using frequency tabulations and qualitative data were analysed by identifying themes that emerged in informants’ responses.
Results: Almost all (N = 79) puskesmas implemented the IMCI strategy; however, only 64% applied it to all visiting children. Several barriers to IMCI implementation were identified, including shortage of health workers trained in IMCI (only 43% of puskesmas had all health workers in the child care unit trained in IMCI and 40% of puskesmas conducted on-the-job training). Only 19% of puskesmas had all the essential drugs and equipment for IMCI. Nearly all health workers acknowledged the importance of IMCI in their routine services and very few did not perceive its benefits. Lack of supervision from district health office staff and low community awareness regarding the importance of IMCI were reported. Complaints received from patients’families were generally related to the long duration of treatment and no administration of medication after physical examination.
Conclusion: Interventions aiming to create local regulations endorsing IMCI implementation; promoting monitoring and supervision; encouraging on-the-job training for health workers; and strengthening training programmes, counselling and other promotional activities are important for promoting IMCI implementation in West Java province, and are also likely to be useful elsewhere in the country.

Keywords: community health centre, integrated management of childhood illness, puskesmas, West Java province, Indonesia

How to cite this article:
Titaley C R, Jusril H, Ariawan I, Soeharno N, Setiawan T, Weber M W. Challenges to the implementation of the integrated management of childhood illness (IMCI) at community health centres in West Java province, Indonesia. WHO South-East Asia J Public Health 2014;3:161-70

How to cite this URL:
Titaley C R, Jusril H, Ariawan I, Soeharno N, Setiawan T, Weber M W. Challenges to the implementation of the integrated management of childhood illness (IMCI) at community health centres in West Java province, Indonesia. WHO South-East Asia J Public Health [serial online] 2014 [cited 2023 Feb 5];3:161-70. Available from: http://www.who-seajph.org/text.asp?2014/3/2/161/206732

  Introduction Top

Approximately 6.6 million children die worldwide every year.[1] In Indonesia, recent estimates indicate that 400 children aged under 5 years die every day.[2] The majority of these deaths are due to preventable causes, including pneumonia, diarrhoea, malaria, measles, malnutrition or a combination of these.[2],[3]

This indicates the need for specific interventions that aim at improving the quality of health-care services for children.[4]

In 1994, the World Health Organization (WHO) developed a comprehensive approach to providing quality care to sick children, called the integrated management of childhood illness (IMCI). This approach has been introduced in more than 100 countries globally, particularly in low- and middle-income countries.[5] Several studies have demonstrated the benefits of IMCI in improving the quality of child care services.[6],[7],[8] The effect of IMCI in reducing child mortality has also been reported.[8],[9] The IMCI strategy has three main components: improving case-management skills, improving overall health systems, and improving family and community health practices for both home care and health-care seeking for sick children.[3] In its implementation, IMCI provides a detailed explanation about the management of common illnesses among infants and children.[9] This covers not only the curative aspects such as the management of pneumonia, diarrhoea and measles, but also the preventive and promotive aspects, such as counselling at every visit and vaccination.[10],[11]

In line with the government’s efforts to reduce mortality rates among infants and children aged below 5 years, the Ministry of Health, Republic of Indonesia, adapted the IMCI guidelines in 1996. The guidelines were further developed and tested in several pilot studies until 1997, when they were launched and ready to be adopted.[10],[11] In 2003, a recommendation letter was sent by the Ministry of Health to all community health centres (puskesmas), endorsing the implementation of IMCI,[12] but a draft regulation was prepared only recently in 2013 by the Ministry of Health, stating that IMCI is an essential component of infant and child health[13] and, to date, the regulation has not been officially published. Nevertheless, ever since the recommendation letter was issued, numerous training programmes on IMCI have been carried out by the Ministry of Health to train health workers throughout Indonesia.

The Health Facility Survey (Riset Fasilitas Kesehatan) conducted by the National Institute of Health Research and Development, Ministry of Health, reported that 80% of puskesmas in Indonesia have adopted IMCI, although its implementation varied widely across provinces, from 38% in Papua to 98% in Bali. West Java province is reported as one of the provinces with a high percentage of puskesmas implementing the IMCI strategy (89% of puskesmas).[14]

In 2012, the Center for Health Research, Universitas Indonesia (CHR-UI), in collaboration with the Ministry of Health and WHO Indonesia, conducted an operational research study on IMCI in 10 districts of West Java province. The objective was to compare the skills of health workers who received conventional IMCI training with those trained with the IMCI Computer Adaptation and Training Tool (ICATT). ICATT is a newly developed computer-based learning programme for IMCI, developed by WHO in collaboration with the Novartis Foundation for Sustainable Development (NFSD).[15] The data reported here are the findings from a qualitative study that followed the operational research to examine the implementation of IMCI at puskesmas level.

  Methods Top

Information used in this study was obtained from an unpublished operational research study that compared ICATT with conventional IMCI training conducted by CHR-UI in collaboration with the Ministry of Health of the Republic of Indonesia and WHO Indonesia. The study was conducted from 3 November to 8 December 2012; details of the operational research study sites and population are briefly summarized below.

The study was conducted in 10 districts in West Java province, Indonesia. West Java is one of the 34 provinces of Indonesia located in the western part of Java Island (see [Figure 1]), which is the most populous island in the country.[16] The total population of West Java is 46 million,[16] making it the most populous province in Indonesia. Of the 17 districts in West Java, 11 agreed to participate. Based on the 2013 data from the Ministry of Health, the mean percentage of puskesmas conducting IMCI in the 11 districts and willing to participate in this study was lower (75%) than that of the six districts that did not participate (95%).[17] From these 11 districts, 10 were selected as study sites by simple random sampling, then randomly allocated to conventional or ICATT training (see [Figure 2]). Districts to be included in the study were formally invited by the Ministry of Health. The 10 districts selected were Bandung, Bogor, Ciamis, Cianjur, Cirebon, Garut, Indramayu, Majalengka, Sumedang and Tasikmalaya (see [Figure 1]).
Figure 1: Study sites Source: Wikipedia, with adjustment

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Figure 2: Sampling frame ICATT: IMCI Computer Adaptation and Training Tool; IMCI: integrated management of childhood illness *= included in this analysis

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From each district included in the study, eight puskesmas were selected by their respective district health offices. The selection of puskesmas was based on the availability of at least two health workers (midwives or nurses), who provided health-care services for children aged below 5 years and had never received any IMCI training, including on-the-job training. Using the sample size formula for one-tailed hypothesis testing between two proportions,[18] 160 health workers (nurses or midwives) were required. Thus, two health workers from each puskesmas were invited to participate (see [Figure 2]). Twelve health workers were not able to participate, owing to ill-health or rotation to other puskesmas; thus, 148 health workers was trained. Both conventional IMCI and ICATT training was conducted by the Ministry of Health, according to standardized guidelines.[19]

Study population and informants

The data reported here were collected from the 148 health workers who received IMCI training as part of the operational research. Information was also collected from the 80 puskesmas heads and one member of pharmacy staff from each study site; the latter were included to triangulate information related to the availability of IMCI drugs and equipment.

Data-collection personnel

Information was collected by 20 observers, who were experienced IMCI facilitators. They were recruited based on several criteria, including that they had been IMCI facilitators for at least 2 years and were willing to work in the field outside their working or residential areas. Observers were responsible for assessing the skills of health providers when providing IMCI services, and for conducting interviews using semi-structured questionnaires.

To reduce inter-observer variability, all observers were required to attend a 3-day training programme, which included how to fill in the study instruments and conduct interviews. The training also included try-out activities, in which observers interviewed informants in a health centre. The recruitment of facilitators was conducted by the CHR-UI in collaboration with Ministry of Health and Provincial Health Office of West Java.

Data-collection procedure and study instruments

Information was obtained at least one month after the IMCI training was conducted. Observations and interviews with informants were conducted at the puskesmas. Findings were recorded using forms adapted from the WHO Health Facility Assessment tool.[20]

A semi-structured questionnaire was used to interview the heads of puskesmas, to collect information concerning the implementation of IMCI at puskesmas level. A separate semi-structured questionnaire was used to interview midwives or nurses, to collect information about their perceptions regarding IMCI implementation at puskesmas level. Additional information regarding the availability of drugs, vaccines and supporting facilities and infrastructure was taken from a third questionnaire, used to obtain information from pharmacy staff.

During the data-collection period, three field coordinators were assigned to assist and supervise observers to ensure that data collection was conducted according to the research protocol. Close supervision was also carried out by CHR-UI researchers and Ministry of Health staff on a regular basis during the data-collection period.

Data management and analysis

Data collected from the field were entered using SPSS13 software.[21] Quantitative data were analysed using simple frequency tabulations, whereas qualitative data from semi-structured questionnaires were analysed by identifying the themes emerging from the responses provided by informants. Triangulation of data sources was conducted by comparing the responses provided by health workers, heads of puskesmas and pharmacy staff, for information collected from those informants.

Ethical clearance

Ethical clearance for the operational study was obtained from the Ethics Committee, Faculty of Public Health, Universitas Indonesia. Research clearance was also obtained from the Ministry of Internal Affairs, National Unity, Politics, and Public Protection of West Java province, and the health office of each district. Prior to each interview, verbal consent was obtained from each informant.

  Results Top

Perceptions of puskesmas heads and pharmacy staff

Although 76% of puskesmas implemented IMCI on a daily basis, only 65% implemented the IMCI strategy for all visiting children. Furthermore, of the 52 puskesmas that had implemented IMCI for more than 6 months, 16 (31%) did not apply it to all children visiting. Only 43% of puskesmas had all health workers in the child care unit trained in IMCI (see [Table 1]) and only 58% conducted on-the-job training.

From these interviews, it was found that 70% of puskesmas did not have a sufficient budget for IMCI implementation and 10% had an insufficient supply of IMCI drugs (see [Table 1]). This finding is also supported by the results of interviews with and observation of pharmacy staff, showing that only 19% of puskesmas had all the essential IMCI drugs (see [Table 2]). Only 15% of puskesmas had all the essential equipments, such as a blood pressure meter with cuff, spring scale and respiratory timer for acute respiratory infection; 22% of puskesmas did not have a special room for IMCI services but, at the time of the interview, all puskesmas had IMCI forms. Detailed information about the availability of drugs, equipment and other supporting facilities and infrastructure, based on the interview and observation with pharmacy staff, is given in [Table 2].
Table 1: IMCI implementation: perceptions of heads of puskesmas (N = 79)

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Table 2: Supporting facilities and infrastructure for IMCI services: perceptions of pharmacy staff (N = 79)a

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IMCI promotional programmes for other health workers within the puskesmas had been conducted by most of the puskesmas (89%), but only 78% of the heads of puskesmas stated that IMCI had been integrated with other programmes in their puskesmas. The promotional programme was mainly conducted during monthly workshops by including IMCI as a topic of discussion in 92% of the puskesmas involved in this study. Furthermore, lack of supervision from the district health office was perceived to be a problem; 30% of the heads of puskesmas reported never having received any supervisory visit from the district health office. Less than half (48%) of the puskesmas had conducted promotional activities in the community for IMCI (see [Table 1]). Even among puskesmas that had implemented IMCI for more than 6 months (N = 52), 48% had not conducted any promotional activities. The promotional activities were usually conducted through midwife counselling during child services in the integrated health post (posyandu) or puskesmas (58%), and/or discussions in maternity classes and/or community meetings (53%).

Perceptions of puskesmas health workers

In accordance with what was found in interviews with the heads of puskesmas, one of the challenges of IMCI implementation mentioned during the interviews with health workers was the shortage of health workers, leading to increased workload (18%) (see [Table 3]). Apart from providing child care services in puskesmas, health workers trained in IMCI were also required to conduct other health-care services, which limited their availability.
Table 3: IMCI implementation and supervision: perceptions of health workers

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The issue of insufficient supply of drugs was raised by 15% of health workers, confirming statements by the heads of puskesmas, as well as findings from the observations at pharmacies in puskesmas and interviews with pharmacy staff. Furthermore, 56% of health workers perceived a problem with shortage of forms, tools, facilities and infrastructure to support IMCI implementation, such as a special IMCI room and IMCI guidelines. Of all health workers interviewed in this study, 43% (N = 63) raised the problem of community acceptance of the IMCI approach (see [Table 3]). Of these health workers, 76% said that there were complaints related to long duration of treatment and 46% that complaints were related to situations where IMCI guidance indicated that no drugs were necessary as parents tended to value clinical management only when it involved drug administration.

Similar to what was mentioned in interviews with heads of puskesmas, health workers interviewed in this study also raised the issue of lack of supervision, including by district health office staff. Twenty-two per cent of health workers stated that they had never received any supervision and 32% that the supervision they received was inadequate (see [Table 3]). Of puskesmas in which health workers had been trained more than 5 years ago (N = 29), nearly 28% (N = 8) reported that they had never received any supervision by staff from the district health office.

Nearly all workers acknowledged the importance of IMCI in their routine services. The reasons given included clearer treatment procedures using standardized guidelines (32%) and rational administration of drugs (22%); workers also mentioned personal advantages gained through increased knowledge of comprehensive health services (48%). Only one worker stated that the IMCI recommended ineffective drugs and one stated that IMCI provided inefficient services that discouraged patients from returning. One head of puskesmas reported a lack of confidence in applying the IMCI strategy, despite having received IMCI training.

  Discussion Top

Main findings

Nearly all puskesmas involved in this study applied the IMCI strategy in providing health care for children aged below 5 years. However, only two thirds applied it to all visiting children. Several challenges to the implementation of IMCI were identified, one of which was the shortage of puskesmas staff trained in IMCI. On-the-job training, which was expected to provide an opportunity for other untrained puskesmas to gain exposure to IMCI, was not fully conducted. Another major challenge found was insufficient supply of IMCI drugs and equipment, as well as lack of facilities/ infrastructure in puskesmas. The study also found a lack of supervision of promotional activities from the district office, and low awareness in the community regarding IMCI, which were reported as barriers to IMCI implementation. However, the majority of health workers trained in IMCI reported the benefits of IMCI implementation.

The results of this study will provide inputs for decision-making processes at the national, provincial and district levels, related to maternal and child health services. The information can be used to design the evidence-based interventions required to overcome various challenges for IMCI implementation at the puskesmas level in Indonesia.

Strengths and limitations of the study

This study has strengths and limitations that should be considered. It was conducted in 10 of 17 districts in West Java province, and thus covered a considerable number of districts in West Java province. Data collectors involved in this study were experienced IMCI facilitators. Interviews were conducted with various informants at puskesmas, which allowed some triangulation of the information obtained. The use of semi-structured questionnaires, which had clear guidelines for interviewers, with open-ended questions to allow interviewers to explore some issues further, increased the reliability and comparability of the qualitative data collected, as the study involved multiple trained interviewers.[22]

Several limitations should also be noted. The study sites were selected based on districts that agreed to participate in the study. Overall, these districts had a lower percentage of puskesmas that conducted an IMCI strategy than those in districts that did not participate.[17] The selection of puskesmas in each district was not random, but based on the availability of health workers not trained in IMCI. Thus, the performance of other health facilities may have been better. However, collecting data in this way probably better reflects possible obstacles that may need to be addressed. All information included in this paper reflects the perspectives of health workers, pharmacy staff and heads of puskesmas. The findings related to community acceptance of IMCI may therefore not reflect accurately the perception of the community but rather that of health workers interviewed in this study, and so caution is needed in interpreting the data. However, the authors believe that these limitations are not likely to affect the validity of the information obtained, as they are systematic findings from all the facilities, with little variation overall, and can be used for health planning and performance improvement, most likely beyond the sampled facilities.

Health-system support for IMCI implementation

Based on the IMCI implementation guideline produced by the Ministry of Health, after 6 months’ implementation of IMCI, puskesmas should be able to provide IMCI services to all visiting children.[11] In this study, only two thirds of the puskesmas were able to do so. Creating local regulations supporting IMCI implementation at provincial and district levels, as well as the inclusion of IMCI in the minimum maternal and child care services, may encourage health professionals to apply the IMCI strategy.

The shortage of IMCI drugs, vaccines, and facilities/ infrastructure and forms greatly impedes IMCI implementation and its benefit in improving some important aspects of care.[23],[24],[25],[26] It is essential to identify potential sources of funds in puskesmas for procurement of equipment to support IMCI. Moreover, strengthening of monitoring systems and regular supervision from the district health office is important to ensure a continuous supply of IMCI drugs. The earlier literature shows a significant correlation between implementation of IMCI and supervision.[23],[27],[28],[29],[30] Regular supervision, coupled with IMCI training, is important to sustain improvement in the quality of child health care at first-level health facilities.[31] Supervision for IMCI can be conducted simultaneously with supervision for other programmes. Supervision from heads of puskesmas is also essential to ensure optimal implementation of IMCI.[32],[33]

Trained health workers in puskesmas

IMCI is associated with better child health care in health facilities.[34] However, a shortage of quality health workers trained in IMCI was identified in this study as one of the obstacles to IMCI implementation. Multiple tasks and responsibilities of health workers are found to affect their commitments to IMCI implementation.[27],[32],[35],[36],[37] As IMCI training organized by the Ministry of Health was not designed to train all health workers, on-the-job training is an alternative to increase the number of workers trained in IMCI. Nevertheless, this study found that on-the-job training for IMCI was not conducted at most puskesmas. Establishing a reward system for health workers conducting on-the-job training might help to encourage implementation in puskesmas.[38],[39] The availability of the computerized training, ICATT, may also help to overcome this obstacle.

Almost all health workers stated that they had benefited from IMCI implementation. This finding is consistent with other studies reporting the benefits of IMCI as perceived by health professionals, including more holistic health-care services,[29],[37] precise delivery of appropriate management[29],[30] and increased confidence among workers.[27],[40] However, some health workers considered IMCI to be less useful than their previous clinical experience, owing to the administration of less effective drugs, or fewer patients returning for further treatment as a result of less efficient health care. This mirrors the need to strengthen IMCI training to increase health workers’ confidence in IMCI. Refresher training for health workers might be beneficial to improve the quality of IMCI services provided.[35],[40] Furthermore, the use of ICATT, developed by WHO and the Ministry of Health, provides valuable opportunities for an improved training programme and continuous professional development, compared to the regular IMCI training.[41]

Community awareness and promotional activities

Community awareness of the importance of IMCI is one of the main pillars of IMCI implementation. Increasing community awareness through the counselling sessions during health visits is important to prevent and reduce misconceptions among families or caregivers; for example, that IMCI involves a long duration of treatment but the resulting overall care and management is more comprehensive.[33] However, counselling sessions are often neglected, because of the large number of patients, tight schedules, limited space, and lack of attention from families to information provided by service providers, particularly when the focus is only on the medications prescribed.[33],[37],[40],[42],[43],[44] This suggests the need to emphasize the importance of counselling sessions during IMCI training.[43],[45]

Another way to increase community awareness is to conduct promotional activities. In this study, only half of the puskesmas staff mentioned that they had disseminated some information about IMCI to the community. Collaboration with the health-promotion unit to develop knowledge, information and education materials such as posters or leaflets is beneficial to improve awareness of the importance of IMCI in the general community.[32],[46]

  Conclusion Top

This study shows some barriers to IMCI implementation in West Java province. Effective interventions, supported by strong commitment from puskesmas and district authorities, are required to overcome problems related to: (i) shortage of skilled human resources; (ii) the lack of IMCI supporting systems including drugs/equipment/infrastructure, supervision, promotional programmes within puskesmas; and (iii) low community awareness regarding IMCI implementation. Development of a reward system may encourage health workers to conduct on-the-job training for puskesmas staff and eventually increase the number of qualified health workers applying the IMCI strategy. Efforts to strengthen training programmes are also vital to increase health workers’ confidence and counselling skills. Enhancing the quality of counselling, in addition to conducting activities promoting IMCI to the community, will prevent any misconception and increase community awareness of the importance of IMCI in the West Java area and beyond, in Indonesia.

  Acknowledgements Top

We would like to thank USAID and WHO Indonesia for the funding provided to conduct the operational research. We also thank Dr Irfan Riswan from WHO Indonesia for the technical assistance provided during the implementation of the study; Ms Asteria Unik and Dr Nindya Savitri from the Ministry of Health, Republic of Indonesia, as well as Dr Luqman Yanuar Rachman from the Provincial Health Office of West Java for their valuable inputs to the manuscript. We are indebted to all interviewers and respondents of the study, as well as district health office staff for their involvement in the study.

Source of Support: World Health Organization.

Conflict of Interest: The study was funded with a grant from the United states Agency for International Development (US AID), through the World Health Organization (WHO) Indonesia. The funder had no role in the interpretation of the study results, nor the decision to submit the paper. TS and MWW are WHO staff members. The opinions expressed are theirs and do not necessarily reflect the positions and policies of the WHO.

Contributorship: CRT, IA and NS implemented the study; CRT and HJ performed data analysis; CRT and HJ prepared the manuscript; IA, NS, TS and MWW provided data analysis advice and revision of the final manuscript. All authors read and approved the manuscript.

  References Top

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