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BASELINE ASSESSMENT OF INTEGRATED MANAGEMENT OF
NEONATAL AND CHILDHOOD ILLNESS (IMNCI)
A CROSS-SECTIONAL STUDY IN RANCHI, JHARKHAND,
INDIA
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TABLE OF CONTENTS PAGE NUMBER
ORGANISATIONAL PROFILE 3
ACRONYMS 5
ACKNOWLEDGEMENT 7
BACKGROUND 8
LITERATURE REVIEW 9
EXECUTIVE SUMMARY 12
INTRODUCTION 16
STUDY OBJECTIVES 17
STUDY METHODOLOGY 17
STUDY AREA 17
STUDY DESIGN 18
SURVEY METHODOLOGY 18
SAMPLING PLAN 18
DATA COLLECTION AND ANALYSIS 20
LIMITATIONS 21
STUDY FINDINGS 22
Section A – ANMs and MOs knowledge and perception for IMNCI programmatic work 22
Section B – Clinical Case Management Observations by ANMs and MOs 28
B1. General Information 28
B2. Pre-Clinical Management Essential Tasks: Determining Infant’s/ Child’s problems
by ANMs and Mos 28
B3. Assessing and classification Analysis: 0 to 2 months’ young infants by ANMs and Mos 30
B4. Assessing and classification Analysis: 2 months to 5 years children by ANMs and Mos 36
Section C – Mothers/Caregivers understanding of health for their under 5 years child 49
Section D – Availability Status of Medicines and Equipment in Health Facilities 52
CONCLUSION 55
REFERENCES 57
ANNEXURES 59
Data Tables
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ORGANISATIONAL PROFILE
VRIDDHI-Scaling up RMNCH+A Interventions
Vriddhi is a USAID flagship program which supports scale up of high impact Reproductive,
Maternal, Newborn, Child and Adolescent Health (RMNCH+A) interventions with the goal of
preventing child and maternal deaths.
The USAID funded Vriddhi project works with national, state and district governments to reduce
preventable maternal, neonatal and child mortality fifteen states. State teams are positioned in
Jharkhand, Uttarakhand, Chhattisgarh and Odisha there is a regional unit in Chandigarh for the states of
Himachal Pradesh, Haryana and Punjab. The priority areas for Vriddhi include its support for large national
programs driven by Govt. of India (GoI) and aligning with national priorities, interventions designed and rolled
out to further strengthen quality and access to care for mothers, new-borns and children designed to address
the most vulnerable population groups with an aim to bridge gaps between policy and intervention through
demonstration models, improving program monitoring and oversight and use of technology to improve
clinical efficiencies and efficacy.
Four strategic outputs guide the project activities and are planned in a manner that supports achievement of
project objective
• Output1: Enhance capacity of state and districts to provide quality RMNCH services
• Output 2: Support monitoring and address bottlenecks for RMNCH service delivery
• Output 3: Innovative RMNCH approaches incubated for evidence generation for scale up
• Output 4: Involve Multiple stakeholders (including medical institutions/ private sector
companies) involved in delivery of RMNCH services
Terre des hommes (Tdh)
Terre des hommes (Tdh) is a leading Swiss child relief non-profit organization headquartered in
Lausanne, Switzerland. The Foundation has been helping over three million children and their
families in need for over 50 years, defending their rights regardless of their race, creed or political
affiliation. Tdh’s mission is to improve the living conditions of the most vulnerable children by direct
support, advocacy, promoting child participation for the respect of their rights, strengthening
communities and institutions to better respond to children’ needs. In over 40 countries, Tdh protects
children against exploitation and violence, improves children’s and their mother’s health and provides
emergency psychological and material support in humanitarian crises.
Tdh Foundation in India has been registered since 2008 as a Liaison Office. Tdh’s main programme
priorities in India are Unsafe Migration, Maternal and Child Health, WASH, and Emergency
response. Tdh’s head office in India is located in Kolkata; and our project interventions cover the
states of Jharkhand, Odisha, and West Bengal. In 2019, through our projects and together with our
partners, they have reached more than 60'000 beneficiaries, including vulnerable children and their
families
Ekjut Management Consultancy Pvt. Ltd. (EMCPL)
Communities coming together, recognizing their predominant health and nutrition related problems,
understanding cause and effect relationship, developing feasible solutions and collectively working
on these solutions. EKJUT’s evidence-based work on Participatory Learning and Action (PLA)
approach has resulted in lowering mortality among new-borns and mothers. The impact has been
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higher amongst most marginalised sections of communities and in high mortality settings (Houweling
et al, 2013).
Ekjut Management Consultancy Private Limited (EMCPL) draws on experience and expertise of this
unique capacity building process of EKJUT extending critical support in adaptation, designing and
core capacity building in scaling up of the approach. It has partnered with several government
departments, bilateral agencies and non-profit organisations in scaling up PLA model in Jharkhand,
Bihar, Odisha and Madhya Pradesh. The approach has been scaled up across 43 districts in the four
states with different Government Departments-Women and Child Development, Health and
Livelihood Mission in collaboration with state and other technical agencies reaching out to more than
30 million population in these states
Professionals from varied fields constitute the team of EMCPL with expertise in the field of Maternal
and Newborn Health, Nutrition, Adolescent Health and wellbeing and Water and Sanitation, capacity
building and management with experience of program development and management in different
states. Besides, EMCPL also undertakes research, studies and evaluation assignments with various
agencies in the country.
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ACRONYMS
ANM – Auxiliary Nurse Midwifery
ARI – Acute Respiratory Infection
ARTI-Acute Respiratory Tract Infection
ASHA – Accredited Social Health Activist
AWC – Anganwadi Centre
AWW – Anganwadi Worker
BCC – Behavioural change communication
BP Apparatus – Blood Pressure Apparatus
BPM – Block Programme Manager
CHC – Community Health Centre
CHW – Community Health Worker
COVID – Corona Virus Disease
cRCT – Cluster Randomized Controlled Trial
DFY – Doctors for You EMCPL – Ekjut Management Consultancy Private Limited
FGD – Focus Group Discussion
HBNC - Home Based Newborn Care
HBYC – Home Based Care for young children
HMIS – Health management Information System
HSC – Health Sub Centre
HW – Health Worker
HWC – Health and Wellness Centre
ICDS – Integrated Child Development Scheme
IDI – In Depth Interview
IEC – Information Education and Communication
IeDA – Integrated e-Diagnostic Approach
IMCI - Integrated Management of Childhood Illness
IMNCI – Integrated Management of Neonatal and Childhood Illness
INR – Indian National Rupees
KAP – Knowledge Attitude and Practices
LBI- Local Bacterial Infection
MAM – Moderate Acute Malnutrition
MCP – Maternal and Child Protection
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MO – Medical Officer
MOIC – Medical Officer In-Charge
MTC – Malnutrition Treatment Centre
MUAC – Mid Upper Arm Circumference
NCD – Non-communicable Diseases
NFHS – National Family Health Survey
NHM – National Health Mission
NRHM - National Rural Health Mission
NVBDCP – National Vector Borne Disease Control Programme
OPD – Outdoor Patient Department
ORS – Oral Rehydration Solution
PHC – Primary Health Centre
PPE – Personal Protective Equipment
PSBI – Possible Severe Bacterial Infection
RBSK – Rashtriya Bal Swasthya Karyakram
RCH - Reproductive and Child Health
RDT – Rapid Diagnostic Test
RIMS – Rajendra Institute of Medical Sciences
RNTCP – Revised National Tuberculosis Control Programme
SAM – Severe Acute Malnutrition
SDG – Sustainable Development Goals
SRS – Sample Registration System
Tdh – Terre des hommes
U5 – Under five years of child
UNICEF – United Nations Children’s Fund
URTI – Upper Respiratory Tract Infection
USAID- United States Agency for International Development
USD – United State Dollars
VHND – Village Health and Nutrition Day
VHSNC - Village Health Sanitation and Nutrition Committee
WHO – World Health Organization
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ACKNOWLEDGEMENT
This baseline study focuses on assessing the status of Integrated Management of Neonatal and
Childhood Illness (IMNCI) in Ranchi district of Jharkhand. The study was conducted in 3 blocks,
namely Angara, Ratu and Namkum with a sample of Auxiliary Nurse Midwives (ANMs), mothers
of under 5 (U5) years children; and government health department officials.
The primary objective of the study was to assess knowledge, clinical case management practices and
perceptions on IMNCI from all section of respondents.
This study was a collaborative effort of several organisations and individuals - whose contribution
ranged from financial assistance, technical support, and spending long hours in the field; and we will
always be grateful to them.
The E-IMNCI pilot is being carried out under sub award by USAID Vriddhi Project. The USAID
funded Vriddhi project works with national, state and district governments to reduce preventable
maternal, neonatal and child mortality across 15 states where USAID is the lead development
partner. The study was made possible due to financial support from USAID Vriddhi project being
implemented by IPE Global with national, state and district governments.
The authorities from National Health Mission (NHM), Government of Jharkhand provided inputs in
choosing the research area and providing the required approvals and communication to concerned
officials in the study area. Vriddhi team from IPE Global and Tdh also provided technical inputs in
developing and finalisation of tools and study methodology; and team members from partner agency,
Doctors for You (DFY) provided support for data collection and planning. Regular inputs from IPE
Global and Tdh at every step of the study were very helpful in finalising the same.
We have received immense support from the ANMs and mothers/ caregivers in the 3 study blocks
who shared their experiences with us. We are very grateful to all of them for their time and
cooperation in conducting this study. The support extended by block health officials in organising
group discussions with ANMs and interviews of health personnel during the ongoing pandemic
situation is worth mentioning here, otherwise data collection would have been very difficult. We
hope this study will be useful in designing future intervention strategies that will be beneficial for
the healthcare workers and community.
We are happy to acknowledge the efforts put in by colleagues from EMCPL for successfully
imparting training, designing the questionnaires, data collection, data analysis and the preparation
of this report.
EMCPL Team
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BACKGROUND
In 1995, WHO and UNICEF developed Integrated Management of Childhood Illness (IMCI) as a
premier strategy to promote health and provide preventive and curative services for children under
five years of age. There has been near universal adoption of the IMCI strategy by target countries,
with widespread reported implementation of IMCI. However, countries were rarely able to scale up
IMCI and the adherence was very low. Poor adherence to the Integrated Management of Childhood
Illness (IMCI) protocol reduces the potential impact on under-five morbidity and mortality. Electronic
technology could improve adherence and the completeness of assessment of children.1
Terre des hommes initiated the Integrated e-Diagnostic Approach (IeDA) programme in 2014, with
the goal of reducing child mortality by enabling better quality of health services through mobile health
tools, quality improvement processes and a data management strategy. IeDA helps the primary
healthcare workers (HCW) improve their level of adherence to the IMCI clinical guideline. The
digital job aid of IeDA is an Android-based application that guides Healthcare Workers (HCWs)
through the IMCI algorithm from the clinical assessment of the child, to the classification,
prescription, referral, and counselling.
In India, IeDA has been contextualised to E-IMNCI in Jharkhand. The E-IMNCI pilot project is being
carried out under sub award by USAID Vriddhi Project. The E-IMNCI project team in India consists
of USAID Vriddhi project team, Tdh India and and Dimagi Inc. Together under the overall guidance
of IPE Global’s USAID project, the E-IMNCI project team will develop a contextualized, E-IMNCI
digital job aid to be used by ANMs and Medical Officers to carry out all IMNCI activities taking
place at the facility, as per national IMNCI Operational guidelines as well as an accompanying Coach
Application to be used to monitor performance of users and measure adherence to the IMNCI gold
standard.The activities under the E-IMNCI pilot project is being implemented with 80 frontline
workers; composed of 70 ANMs (Auxiliary Nurse Midwives) and 10 MOs (Medical Officers) at 55
facilities in 3 blocks (Namkum, Ratu and Angara) of Ranchi district in Jharkhand; selected by IPE
Global in consultation with MoHFW and State Government.
E-IMNCI in India will be developed according to the Digital Development principles. It will go
through a thorough validation and its protocol will be approved by Ministry of Health and Family
Welfare (MoHFW) to ensure faithful alignment with the national IMNCI. IPE Global is responsible
for reporting and successful demonstration of the innovation to USAID. Dimagi is responsible for the
design, development, quality assurance and deployment of an electronic Tdh along with its local
partner is responsible for implementation of the field activities under the project on a timely manner,
in coordination and consultation with Vriddhi team and Dimagi
1 https://www.ncbi.nlm.nih.gov/pubmed/23981292
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LITERATURE REVIEW
The objective of the literature review was to review existing literature on Integrated Management of
Neonatal and Childhood Illness (IMNCI)package efficacy, cost-effectiveness, and electronic
utilisation to get an overall picture about IMNCI as a scalable practice in current context. Keywords
were searched in the online PubMed journal library (https://pubmed.ncbi.nlm.nih.gov/) and Google
scholar (https://scholar.google.com/). Key words used were 'IMNCI', ‘IMNCI observations’ and
‘IMNCI research’. To include recent literature, the search filter was put to show recent studies
published within 10 and 12 years ago respectively. 39 and 52 studies came out as a result respectively.
The summary of all the studies were read carefully and total 16 studies matching the interest of review
were included from PubMed and Google scholar online. Besides, Government of India (GoI)’s
website on innovation section and World Bank data on U5 and neonatal mortality were referred.
India is home to the highest neonatal and U5 deaths across the globe (1). As per the World Bank
Report 2019, the U5 mortality in India is 34.3 per 1000 live births while neo-natal mortality is 21.7
per 1000 live births (2). In 2019, an estimated 5.2 million U5 children died across the world due to
preventable and treatable causes whereas in India, 858,000 children died the same year due to similar
causes (2). This means that out of every six U5 deaths in the world, one U5 death happened in India.
Neonatal mortality contributes to the maximum number of deaths among U5 children, 63% of
children U5 years of age die within the first 28 days of life in India (2). Widespread disparities are
found in the deaths and predominantly tribal and underserved areas have higher rates of mortality. To
meet the sustainable development goal target of reducing U5 mortality to 25 per 1000 live births by
2030, concerted efforts are required to prevent new-born and U5 deaths. As an effort to combat the
high U5 mortality, implementation of Integrated Management of Neonatal and Childhood Illness
(IMNCI) started in India in 2003. By June 2010, it had been implemented in 223 of India’s 640
districts and more than 200 000 workers had been trained (3).
A study on IMNCI done with children born at home by Bhandari et al, 2012 (3) focussed on training
community health workers to conduct postnatal home visits and women’s group meetings together
with training of physicians and nurses to treat or refer sick new-borns and children while the supply
of drugs and supervision was strengthened. In this cluster Randomized Control Trial (cRCT) it was
found that infant mortality rate and neonatal mortality rate beyond the first 24 hours were significantly
lower in intervention clusters than in control clusters. The study concluded that IMNCI
implementation resulted in substantial improvement in survival of children born at home and
recommended its integration to achieve Sustainable Development Goal (SDG) on child survival.
The study by Maheshwari et al, 2012 (1) on facility based IMNCI appreciates IMNCI as the major
instrument of new-born and child health strategy under the Reproductive and Child Health
programme (RCH) II programme of the National Rural Health Mission (NRHM). The study also
mentioned the importance of skills of health workers for further management at the referral hospital
as well, thus also recommended for the capacity building of professionals for providing optimum care
to sick children in referral units as an obvious path to optimize the benefits of IMNCI on child
survival. An observational study by Kaur et al, 2011 (4) conducted for testing validity of IMNCI
algorithm for 419 young infants (0-2 months) found that IMNCI algorithm for assessment and
management of young infants has good sensitivity and specificity for referring cases with severe
illness.
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In 2013, a study conducted to assess IMNCI skills of Integrated Child Development Services (ICDS)
workers of Panchkula district by Shewade et al (5) used a skill assessment checklist. The workers
received IMNCI training in 2006 and a one-day refresher training in 2009. It was found that skills
were poor overall for young infants and for 2 months to 5 year old children. The workers performed
well in all aspects of counselling only except follow up. The study recommended that training without
effective implementation plans will not result in long term skill retention. A systematic review and
meta-analysis were done in 2013(6). This includes 46 systematic reviews and 26 meta-analysis
studies. The study findings show that, IMNCI trained workers were more likely to correctly classify
illnesses (RR=1.93), studies of workers with lower performance showed around 4 times
improvements in prescribing medications (RR=3.8), increase in vaccinating children and counselling
families on adequate nutrition and administrating oral therapies (6). Also, the trends towards greater
training benefits were observed and showed that trainings were conducted in lower resource settings
and reported greater supervision (6).
The study conducted by Prinja et al, 2016 (7) evaluated the cost-effectiveness of implementing the
IMNCI program in India and found that IMNCI program incurs an incremental cost of USD 34.5
(INR 1554) per Disability Adjusted Life Years (DALY) averted, USD 34.5 (INR 1554) per life year
gained, and USD 1110 (INR 49,963) per infant death averted. The study recommended that the
IMNCI program in the Indian context is very cost effective and should be scaled-up as a major child
survival strategy. In the same year, a study conducted by Gera et al (8) evaluated the effects of
programs that implement the IMCI strategy in South Asia in terms of death, nutritional status, quality
of care, coverage with IMCI deliverables, and satisfaction of beneficiaries. It found that implementing
the IMNCI strategy may reduce child mortality, and packages that include interventions for the
neonatal period may reduce infant mortality.
Another study by Yadav et al, 2016 (9) on skills assessment of health and ICDS workers of Rajasthan
to classify sick U5 children revealed that the low level of adherence particularly among ASHA-
Sahyoginis is due to a lack of motivation, monitoring and supervision. Apart from the weak
monitoring and supervision, overburden of ANMs with various programmes, maintenance of several
types of records and reports serve as a major hindrance in the adherence of ANMs to IMNCI
guidelines. The IMNCI has three components- capacity building of health workers, health system
strengthening and improving community and family practices. In the study by Satinder Aneja, 2019
(10), he points out that for getting better results all the three components should be implemented in a
coordinated manner, which in India has not been the case as focal point has traditionally remained
the capacity building of health workers.
A study by Gerensea et al, 2018 (11) with 384 registered cases (both under 2 months old and 2 months
to 5 years old children) assessed the consistency and completeness of integrated management of
neonatal and childhood illness in primary health care units. It found that out of 384, only 62.8% cases
were correctly classified, and only 42.7% were treated correctly. The study revealed that overall
consistency of IMNCI implementation was poor and recommended that continuous follow up and
training is required for adequate implementation of IMNCI protocols. Moreover, the study
recommended that using electronic method is expected to alleviate the problem. A recent study on
large-scale implementation of electronic Integrated Management of Childhood Illness (eIMCI) at the
primary care level in Burkina Faso by Bessat et al, 2019 (12) concluded that use of eIMCI was widely
accepted and perceived as a powerful tool guiding daily practice. Findings suggest that it has positive
effects on the health care system beyond the quality of consultation. To support large uptake and
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sustainability, better training of health workers in infectiology is essential and the medical content of
eIMCI should be optimized to include frequent diseases and, for each of them, the appropriate
management plan.
A recent scoping review on key challenges of health care workers in implementing the integrated
management of childhood illness (IMCI) program at primary health care facilities by Renosa M et al,
(13) concluded that, lack of trainings, mentoring and supervision; insufficient finance resources;
length of time required for effective and meaningful IMCI consultations conflicts with competing
demands and lack of planning and coordination between policy makers and implementers resulting
in ambiguity of roles and accountability were the challenges majorly faced by the healthcare workers.
The study investigated 24 published articles for the scoping reviews. Also, recognizing and
understanding insights of those health programs can spark meaningful strategic recommendations to
improve the IMCI program effectiveness (13).
Based on the review of available literature on IMNCI program published within 10 years, it is well
established that IMNCI is an effective strategy to address neonatal and childhood illness to reduce
neonatal and under-five mortality. There is also evidence that Integrated Management of Neonatal
and Childhood illnesses (IMNCI) is a cost-effective strategy to improve child survival. The most
recent evidence of using the package electronically is also established and it is expected that using e-
IMNCI package will bring added benefits to handling the situation in India. In this context, the
government of India has taken up a mobile application based on IMNCI guidelines originally
designed by School of Public Health, Post Graduate Institute of Medical Education and Research,
Chandigarh-India for effective management of children under 5 years of age by the healthcare
workers (HCW) posted in the villages of country (14).
As an innovation, the mobile application (14) is expected to improve adherence and efficiency of
HCW to IMNCI guidelines by facilitating in clinical examination through relevant gifs, videos and
separate library version. In addition, it will automatically classify the patient into colour coding based
on their clinical status and assist in treatment and referral. There will be additional features like auto-
generation of monthly reports sharable online with the supervisors, daily planner of HCW activities,
messaging and calling patients through application, reporting and counselling of mothers which will
boost towards health seeking of children in vulnerable settings. Thus, this holistic package of
technology and digitization in health care will assist in confronting the challenges faced by health
workers and outreach population in providing healthcare services.
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EXECUTIVE SUMMARY
Integrated Management of Neonatal and Childhood Illnesses (IMNCI) is a cost effective and efficient
strategy to improve child survival and is tried and tested across various parts of the globe. There is
also evidence that IMNCI package if used digitally results in better child health outcomes and robust
real time reporting. IMNCI has three components- capacity building of health workers, health system
strengthening and improving community and family level practices (10). The baseline study will help
to understand the local situation of healthcare, knowledge and practices of the ANMs and MOs, the
available referral mechanism and the situation of existing health facilities in the proposed area. This
baseline will provide an extensive understanding of the situation and level of knowledge and skills;
and data use among the frontline healthcare workers on IMNCI in the project area. The study will
establish a benchmark for assessing the project’s progress, and figures obtained will act as reference
for measuring the improvement in knowledge and skills on IMNCI and use of data for decision
making to impose of service delivery on IMNCI by the health workers; answering the outcome and
output indicators as set in the project logical framework. The objective of the baseline study is to
explore the status of knowledge and practices on IMNCI (including Clinical Case Management as
per the IMNCI standards), so that the relevance of intervention may be ascertained, the problem areas
may be identified, intervention may be planned strategically, and the effect of intervention may be
measured in future. The baseline will also serve as reference document for the endline study after the
e-IMNCI pilot.
The baseline between September 2020 to February 2021 was conducted in two rounds. Round 1
survey, face-to-face quantitative survey was conducted with 40 ANMs and 40 mothers/caregives of
under-5 children to assess their knowledge and perceptions with regards to IMNCI guidelines.
Interviews with mothers helped to understand the experiences and level of satisfaction of mothers of
under-5 children. Qualitative in-depth interviews were also conducted with government health
officials about their role in IMNCI. The qualitative exploration was done with ANMs about IMNCI
through focus group discussions in respective blocks. For assessing the IMNCI practices of ANMs
and MOs, round 2 survey through clinical case observation using IMNCI observation guides were
used. A total of 40 clinical case observations through 87.5% (35) actual cases and 12.5% (5)
simulations was performed with a set of 37 Auxiliary nurse midwives (ANMs) and 3 Medical Officers
(MOs) to assess the adherence to IMNCI protocols like assessment, classification, identifying and
providing treatment, counselling and providing follow-up care. This baseline exploration serves as
the pre-intervention status before rolling out e-IMNCI intervention, which should be followed by a
post-intervention study.
The 40 ANMs interviewed during round 1 were facility based (Health Sub Centre or Primary Health
Centre) and most of them had an experience of more than 10 years. All ANMs had heard about the
term IMNCI, majority of them knows about the relevant age group IMNCI deals with and the
components of health care included in the protocol; but they were not able to remember the other
important standard included in the protocol as most of the ANMs received IMNCI trainings 2-10
years back; and till the time of data collection no refresher trainings were conducted. There is no
designated government cadre of IMNCI supervisors. ANMs reported that mothers bring their children
to facilities for common illnesses like fever, Upper Respiratory Tract Infection (URTI)/Acute
Respiratory Tract Infection (ARTI), diarrhoea, dehydration, skin infections and others. In case of
referral, most ANMs (95%) referred children to Community Health Centres (CHC), shortage of
equipment and medicines also emerged as a reason behind referral. Only 35% ANMs have filled
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IMNCI forms in 2020. ANMs received tablets two years back; but due to compatibility and internet
issues they were not using it. Only 12.5% were able to mention that they were currently using
ANMOL platform for Behaviour Change Communication (BCC) activities. Treating children is
routine work for ANMs; but observation was that they were finding difficulty in remembering the
steps mentioned in the IMNCI guidelines.
While conducting the clinical observation of ANMs, it was quite clear that although ANMs had the
confidence on their knowledge but the practice of IMNCI guidelines was not found very existent. It
was found that IMNCI chart which must be used during assessments were not available during 72.5%
observations of healthcare workers (ANMs and MOs). Majority of ANM did not check important
applicable tasks of asking and looking or feeling the signs of major ailments while assessing 0 to 2
months’ children. Signs of Possible Severe Bacterial Infections (PSBI) / Local Bacterial Infections
(LBI), Jaundice/ dehydration and low weight were not checked by majority of the ANMs. Similarly,
important applicable tasks of IMNCI assessment for illnesses like general danger signs, severe
pneumonia, dehydration, very severe febrile disease/ malaria, malnutrition, Anaemia and
immunization related tasks were not checked by majority of ANM for 2 months to 5 years old
children. The overall adherence to IMNCI assessment protocols amongst ANMs was not satisfactory.
In only 16.2% (6) observations of ANMs; they were able to classify the illness based on their
assessment (n=37); and out of which only in 8.1% (3) they could classify correctly. However, the
counselling to mothers was performed by 46% (5) ANMs (n=37). The overall adherence to protocols
by MOs is also not as per the standard. MOs were able to correctly classify the ailment but could not
adhere to IMNCI protocols. However, owing to the small size of MO sample (n=3) the findings of
MO observations cannot be conclusive. None of the healthcare workers followed the sequence as
given in the IMNCI chart.
The study through a scoping exercise also assessed the availability of equipment and medicines in 52
health facilities (HSC, HWC and PHC) of the three blocks. It was observed that basic instruments
like stethoscope, BP Apparatus- table model, Glucometer, weighing scale (adults), test kits for
essential laboratory investigations and kidney trays are available and functional in more than 85%
facilities. However, important anthropometry measurement devices like stadiometer and length
measuring boards are only available in 25% and 44% facilities respectively. Weighing scales for
infants and children were unavailable in every facility visited during the scoping exercise. Pulse
oximeter, an important device to measure capillary oxygen which has gained importance during
COVID-19 pandemic were only available in 33% health facilities. Most basic device Torch with
batteries was found to be unavailable in 31% health facilities. It was found that majority of health
facilities (71.2%) had Amoxicillin medicine available; and only 23.1% (12) health facilities only had
Gentamycin which is used as essential drug. Also, Oral Rehydration Solution (ORS) used to treat
diarrhoea in young infants was unavailable in 32.7% (35) health facilities. Other important drugs like
Vitamin A syrup, and Iron-Folic Acid syrup were unavailable at 40-49% facilities. 71% or more
facilities only had medicines Paracetamol and Chloroquine available at the time of the scoping
assessment.
All caregivers who gave consent for face-to-face interviews were mothers of under-5 children. 40
mothers were interviewed during the baseline study of IMNCI from blocks of Namkum (13), Ratu
(13) and Angara (14). Majority of mothers of under-5 children interviewed had visited nearby health
facility within last six months. Almost all mothers (39 out of 40) had maternal and child protection
(MCP) card available with them which had information related to vaccination of their children. Most
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mothers (85%) largely relied on public health system out of which 91% sought support from the
public frontline health workers and facilities like ASHAs, Health Sub-Centre, Primary Health Centre,
and Sadar hospital. Half the mothers interviewed, received services from the local Health sub-centres
(HSC); and they have shown signs of satisfaction on the account of accessibility, affordability and
the behaviour of staff, however dissatisfied was found on the availability of staff and provision of
effective medication. The list of indicators for the baseline is given below:
1. Training
1.1 Proportion of ANMs reported all the aspects of IMNCI were covered during training
(in %) 82.5
1.2 Proportion of ANMs (in %) found training on IMNCI was easy to understand (in %) 87.5
2 Case Load
Average weekly case load per facility of children between 0 to 5 years of age (as
stated by ANMs) 5.2
3. Infrastructure
3.1 Proportion of facilities having all the medicines related to IMNCI (in %) 0
3.2 Proportion of facilities have all the diagnostic equipment’s related to IMNCI (in %) 11.5
4 Supportive Supervision
Proportion of ANMs reported to have received supportive supervision in the current
year (in %) 65
5 Use of technology
Name of the technological platform ANMs were able to tell which they are
currently using for BCC (in %) 12.5
6 Behaviour of ANMs with caregivers
6.1 Proportion of ANMs greeted mother appropriately and asked her to sit with
infant/ child (in %) 89.2
6.2 Proportion of ANMs recorded weight and temperature (in %) 37.8
6.3 Proportion of ANMs listened carefully to what mother tells (in %) 62.2
6.4 Proportion of ANMs checked if it is initial visit or follow-up visit (in %) 0
7 Clinical Case Management
7.1 Proportion of ANMs checked for all the signs/ symptoms listed in IMNCI guideline
for the infant (0 to 59 days) (in %) 0
7.2 Proportion of ANMs checked for at least 50% the signs/ symptoms listed in IMNCI
guideline for the infant (0 to 59 days) (in %) 0
7.3 Proportion of ANMs checked for all the signs/ symptoms listed in IMNCI guideline
for the infant (2 months to 5 years) (in %) 0
7.4 Proportion of ANMs checked for at least 50% the signs/ symptoms listed in IMNCI
guideline for the infant (0 to 59 days) (in %) 0
7.5 Proportion of ANMs checked for all the signs/ symptoms listed in IMNCI guideline
for both the age group (in %) 0
7.6 Proportion of ANMs checked for at least 50% the signs/ symptoms listed in IMNCI
guideline for both the age group (in %) 0
7.7 Proportion of ANMs did classification of ailment for the infant (0 to 59 days) (in %) 27.3
7.8 Proportion of ANMs did classification of ailment for the child (2 months to 5 years)
(in %) 11.5
7.9 Proportion of ANMs did classification of ailment for children in both the age group
(in %) 16.2
7.10 Proportion of ANMs did right classification of ailment for children in both the age
group (in %) 8.1
7.11 Proportion of ANMs provided medication for the infant as per the requirement (0 to
59 days) (in %) 9.1
7.12 Proportion of ANMs provided medication for the child (2 months to 5 years) (in %) 7.7
Page | 15
7.13 Proportion of ANMs provided medication in both the age group (in %) 8.1
7.14 Proportion of ANMs provided counselling for the infant as per the requirement (0 to
59 days) (in %) 45.5
7.15 Proportion of ANMs provided counselling for the child (2 months to 5 years) (in %) 45.9
7.16 Proportion of ANMs provided counselling in both the age group (in %) 46
7.17 Proportion of ANMs provided urgent referral for both the age group as per the
requirement (in %) NA
7.18 Proportion of ANMs who correctly followed sequence of IMNCI chart (in %) 0
8 Caregivers perspective
8.1 Percentage of caregivers satisfied with the behaviour of medical staff (in %) 80
8.2 Percentage of caregivers satisfied with the availability of medical staff (in %) 55
8.3 Percentage of caregivers satisfied with the effectiveness of treatment (in %) 15
8.4 Percentage of caregivers satisfied on all three aforesaid parameters (in %) 15
Page | 16
INTRODUCTION
Integrated Management of Neonatal and Childhood Illness (IMNCI) was adapted from global
Integrated Management of Childhood Illness (IMCI) and was initiated as an effort to reduce infant
and child mortality and morbidity by government of India with assistance from World Health
Organization(WHO) and United Nations Children’s Fund (UNICEF) (Gerensea et al., 2017, WHO )
(11,15). The IMNCI protocols were developed over time to promote health and care provisions for
curative and preventive services for under five years of children (ibid.) (11,15). IMNCI is a globally
proven, primarily community based strategy to improve child survival and therefore implemented
worldwide especially in the countries with high burden mortality (ibid.) (11,15). The IMNCI has three
components- capacity building of health workers, health system strengthening and improving
community and family practices (10). The IMNCI package offers assessment, classification,
treatment, counselling and follow up of children till 5 years of age. The cluster randomised trial
conducted in Bangladesh about effect of IMCI strategy on childhood mortality and nutrition in a rural
area concluded that, the mortality rate was 13.4% lower in the IMCI intervention areas compare to
control and shows improvement in exclusive breastfeeding among children under 6 months of age,
increased care seeking behaviour among parents of under 5 children (Arifeen et al., 2009) (16). The
Sustainable Development Goals (SDG) aims to reduce neonatal mortality in all countries to at least
as low as 12 per 1000 live births and under 5 mortality to as low as 25 per 1000 live births by 2030
(17). A study conducted in Tanzania (18) by assessing the quality of case management for children’s
illness, drug and vaccine availability and supervision involving case management, through a health-
facility survey shows the reduction in mortality of under 5 children by 13% and propose proper IMCI
implementation by training and provide timely supportive supervision for better results (18). Various
research studies in South Asian and West African regions revealed that IMNCI is a cost-effective and
efficient strategy to improve infant and child survival. Similarly, study done in India for assessment
of implementation of IMNCI strongly recommend that, measures need to be taken to improve
supportive supervision, availability of essential supplies and monitoring of the programme if the
strategy has to translate into improved child survival (19). With continuous efforts of government of
India and other development partners, under five and neonatal mortality has consistently decreased
over last 2 decades; but still the reduction is not as much as required, and one of the important factors
might be due to the poor adherence to IMNCI guidelines and inconsistent implementation of IMNCI
protocols (15).
In Jharkhand, implementation of IMNCI started in fifteen districts including Ranchi (the study
district) in 2009 according to National Rural Health Mission (NRHM) report (20). As per the Sample
Registration System (SRS)reports and Niti Ayog, reduction in Under 5 mortality rate per 1000 live
births was from 54 (2011) to 27 (2015) in Jharkhand state (21,22). AS per National Family Health
Survey 4, 2015-16 data, out of total births in Ranchi, only 76.2% were registered, and only 24.7%
children received a health check from respective health personnel within 2 days of birth, 67.7%
children received full immunization between 12-23 months of age and prevalence of diarrhoea and
symptoms of acute respiratory infection (ARI) in the last 2 weeks preceding the survey were 7.5%
and 3.2% respectively (23). The key indicators for undernutrition- stunting, wasting and underweight
were 40.7%, 27.2% and 43.8% respectively in Ranchi district (24).
In the context of attainment of SDG by 2030, we need to invest in early identification, better
diagnosis, capacity building of the existing staff in the primary health sector; and strengthening of
healthcare infrastructure and referral services. In the current pandemic situation, the capacity building
Page | 17
of the existing staff is an additional burden when they not only have to perform their regular duties,
but also are required to provide IMNCI services along with prevention and control the spread of
COVID-19 pandemic in their communities. Most recently, owing to recent studies in West Africa,
the government of India has shown willingness to implement electronic IMNCI (E-IMNCI) package
through mobile applications. There are other studies that recommend using IMNCI package via
electronic mode for better infant and child health. One of the promising practices is the Integrated-e
Diagnostic Approach ( IeDA); which is the implementation of IMNCI package through digital
platform to save children’s lives in Burkina Faso, West African region which has given promising
results (24). There was 6 to 15% reduction in prescription of antibiotics, 50% improvement in
adherence to the IMNCI protocol, and most importantly 92% usage rate of IeDA in the consultations
of children under 5 (24). IeDA being a technology-based intervention; may also be helpful in
minimising physical contact and thus may be a suitable choice during the present ongoing pandemic
crisis which has affected accessibility and service delivery in hard-to-reach areas. The present
situation calls for implementation of electronic and digital innovations for effective IMNCI
implementation. In pursuit to explore the current scenario of IMNCI implementation, a mixed
methods baseline study with ANMs and Medical Officers was conducted in October 2020. This report
explains the findings of the baseline study in 3 blocks of Ranchi district in Jharkhand, where the
project is planned to be implemented with the government healthcare workers.
STUDY OBJECTIVES
1. To understand the knowledge and attitude of healthcare workers (ANMs and MOs) on IMNCI
2. To gauge the adherence to IMNCI protocol through Clinical Case Management Skills by health
workers (ANMs and MOs)
3. To understand the readiness of the facilities for providing IMNCI services (which includes
availability of medicine at facility and diagnostic tools listed in IMNCI protocol and infrastructure
required for digital job aid)
4. To explore the experience of caregivers between 0 to 5 years who visited the health facilities under
the study
STUDY METHODOLOGY
STUDY AREA
The study was conducted in 3 blocks named Angara, Namkum and Ratu of Ranchi district in South
Chota Nagpur region in Jharkhand.
STUDY DESIGN
The study design was mixed method in which qualitative method were used to supplement and
triangulate the findings received from quantitative method. The data collection tools were finalised
with the consent of state government. The study was conducted with selected ANMs, MOs and
caregivers of children aged between 0 to 5 years. Clinical case observations were conducted at HSC
Page | 18
and PHC level with ANMs and MOs, structured interviews were conducted with frontline workers
(ANMs) and mothers of under 5 children. The In-depth interviews (IDIs) with government officials,
focus group discussions (FGDs) with ANMs were done. The data was collected from three subsequent
blocks of Ranchi district in two rounds. In the first round, structured interviews, IDIs and FGDs were
done with ANMs, MOs and mothers. During second round clinical case observations were done at
subsequent facility levels to see the actual case management at ground level regarding IMNCI. The
data on readiness of the facility to provide IMNCI services was provided by project team, which came
out from the assessment of the facilities.
STUDY PARTICIPANTS
Study Participants were the ANMs placed at different HSCs, health and wellness centres (HWCs)
and PHCs, who provide IMNCI services in the respective areas. The Medical Officer (MO) or
Medical Officer In-charge (MOIC) of the Community Health Centres (CHC) from these respective
blocks were also interviewed and observed for clinical case management. Mothers of children under
5 years of age, who visited at least once the health sub-centres of the Angara, Namkum and Ratu
blocks of Ranchi district in last one year were also interviewed.
SAMPLING DESIGN
Sampling was done for two different rounds of study –
The study tried to approach full enumeration of the health workers selected for the intervention. The
selection of health workers was based on readiness of the facility and ability of health workers to
adopt the intervention. The selection was done by IPE Global with the consultation with health
department, National Health Mission (NHM), Jharkhand. In first round, the quantitative data
collection was done with 40 ANMs and 40 mothers. The mothers of children under 5 years of age
living in the respective study areas of these 3 blocks of Ranchi district, who visited at least once to
health facilities were randomly selected and interviewed with the help of structured questionnaire.
The distribution of respondents as shared below in the table 1.
Table 1: Distribution of Respondents
Name of Block Total ANMs Interviewed Total Mothers/ Mothers
Interviewed
Angara 13 14
Namkum 14 13
Ratu 13 13
Total 40 40
Three Focus Group Discussions were conducted with 12, 10 and 15 ANMs in Angara, Namkum and
Ratu blocks respectively. Three in-depth interviews (IDIs) of the MO or Medical Officer In-charge
(MOIC) of the Community Health Centres were conducted. Owing to the COVID-19 pandemic, it
was difficult to get the appointment from ANMs and Medical Officers due to added workload on
them; and some of the healthcare workers were required to go for home quarantine.
In the second round of the survey, 40 clinical case management observations were done with the help
of observation checklist. The case management was conducted by ANMs and MOs at the facility in
the presence of an investigator trained on IMNCI. Investigators selected for the study were trained
Page | 19
on the IMNCI chart booklets; and they observed adherence to IMNCI protocol by the healthcare
workers during clinical case management. The selection of participants in the second round is done
in the same way as it was done for the first round. A total 37 ANMs and 3 MOs (including 1 MOIC)
participated in the study, and one case management was observed for each health worker. List of
health workers included is given in annexure of Section B, table 1.1
Table 2: Block-wise Distribution of Observations
Name of Block Total clinical case observations
done with ANMs
Total clinical case observations
done with MOs
Angara 14 01
Namkum 10 01
Ratu 13 01
Total 37 03
It was targeted that; all the case management observations will be done with real healthcare seekers
at the health centres, however in the absences of the real cases (due to low turnout of patients at the
facility at the time of pandemic), simulation exercise was also planned to be conducted for the
observation. Out of 40 observations, 5 observations were based on simulation exercise. With the
ANMs, 4 out of 37 cases were based on simulation and with MOs, 1 out of 3 cases was based on
simulation. For ANMs 11 observations were done with the infant age group of 0 to 2 months (real
and simulation), and rest of the 26 observations were done with the children age group of 2 months
to 5 years. For MOs, one observation was done with the lower age group and 2 observations were
done with the higher age group.
Table 3: Age-wise distribution of type of observation
Age Category For ANMs For MOs
For 0-2 months 11 1
Actual 9 1
Simulation 2 0
For 2 months to 5 years 26 2
Actual 24 1
Simulation 2 1
The data on the readiness of a facility is based on assessment of all the 52 ( HSCs, HWCs and PHCs)
facilities included in the current phase of the intervention.
DATA COLLECTION AND ANALYSIS
Data collection done in two rounds. In first round of data collection structured interviews with ANMs
and mothers of under-5 years’ children were done. Also, IDIs and FGDs with MOs and ANMs
respectively were the part of first round of data collection. In first round of data collection, the team
comprised of 6 field investigators and 2 supervisors and has fluency in reading, writing and speaking
Hindi and local language of the region. Data collection for the first round was done in between 15th
Page | 20
to 21st October 2020. For quality control, the data collection team was trained by senior project
coordinator for using CommCare application for data collection. For supervision, around 12 ANM
interviews and 7mothers’ interviews were visited. Dictaphones, Fig. papers and sketch pens were
used to document common illnesses, classification, treatment/management and referral systems
during FGDs. All the data collection was done with prior informed consent from all the participants;
adhering to all the necessary COVID-19 related precautionary measures.
In second round of data collection, clinical case observations were done with ANMs and MOs of
selected block areas with the help of structured checklist format. All the three data collectors were
IMNCI trained personnel. Data collectors’ orientation was conducted on 2nd January 2021 by EMCPL
team with involvement of the IPE Vrddhi team; for gaining understanding and hands on practice of
CommCare app. After the orientation, data collectors were placed in three blocks where the E-IMNCI
approach will be implemented. The data collection for second round was done in between 4th to 9th
January 2021 in all three blocks. Purpose and process of both round of survey was well explained to
the participants. The data was collected with prior informed consent from participants; adhering to
all the necessary COVID-19 related and all the necessary COVID-19 related precautionary measures.
The clinical observations were conducted following the IMNCI guidelines issued by the Government
of India, making sure that a minimum of 6 feet distance is maintained from the healthcare workers
and children; so that clinical management is not affected. While clinical observations were underway;
the observers did not speak up unnecessarily unless it was required to do so. For MOs, the sample
size is very small for both rounds of surveys. During the 1st round, IDIs were conducted with 3 MOs;
and during the 2nd round, clinical observations were conducted with 3 MOs. Quantitative data analysis
was done using STATA14. Missing values under each variable (hardly any) were not considered in
the analysis but mentioned in the tables. For qualitative data analysis formative method was used in
consideration of not to miss any valuable point.
CONTENT OF DATA COLLECTION TOOL
The observation checklist for clinical case management was developed against the norms/ standards
listed in the training manual and latest available IMNCI chart booklets for ANMs and MOs. Survey
questionnaires were finalised with the consent of the state government of Jharkhand.
There were two major sections in the ANMs and MOs observation checklists-
A. Management of Sick Young Infant Aged Up to 2 Months; and
B. Management of Sick Child Aged 2 Months Up to 5 Years.
The content of the checklist was aimed to understand
i. How healthcare workers are assessing the sign of illness
ii. How healthcare workers are providing referral, treatment, and counselling for the illness she/
he identified
For performing simulation exercise, the health condition of dummy infant/child was mentioned in the
checklist.
The quantitative survey questionnaire for ANM included,
1. Demographic information
Page | 21
2. Training of ANMs on IMNCI (including training timeline and quality)
3. Knowledge and perspectives related to IMNCI
4. Reporting details/documentation related to IMNCI
The quantitative survey questionnaire for mothers included information on,
1. Demographic information
2. Knowledge, attitude, and practices related to health of children under 5 years of age
3. Perceptions about the ongoing healthcare provisions and role of ANMs within the community
To serve the purpose of qualitative part, FGDs and IDIs were conducted. FGDs were conducted with
ANMs placed in different sub-centres of these three blocks, with the help and permission of the
respective block level officials. The Key Informant in-depth interviews (IDIs) were conducted with
the government health officials. Data collection was done in the three blocks, where the approach of
e-IMNCI and digital innovation will be implemented.
LIMITATIONS
This study may have few limitations common in cross-sectional studies including the recall bias,
social acceptance, desirability bias and responder bias. (Probable cause of recall bias can be that
IMNCI training has last happened 3 to 4 years back; and since then, no formal refresher was
conducted). This was mitigated through observations of clinical case management by ANMs and
MOs; to understand the knowledge level and subsequent adherence to IMNCI protocol during case
management.
Prevailing COVID-19 situation during data collection limited availability of senior health officials
and field movement of the team members. Also, majority of footfall in health facilities are usually
due to seasonal illnesses like common cold and cough; due to which variation in illnesses might be
affected. To overcome this, both the checklists have three simulation exercises focussed on three
important childhood illness, which occur in under 5 years’ children. The participants were asked to
demonstrate the IMNCI steps according to the given scenario. This was expected to provide a
comprehensive assessment of adherence to the IMNCI guidelines; in case there is minimal variation
in illnesses or in case there is absence of any case on a particular day during case observation activity.
Page | 22
STUDY FINDINGS
SECTION A – ANMs’ AND MOs’ KNOWLEDGE AND PERCEPTION FOR IMNCI
PROGRAMMATIC WORK
Section A1 - Demographic information of respondents
All the interviewed ANMs were posted in health facilities offering their services (Annex. Table A3).
Maximum (95%) ANMs are providing services at Health Sub-centres (HSC) and rest were engaged
at PHC level (Annex. Table A1). In table A 1.1, age distribution of all the interviewed ANMs ranged
from 20 years to 59 years; maximum (80%) ANMs belonged to 31 to 50 years’ age group. All the
ANMs had undergone professional ANM courses in which 82.5% ANMs completed the course just
after 10th or 12th std. and 17.5% ANMs did it after graduation or post-graduation. When asked about
years of experience as ANM, 75% ANMs were in services for 10 to 15 years while 15% of ANMs
were working for more than 30 years. In Table A 1.1, distribution of ANMs shows that 75% ANMs
were in services for 10 to 15 years while 15% of ANMs were working for more than 30 years.
Table A1.1– Background characteristics of ANM (Age, Education, and Years of Experience in
ANM service)
IMNCI Baseline 2020 N = 40
Age in
Completed
years
(grouping)
Percentage
(%)
Education with
professional training
(grouping)
Percentage
(%)
Total years of ANM
service (grouping)
Percentage
(%)
20 - 30 years 5.0 10th and ANM course 27.5 Less than 10 years 5.0
31 - 40 years 55.0 12th and ANM course 55.0 10 - 15 years 75.0
41 - 50 years 25.0 Graduation and ANM
course
15.0 16 - 20 years 0.0
51 - 60 years 20.0 Above graduation and
ANM course
2.5 21 - 25 years 0.0
26 - 30 years 5.0
More than 30 years 15.0
Section A2 – Basic understanding of IMNCI and Ongoing Practices
All ANMs shared that they know the term IMNCI (Annex. Table A3) and received training between
year 2005 to 2017, 27.5% ANMs received last training in 2009 (Annex. Table A5). Looking at the
block wise distribution, the most recent training was received in the Angara block in 2017. There was
no IMNCI training in Namkum block after 2015 and last training done in Ratu block was in 2016.
Similar information was obtained during FGDs and also matches the information received from health
officials during IDIs.
Although maximum ANMs received last training a long time back, 95% respondents had knowledge
that IMNCI deals with the children under 5 years of age (Annex. Table A4). However, 15% ANMs
were unable to clearly answer about the two categories of children mentioned in the IMNCI guidelines
(Table A2.1).
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Table A2.1 Distribution of respondents according to the knowledge on IMNCI categories for
different age group of children
IMNCI_Baseline 2020 N = 40
Knowledge on IMNCI categories for different age groups of
children
Percentage (%)
Yes 85.0
No 12.5
Don’t know 2.5
The qualitative analysis showed similar results, especially with the ANMs who received training in
very initial years of this programme more than 10 years ago. They mentioned that no formal refresher
training happened till now. Also, the ANMs who were most senior failed to explain the categories.
As per the Fig. A2.2, 90% ANM informed that names of all the aspects of IMNCI were known to
them.
Fig. A 2.2 – % of respondents aware of the name of components included in IMNCI protocol
The analysis of qualitative data showed that ANMs who were working in difficult areas felt the
referral as most relevant. As per the ANMs sharing during discussions, “we still have areas where
patients have to travel more than 3-5 km to reach to the main road, from where they can receive
ambulance services. These ‘kachha’ roads are difficult to walk during rainy season due to which
people face difficulties”
Training of Healthcare Workers
All (100%) ANMs received training in between year 2005 to 2017, 27.5% ANMs received last
training in the year 2009 (Annex. Table A8). As per the respondents, the aspects covered in the
trainings are more than 90% in all except the follow-up, 17.5% respondents shared that the aspect of
follow-up had not been covered during the trainings they received.
100 100
97.5
95
100
90
8486889092949698
100
Assssment Classification Treatment Referral Counselling Follow-up
% of responses (IMNCI aspects knowledge)
Page | 24
Fig. A 2.3 – Distribution of % of respondents according to IMNCI aspects covered during
training
All the ANMs were asked about the training duration and the level of difficulty they felt, the responses
are presented in Table A2.4 below
Table A2.4 – Distribution of respondents as per the level of difficulty of the training
IMNCI_Baseline 2020 N = 40
Level of difficulty of the IMNCI training received Percentage (%)
Easy 87.5
A bit difficult 12.5
Quite difficult 0.0
As mentioned in Table A2.4, the training received was easy for majority ANMs (87.5%). 77.5%
ANMs reported that they received training of 5 to 10 days. 17.5% ANMs reported to have received
training for more than 10 days. 80% ANMs in survey mentioned that the training was helpful in
improving IMNCI services, however, 5% did not find it of much help (Annex. Table A6). During
FGDs, all ANMs shared that the last training on IMNCI was conducted more than 3 years back and
there is a need for refresher as they are unable to retain aspects that are not very frequent in their day
to day work. There is likelihood that such a higher percentage regarding the positive feedback on
difficulty level of trainings may be an outcome of the social desirability bias. Thus, to validate the
response of ANMs, their ongoing IMNCI related practices would be a more dependable parameter to
gauge the actual status of adherence.
Section A3 – Knowledge about care provision according to IMNCI and Reporting
Understanding the signs and symptoms is very important to reach at proper classification of ailment.
In the context of IMNCI, understanding of common illnesses among under 5 children like fever,
Acute Respiratory Tract Infection (ARTI), pneumonia, diarrheal diseases, jaundice, anaemia and
malnutrition is very important. The availability of guidelines and its reference in case management is
very important for quality care especially in health facilities in rural areas. 95% ANMs responded
that they have manual for hospital care on IMNCI (Annex. Table A9) and during FGDs all ANMs
shared that the manual is referred when children below 5 years are brought to the facility. However,
on further probing, it was realised that it may not be a mandatory practice for all cases as referring
95 92.5 92.5 90 92.582.5
0
20
40
60
80
100
Assssment Classification Treatment Referral Counselling Follow-up
% of respondents (IMNCI aspects covered during training)
% of respondents (IMNCI aspects covered during training)
Page | 25
the manual was cumbersome and time consuming. The data from clinical case management also
suggests that ANMs usually don’t refer the manual, which contradicts their claim. During FGD,
ANMs shared that the initial questions they ask to mother/parents always helps them to decide the
course of examination. One of the ANM explained it in detail as,
“As the parents came to the facility, we first ask about the problem child is facing, for example – a
2-year-old girl shows up with problem of loose motion, we ask for frequency, colour, smell of the
stool, then we check if the child is crying, awake, check for the pinch of skin test, so we can assess its
severity. Then we weigh the child and accordingly decide whether to treat or refer.”
ANMs mentioned that parents take their children to facilities mostly due to common illnesses (cough/
cold/ fever/ diarrhoea), vaccination, and for counselling (80 to 100%). Other next major reasons given
were examining (70%) and malnutrition (70%). Less common reasons to visit facility were causality/
emergency (42.5%), medical certificates (12.5%) and infection (2.5%) (Annex. Table A8). To
understand the knowledge related to Malnutrition, pneumonia, anaemia, diarrhoeal dehydration, and
jaundice specific questions were included in the interview schedule, which was further probed during
FGD.
Table A3.1 - Distribution of respondents according to knowledge of methods/tools for
identifying malnutrition among children under 5 years
IMNCI_Baseline 2020 N = 40
Methods/tools for identifying malnutrition among children under 5
years
Percentage (%)
By maintaining growth charts (every month records of weight and
length/height measurement during immunization/VHND meeting)
87.5
By physical observations 12.5
By recurrent illness 0.0
Any other 0.0
As per Table A3.1, 87.5% ANMs understood the method of identifying malnutrition by observing
growth charts and 12.5% ANMs reported that they choose the physical observation as method for
identifying malnutrition among children under 5 years of age. During FGD, ANMs informed that
they maintain the records of weight and length/height during immunization/VHND meeting every
month with the help of Anganwadi Worker and Accredited Social Health Activist (ASHA).
When asked about sign of bacterial infection only 57.5% of ANMs responded it correctly (Annex.
Table A11). During the discussions also with ANMs it was found that, some were able to mention
the signs of ‘severe bacterial infection’ correctly and able to name the recommended antibiotics
(either Amoxicillin or Cotrimoxazole) and also mentioned that quick referral is needed for such cases.
Most of the ANMs mentioned that keeping child warm (‘kangaroo mother care’ in case of newborns)
is an essential while referring such cases. During discussion they also mentioned about unavailability
of medicines and equipment’s that poses challenge to deal with the cases at the facility. As stated by
one ANM-
“Any parent is sensitive for their child; they do come to me once or twice but if I’ll not be having
appropriate medication every time then next time they will directly go to the other facility or to the
private facility. Even if we provide the list of necessary materials, we do not always receive it in time”
Page | 26
All the ANMs (100%) understood palmer pallor as a sign of anaemia (Annex. Table A12). During
the qualitative interactions, ANMs mentioned about the irregularity in the supply of syrup IFA (Iron
folic acid) and that children below 3 years are unable to eat tablet.
Regarding medication, 97.5% (39) ANMs had knowledge about few the medicines recommended in
IMNCI guidelines. They mentioned about ORS, Amoxicillin, Cotrimoxazole, zinc tablets etc. 5%
ANMs mentioned paracetamol separately (Annex. Table A10). The table indicates that ANMs’
knowledge on medicines is limited to a few medicines used to treat under 5 children.
67.5% of the ANMs shared that in their health facilities, less than 5 children under-5 years of age
were treated on an average per week, 20% reported that 5 to 10 children per week and 10% reported
more than 10 per week (Annex. Table A7). The average weekly case load per facility as stated by
ANMs is 5.2 children of the relevant age group. Similar responses were observed in qualitative
analysis. However, parents, who can afford, prefer taking their children to the private practitioner
(mostly paediatrician) for major health issues while among less privileged families, parents try some
traditional ways initially for minor health issues and come to facility when situation deteriorates.
From the FGD it was revealed that during COVID-19 situation, parents refrained from bringing their
children to facilities due to fear of COVID 19 infection. However, one of the participants stated that
“parents had shown a greater faith and reliance on us, the local private hospitals were closed during
COVID-19 lockdown and so parents had no other choice rather than coming to us. I also feel the
faith in the villagers has increased for our facility (HSC) during this situation, as only we were
working risking our lives and community does understand it”.
As per the respondents (ANMs), majority of them provided counselling in past on breast feeding,
child feeding practices, giving oral drugs, how to keep young infant warm, taking care of their own
health (mother) (Table A3.2).
Table A3.2: Type of counselling ANMs provided in past to the Mothers/Caregivers
IMNCI_Baseline 2020 N = 40 (multiple
responses)
Type of counselling ANMs provide to the Mothers/mothers Percentage (%)
On breast feeding practices 17.1
On giving oral drugs 11.9
On treat local infections 12.4
On How to keep young infant warm 14.5
On taking care of her own health (to mother) 14.5
Advising mothers/mothers on proper feeding 15.4
On follow-up 13.7
Any other 0.4
Community health centre (CHC) was the choice of referral for more than 95% of the ANMs (Annex.
Table A13), as all the CHCs supposed to have dedicated paediatrician and are equipped with the basic
healthcare for under 5 children, as per the ANMs. However, health officials explained about their
own challenges they face at CHC, “Paediatrician provisioned for CHCs are either vacant or are not
present every day (were in deputation for COVID related work elsewhere when interview was
Page | 27
conducted), other health officials attending these cases prefer referral if child shows severe
symptoms”.
All Medical Officers mentioned difficulty in following IMNCI guidelines due to various reasons like
no training, different expertise like general surgery or gynaecology, unavailability of paediatrician,
overburdening with general patients and more recently the pandemic situation. One of the health
officials shared,
“Although I am a qualified gynaecologist, I do work like a general physician and check more than
120 patients everyday due to unavailability of staff. COVID -19 pandemic situation made it even
worse for us and while doing double duties we are also increasing our own health risks.”
Section A4 – Supportive Supervision
Table A4.1 – Distribution of Respondents according to the year of last supervisory visit
IMNCI_Baseline 2020 N = 40 (multiple response)
Year of the Last supervisory visit regarding IMNCI Percentage (%)
2017 2.5
2018 5.0
2019 27.5
2020 65.0
ANMs mostly received the supportive supervision from the staff of UNICEF, the FGD revealed that
they were considered by ANMs as their official IMNCI supervisor. The ANMs revealed that they
were receiving the supportive supervision on irregular basis, as only 65% said it happened in year
2020 before March (before COVID-19 pandemic), and 27.5% remembered it happened in year 2019
(Table A4.1). During FGDs it was mentioned that initially UNICEF supervisors were collecting the
filled IMNCI forms and ANMs were reporting them but since last year the process has stopped.
Section A5 – Use of Technology
Use of technology and tech based tools/solutions may be useful in improving the quality of services
by ease of referring protocol at different steps, reporting and data management and also in reducing
touchpoints from COVID 19 precaution perspective. The baseline findings showed that ANM were
currently not using any technological platform (Annex. Table A14). Even during open discussions,
they agreed that almost all of them have received Tablets, but due to SIM Card and compatibility
issues they have not used it. However, majority of them were comfortable in using technological tools
and online reporting and were using their personal mobile phones to complete the data entry for
family planning programme.
Table A5.1 – Distribution of respondents according to technological platform ANMs currently
using for BCC
IMNCI_Baseline 2020 N = 40
Name of the technological platform ANMs currently using for BCC Percentage (%)
Anmol 12.5
mHealth 0.0
E Health 0.0
Pamphlet 2.5
None 85.0
Page | 28
Only 12.5% mentioned they are currently using ‘Anmol’ as technical platform for BCC. It underlines
the need of technological intervention with appropriate platform supported by up to date hardware
and net access. this may help in further improving quality of IMNCI services and reporting.
SECTION B-CLINICAL CASE MANAGEMENT OBSERVATIONS BY ANMs and MOs
Section B1- General Information
Observation of clinical case management was conducted for 37 ANMs and 3 MOs from the three
blocks of Ranchi district. A block-wise break up of 37
ANMs and 3 MOs observed during the study is given in
table 2 of methodology.
The place of observation of 40 health workers (ANMs
and MOs) were 35 health facilities (HSCs, HWCs, PHCs
and CHCs). 12 facilities were visited in Ratu, 8 in
Namkum and 15 in Angara block.
Out of 35 facilities covered, 37.1% (13) HSC, 45.7%
(16) HWCs, 8.6% (3) PHCs and 8.6% (3) CHCs were
the place of observation of clinical management (Fig.-
B1.1).
Out of 40 observations, 87.5% (35) were actual
cases of children who visited the health facility
along with their mothers/ caregivers, while
remaining 13% (5) observations were
simulations. Out of 87.5% actual observations,
50% (20) children were males and 37% (15) were
females (Fig.- B1.2).
Out of 40 observations 12 children (30%) comes
in the age group 0 to 2 months and 28 children
(70%) comes from the age group (2 months to 5
years) (table 3 in of methodology).
B2-PRE-CLINICAL MANAGEMENT ESSENTIAL TASKS: DETERMINING
INFANTS/CHILD’S PROBLEMS BY ANMs and MOs
The IMNCI strategy includes both preventive and curative interventions that aim to improve practices
in health facilities, the health system and at home. The case management process presented
sequentially on a series of chart provide information for performing the steps of assessing the young
infant or child, classifying the illness, identifying treatment, treating the infant or child, counselling
the mother and giving follow up care. The IMNCI approach mandates to holistically assess the young
infant or sick child not only for a particular problem or symptom but for all signs of possible diseases.
IMNCI while considering what signs are asked and assessed also gives vital importance to how an
37.1
45.7
8.6
8.6
Fig.B1.1- % of health facilities covered
HSC HWC PHC CHC
50%37%
13%
Fig.B1.2. - Sex of Observations (in Percentage)
Male Female Simulation
Page | 29
effective communication is established with the mother so that correct information about infant/child
is given by her.
The IMNCI chart guides the overall process of engaging the mother/caregiver from the time she
arrives the health facility with her infant/child till she leaves the facility and follow up care is given.
This section discusses about the initial tasks that the ANM has to perform before the actual case
management process. The first step towards establishing a good connection with mother/ caregiver is
to greet her appropriately and asking her to sit with her infant/ child. It was found that 89.2% (33)
ANMs did greet the mothers appropriately and asked her to sit with their infant before proceeding
any further (Table. B2.3)
As the next step of following the IMNCI
protocol, although all the 37 ANMs asked about
infant/ child’s age, following this however,
70.3%% (26) ANMs did not take out and referred
the age-appropriate IMNCI chart for following
the steps (Fig. B2.1). Out of these 26 ANMs, the
reason for unavailability of the chart was sought
and it was found that 57.7% (15) ANMs have
received it but have missed it, 3.8% (1) ANM
mentioned that she never received it and 38.6%
(10) ANMs did not give any reason for its
unavailability (Fig. B2.2).
Fig. B2.1: Percentage of Observations in which ANMs referred Age-appropriate IMNCI Chart
After taking out the age appropriate IMNCI chart, the
ANM were expected to look to see if the young
infant’s/ child’s weight and temperature are recorded.
If not, weight and temperature are to be taken later
during assessment and classification which only
37.8% (14) ANMs did. 62.2% (23) ANMs did ask the
mother about the young infant/ child’s problems. An
important reason to ask this question is to open
communication with the mother and listening to her
reply also shows that mother’s concerns are taken
seriously. Same percentage (62.2%) of ANMs who
asked about infant/ child’s problems also listened
carefully to what mothers said. However, only 27%
(10) ANMs recorded in a format (Table B2.3).
64.9% (24) ANMs communicated with mothers using the words that she understood. 56.8% (21)
ANMs gave appropriate time to mothers to answer the questions that she asked. Only 16.2% (6)
ANMs asked additional questions to better understand the main symptoms or related signs. None of
the ANMs determined that whether it was mother’s initial or follow up visit for infant/ child’s
29.7
70.3
0
10
20
30
40
50
60
70
80
Used IMNCI Chart booklet
% used age-appropriate IMNCI Chart (n=37)
Yes No
57.7
3.7
38.6
Received but now Missing
Never received the chart
No reason
Fig B2.2: Reason for Unavailability of IMNCI
chart
Page | 30
problem. No ANM also checked for follow-up slips which mentions about when to return and all the
ANMs considered their cases as initial visit (Table B2.3).
Table B2.3: Pre-Clinical management essentials to be performed by health workers:
IMNCI Baseline 2020 ANM (n=37)
0- 5 years
MO (n=3)
0-5 years
Pre-clinical management essentials to be performed by ANMs
& MOs
Number Number
Greeted mother appropriately and asked her to sit with infant/ child 33 3
Recorded weight and temperature 14 3
Asked the mother what the young infant’s problems are? 23 3
Listened carefully to what mother tells 23 3
Used words that mother would understand 24 3
Given the mother time to answer the questions 21 2
Recorded what the mother tells about infant’s/ child’s problems? 10 1
Asked additional questions 6 2
Checked if it is initial visit or follow-up visit 0 2
MOs at each CHC of Ratu, Namkum and Angara blocks were observed while managing one case
each. 2 out of 3 MOs were observed while managing actual case; and one was observed while
conducting a simulation of a 2 months to 5 years old infant. Before initiating the clinical management,
all the 3 MOs greeted the mother appropriately and asked her to sit with infant/ child followed by
asking the mothers about infant/ child’s problems. All the 3 MOs also recorded weight and
temperature of the infants.
None of the MOs used age appropriate IMNCI chart as per them they never received it. All the MOs
carefully listened to what mothers informed and also used words that mother understands, however,
only 1 recorded what the mothers told about child’s problems. The MOs seeing actual cases gave
appropriate time to the mothers to answer questions; asked additional questions and also checked
whether it was their initial or follow-up visit (Table B2.3).
B3. ASSESSMENT AND CLASSIFICATION ANALYSIS: 0 TO 2 MONTHS’ YOUNG
INFANTS
B3.1 OBSERVATION OF 0 TO 2 MONTHS YOUNG INFANTS ON INFECTION: ANMs and
MOs
The clinical management of 0 to 2 months’ young infants begins with assessment for Possible Serious
Bacterial infection/ Local Bacterial infection. IMNCI chart directs the ANM to ask two questions and
Page | 31
perform 6 tasks, a representation of which is given in Fig. B3.1.1 The analysis of graph shows that
out of 11 observations of ANMs who managed 0 to 2 months of young infants, 63.6% (7) ANMs
asked the mother about difficulty in feeding correctly and giving explanations until the mother
understood and gave the correct answer. However, in none of the observations ANMs asked whether
the infant had Convulsions.
Fig. B3.1.1: Observations of 0 to 2 months’ young infants on Infection by ANMs
In 54.5% (6) observations, ANMs checked for fast breathing while the infant was calm. In only 18.2%
(2) observations ANMs counted the number of breaths in one minute using a watch with a second
hand or a digital watch placed in line of their vision of observing the infant. The same proportion
(18.2%) of ANMs looked for breathing movement anywhere on the infant's chest or abdomen. Breath
count was not repeated by these ANM most likely due to absence of elevated breath count. No ANM
recorded the breath count in the IMNCI format.
In only 27.3% (3) observations, ANMs checked for chest indrawing without a shirt when the young
infant was breathing in. Only in 9.1% (1) observation young infant’s umbilicus was checked to see
presence of redness or pus drain. Only in 9.1% (1) observation ANM examined the whole body for
red spots or blisters containing pus (skin pustules). In none of the observations axillary temperature
of young infants was taken at this stage of assessment.
Observation of one MO was conducted while clinically managing 1 actual case of 0 to 2 months’
young infant. As per the observation, the MO checked all the symptoms of PSBI/LBI except
convulsion/ history of convulsion. Also, redness or drainage of pus from umbilicus region, and
presence of skin pustules were not checked (Table B3.2.3).
B3.2. OBSERVATIONS OF 0 TO 2 MONTHS YOUNG INFANTS ON SEVERE JAUNDICE/
JAUNDICE
Sign of Jaundice was not checked by ANMs in any observations.
63.6
0
27.3
54.5
18.2
9.1
0
9.1
0 10 20 30 40 50 60 70
Asked about infant have any difficulty in feeding
Asked for convulsions
Checked for severe chest indrawing
Fast breathing checked while the infant calm
Looked for breathing movement anywhere on the infant’s …
Checked for umbilicus red or draining pus
Checked for Axillary temperature
Checked for skin pustules
Percent of 0- 2 months age young infant observations (n=11)
Page | 32
Fig: B3.2.1: Signs of Jaundice was not checked by ANMs
For assessing Jaundice, although MOs asked question to mother about its presence, but signs of
jaundice were not checked. Tasks performed for assessment of PSBI/ LBI and Jaundice by MO is
shown in table B3.2.3.
Table B3.2.3: Assessment of PSBI/LBI and Jaundice: MO
IMNCI Baseline 2020 n=1
Task Task performed (Yes/No)
Asked about difficulty in feeding Yes
Asked about convulsions No
Checked for fast breathing Yes
Checked for severe chest indrawing Yes
Checked for Umbilicus red or draining pus No
Checked for skin pustules No
Measured child's axillary temperature Yes
Infant's movements checked properly Yes
Asked, when did the jaundice first appear? Yes
Checked for Jaundice No
B3.3. OBSERVATIONS OF 0 TO 2 MONTHS YOUNG INFANTS ON DEHYDRATION
In only 36.4% (4) observations, ANMs asked the mothers about presence of Diarrhea using the words
that she understands. In addition to asking about Diarrhea, the ANMs are also supposed to look and
feel for signs related to Diarrhea. In none of the observations the ANMs checked for the young infant's
movements, checked for sunken eyes, or checked for skin pinch test. Also, none of the ANMs
recorded them (fig. B3.3.1).
0
100
0
20
40
60
80
100
Checked Not Checked
% Checked for Jaundice (n=11)
Page | 33
Fig. B3.3.1: Checking Diarrhea and Related Signs: ANM
For assessing Dehydration, the MO asked question to the mother to rule out diarrhoea but did not
check for sunken eyes and skin pinch test. Infant’s movements were checked before during assessing
PSBI. Assessment of signs of Dehydration by MO is shown in Table B3.3.2
Table B3.3.2: Assessment for Dehydration: MO
IMNCI Baseline 2020 n=1
Tasks Task performed (Yes/No)
Asked, does the young infant have diarrhoea Yes
Checked for infant's movement properly No
Sunken eyes checked No
Skin pinch test done No
B3.4. OBSERVATION OF 0 TO 2 MONTHS YOUNG INFANTS ON VERY LOW WEIGHT
OR FEEDING PROBLEM
In order to assess very low weight or feeding problems of the young infant, ANMs are required to
ask three questions related to infant’s feeding and perform a task of weighing the infant. Each of the
first two questions has an additional question which are to be asked to mothers who answer yes to
each of them. In 81.8% (9) observations it was found that ANMs asked the first question, i.e., is the
infant was breastfed. ANMs who asked this question were also supposed to ask about the frequency
of breastfeeding in 24 hours. It was found that out of them only 55.6% (5) asked about frequency of
breastfeeding in 24 hours. The second question about infant receiving any foods or drinks other than
mother’s milk was asked only by 9.1% (1) ANM. In none of the observations ANM tried to know
about use of feeding bottle or cup by asking about what was being used to feed the infant. Only 9.1%
(1) ANM determined weight of the infant using functional basin weighing scale placed on a flat, hard,
even surface and reading was done at ANMs eye level (Fig. B3.4.1).
63.6 100 100 100
0
50
100
Asked about diarrhoea tomother
Checked for infantsmovements (considering
dehydration in mind)
Checked for Sunken eyes Checked for skin pinch test
DIARRHOEA AND RELATED SIGNS NOT CHECKED (N = 11)
Not checked (%)
Page | 34
Fig.: B3.4.1: Observation of low weight and feeding problem related tasks performed by ANMs
As none of the young infants during observation had indications to urgently refer to a hospital, as per
the IMNCI protocol, ANM were supposed to assess breastfeeding by the infant. It was found that in
only 27.3% (3) observations, ANMs checked for infant’s attachment during breastfeeding through
observing 4 signs of attachment (chin touching breast, mouth wide open, lower lip turned outward,
and more areola visible above than below the mouth). Same percentage of ANMs (27.3%) checked
whether infants were sucking effectively through signs of suckle (observing slow deep sucks and
seeing or hearing the infant swallowing). Also, same percentage of ANMs (27.2%) looked for thrush
in oral cavity of the young infant. In only 9.1% (1) observation the ANM checked for mother having
any pain while breastfeeding. None of the ANMs during observation examined mothers to find out
flat/ inverted or sore nipples or engorged breasts or abscess problems (Fig. B3.4.2).
Fig. B3.4.2: Assessment of Breastfeeding by ANMs
The MO assessed feeding problems or low weight for age. Essential question was asked by her on
breastfeeding, feeding practice was also assessed and weight was checked and recorded, however,
weight for age was not determined. Infant’s attachment to breast and effective suckling were not
examined while presence of oral thrush was checked by the MO (Annexure Table B3.4.3).
72.7 72.7 72.790.9 100
0
50
100
Checked for infantsattachment during
breastfeeding
Checked for infantssuckling effectively
Looked for oral thrush Checked for did motherhave any pain while
breastfeeding
Checked flat/ inverted orsore nipples or engorged
breasts or abscessproblems
% Not Assessing breastfeeding (N=11)
Not checked (%)
81.8
9.10
9.1
0
20
40
60
80
100
Asked if the infant isbreastfed
Asked, if the infant usuallyreceive any other foods or
drinks?
Asked, what is used to feedthe infant
Determined weight of infant
% low weight and feeding problem related tasks (n=11)
Page | 35
B3.5. OBSERVATIONS OF 0 TO 2 MONTHS YOUNG INFANTS ON IMMUNIZATION
AND ASSESSING ANY OTHER PROBLEMS:
In 72.7% (8) observations, ANMs checked
the immunization status of the young infant
that if they have received all the
immunizations recommended for their age,
and if not, immunization can be given the
same day (Fig. B3.5.1). ANMs are also to
look at the IMNCI Assess and Classify the
sick infant chart and locate the recommended
immunization schedule. It was found that in
only 27.3% (3) observations ANMs looked at
the Assess and Classify the sick infant chart
and located the record accordingly. Also, in only 18.2% (2) observations ANM advised mother to be
sure that other children in their family are immunized (Table B3.5.2).
Table B3.5.2: ANMs performing Immunization related tasks by ANM
IMNCI Baseline 2020 N = 11 (multiple choice)
ANMs performing Immunization related tasks Number of
responses
Percent of
cases (%)
Looked at the Assess and Classify the sick infant chart and
located the record accordingly
3 27.3
Advised mother to be sure the other children in the family are
immunized
2 18.2
In 90.9% (10) 0-2 months’ infant observations, the ANMs did not assess any other problems asked
by mother or observed (Table. B3.5.3). The immunization schedule for the infant was checked by the
MO. Also, any other problems mentioned by mother or observed were assessed by MO.
Table. B3.5.3: Assessing Other Problems by ANM
Proportion of ANMs assessed other problems mentioned by mother or
observed (0-59 days)
9.1%
72.7
27.3
Fig. B3.5.1: % of Observations in which ANMs checked for Immunization status (N= 11)
Checked Not Checked
Page | 36
B3.6. CLASSIFICATION, IDENTIFYING TREATMENT AND COUNSELLING FOR 0 TO
2 MONTHS INFANTS
In only 27.3% (3) observations ANM were able to
classify the ailment based on their assessment (Fig.
B3.6.1). In all these 27.3% observations, the
classification was No Feeding problem. In 54.5%
(5) observations, ANMs did not counsel the
mothers wherever required (Fig. B3.6.2).
Fig. B3.6.2: % of observations in which counselling was provided to mothers where required
The MO classified the young infant suffering from Feeding Problem or Low weight for age. The
classification of the case was done correctly but no medications were suggested. Mother received
advice regarding exclusive breastfeeding, keeping infant warm, Apply nothing to umbilicus (cord),
and proper handwashing. MO counselled mother wherever required.
B4. ASSESSMENT AND CLASSIFICATION ANALYSIS: 2 MONTHS’ TO 5 YEARS
INFANTS/ CHILDREN: ANMs and MOs
B4.1 OBSERVATIONS OF 2 MONTHS’ TO 5 YEARS INFANTS/ CHILDREN ON
GENERAL DANGER SIGNS:
Out of 26 observations of 2 months to 5 years’ infant/ children, 92.3% (24) were actual cases and
7.7% (02) were simulations. There are three questions and one task to be performed to assess the
general danger signs in infant/ children. In 26.9% (7) observations ANMs did not ask the mother
about child being able to drink or breastfeed. In 80.7% (21) observations the ANMs did not ask
mother whether the child vomits everything. Only in 15.4% (4) observations sufficient time was given
to mothers to answer about vomiting. In none of the observations ANMs checked whether the child
has convulsions and checked if the child is lethargic or unconscious (Fig. B4.1.1).
72.7
27.3
Fig B3.6.1: Classification in %
Not classified
No feedingproblem
45.554.5
0
50
100
Yes % No %
% Counselling mothers (N = 11)
Yes %
No %
Page | 37
Fig. B4.1.1: Not checked for General Danger Signs by ANMs
2 observations of MOs managing cases of 2 months to 5 years’ children was done. One MO was
observed managing an actual case and another through simulation. For checking the general danger
signs, in both the 2 cases MOs asked whether the child is able to drink or breastfeed, 1 MO asked
whether the child vomits everything, and 1 MO asked whether the child had convulsions. In 1 case,
MO checked to see if child is lethargic or unconscious.
B4.2. OBSERVATIONS OF 2 MONTHS’ TO 5 YEARS INFANTS/ CHILDREN ON SEVERE
PNEUMONIA/ PNAUMONIA/ COUGH OR COLD
This section directs the ANM to begin with asking question whether the infant/child has cough or
cold. It was found that in 57.7% (15) observations ANM have asked this question to the mother
correctly (table 9.25). On the response of ‘yes’ by mother, ANM has to ask about the duration (for
how long) of cough or cold; in 3.8% (1) observations ANM asked to know the duration from which
cough or cold was present. Irrespective of response of the mother, ANM also have to count the
breathes in one minute and look for chest indrawing while the child is calm. It was observed that
regardless of the mother's response 34.6% (9) ANMs counted the child’s breathing herself while
uncovering child’s chest (Table B4.2.1).
Table B4.2.1: Cough or Cold Related Questions and Tasks by ANMs
IMNCI Baseline 2020 N= 26
Cough or cold related questions and tasks Percentage
Asked does the child has cough or cold 57.5%
Counted breathes in one minute with child’s chest uncovered 34.6%
In 38.5% (10) observations ANM checked for chest indrawing. In all of these observations (100%)
chest indrawing was checked in uncovered chest while in 80% (8) observations ANMs correctly
assessed the chest indrawing noticing the movement of the lower chest wall getting inner when the
child inhaled (Table B4.2.2).
26.9
80.7
100 100
0
20
40
60
80
100
Asked whether child isable to drink or
breastfeed
Checked does the childvomit everything
Checked for the signs ofconvulsions
Checked the child islethargic or unconsious
Checked for ‘general danger signs’ (n=26)
Not checked(%)
Page | 38
Table B4.2.2: Observations in which chest indrawing was checked by ANMs
IMNCI Baseline 2020 N= 10
Observations in which chest indrawing was checked by ANMs Percent of cases (%)
Chest indrawing checked in uncovered chest 100
Correct assessment of the chest indrawing done 80
MOs assessed cough or difficult breathing by asking opening question in both the observations.
Regardless of the mother’s response, detailed assessment was done in 1 case including observation
of breathing while keeping the child’s chest uncovered. However, none of the MOs counted breathes
in one minute, did not check for chest indrawing or looked or listened for stridor.
B4.3. OBSERVATIONS OF 2 MONTHS’ TO 5 YEARS INFANTS/ CHILDREN ON
DEHYDRATION:
In 34.6% (9) observations ANMs asked the mother whether the child have Diarrhea (Table B4.3.1).
Table B4.3.1: Asking about Diarrhea by ANMs
IMNCI Baseline 2020 N = 26
Asked about child have Diarrhoea Percentage (%)
Yes 34.6
No 65.4
However, in none of the observations (0%) ANMs performed the four tasks for checking the signs of
dehydration i.e., looking and feeling for a). child’s general condition (lethargic or unconsciousness;
restlessness and irritable); b). looking for sunken eyes; c). offering the child fluid to drink; and d).
pinching the skin of the abdomen and observing it to go back (Fig. B4.3.2).
Fig. B4.3.2: Checking for signs of Dehydration by ANM
0 0 0 0
100 100 100 100
0
50
100
Looked at child's generalcondition
Looked for Sunken eyes Offered the child fluid to drink Pinched the skin of theabdomen
CHECKED FOR ‘SIGNS OF DEHYDRATION’ (N=26)
Checked (%) Not checked(%)
Page | 39
Out of two MO observations, question of Diarrhoea was asked only by one MO, which was the actual
case observation. None of the MOs checked child’s general condition (lethargy or unconsciousness;
restlessness or irritability). None of the MOs checked for sunken eyes, offered the child fluid to drink
or checked skin pinch test.
B4.4. OBSERVATION OF 2 MONTHS’ TO 5 YEARS INFANTS/ CHILDREN ON VERY
SEVERE FEBRILE DISEASE/ MALARIA:
In 34.6% (9) observations it was found that ANMs asked whether the child has fever as the first task
to assess signs related to very severe febrile disease/ Malaria (Table B4.4.1).
Table B4.4.1: Asking about presence of fever by ANMs
IMNCI Baseline 2020 N= 26
Asked about child having Fever Percentage (%)
Yes 34.6
No 65.4
Out of the ANM who asked about fever, 100% (9) asked it correctly giving explanation until mother
understood and responded correctly and only 11.1% (1) assessed the child’s fever even when the child
did not feel hot to touch (Table B4.4.2). In none of the observations (0%) ANMs looked or felt for
child’s Neck rigidity (Fig. B4.4.3).
Table B4.4.2: ANM Observations in which fever was asked Fig. B4.4.3: Checking neck rigidity
IMNCI Baseline 2020 N= 9
Observations in which fever was
asked
Percentage
(%)
Asked about fever correctly 100
Assessed the child’s fever even
when the child did not feel hot to
touch
11.1
Both the MOs asked whether child was having fever, whereas the MO assessing actual case also
checked for it. None of the MOs checked for stiff neck. IMNCI chart directs MOs to perform a few
extra tasks which include- looking for any bacterial cased of fever and looking for signs of measles.
None of the MOs looked for any bacterial cause of fever or undressed the child to look for generalised
rash as a sign of Measles; however, in the actual case observation the MO checked for cough and
runny nose. In none of the cases mouth ulcers, eyes (for draining pus), or clouding of cornea was
checked. MOs are also to assess ear problems, it was found that none of the MOs asked about ear
problems, neither pus draining from ear or tender swelling behind the ear was checked.
0
100
% Looked or felt for neck rigidity Percentage (n=26)
Yes
No
Page | 40
B4.5. OBSERVATION OF 2 MONTHS’ TO 5 YEARS INFANTS/ CHILDREN ON
MALNUTRITION:
As the next step, ANM had to check for presence of visible severe wasting, oedema of both feet and
Measure Mid-upper arm circumference (MUAC) in 6 months of older children using the UNICEF
MUAC tape. It was found that in only 73.1% observations ANM did not look for presence of severe
wasting, 96.1% did not look for edema of both feet; and none of the ANMs measured MUAC (Fig.
B4.5.1).
Fig. B4.5.1: Observation of Screening for Malnutrition by ANMs
In the MO observations, no tasks related to assessment of nutritional status was performed. Weight
and length were not taken and so Weight for Length (WFL) was also not derived, neither oedema of
both feet was checked. As actual case child was younger than 6 months so MUAC was not to be
measured, however, it should have been measured in simulation which was not however performed.
B4.6. OBSERVATION OF 2 MONTHS’ TO 5 YEARS INFANTS/ CHILDREN ON
ANAEMIA:
In 69.2% (18) observations ANM did not check for palmar pallor. However, only 26.9% (7) ANMs
checked the palmar pallor under conditions favorable for checking like availability of good light or
under day light. None of these ANMs (0%) applied correct assessment technique for checking palmar
pallor. Correct assessment is done by holding the child's palm open by grasping it gently from the
side (not stretching the fingers backwards) and comparing the colour of the child's palm with ANMs
own palm and with the palms of other children. Depending on palm’s paleness some palmar pallor is
classified or on finding the palm skin very pale severe palmar pallor is classified. Also, in only 11.5%
(3) observations, result of assessment was recorded by ANM (Fig. B4.6.1).
73.1
96.1 100
020406080
100
Looked for visible severewasting
Looked and felt for Oedema ofboth feet
Measured MUAC in child > 6months
Screening for Malnutrition (N=26)
Not checked (%)
Page | 41
Fig. B4.6.1: Assessment of palmar pallor (checking for Anaemia) by ANMs
For checking sign of Anaemia, Palmar Pallor was checked under good light by the MO performing
actual case management.
B4.7. OBSERVATION OF 2 MONTHS’ TO 5 YEARS INFANTS/ CHILDREN ON
IMMUNIZATION, PROPHYLACTIC VITAMIN-A, IRON-FOLIC ACID
SUPPLEMENTATION, AND DEWORMING STATUS
In 69.2% (18) cases ANMs did check for Child’s Immunization status and in 18.2% (4) cases the
ANM checked and provided age specific immunization following the National recommended
immunization Schedule. As shown in Fig. B4.7.1, in only 7.8% (2) cases ANM checked for
Prophylactic Vitamin A supplementation status, while no ANM checked for child’s prophylactic iron-
folic acid supplementation status and deworming status.
Fig. B4.7.1: Checking Immunization, Prophylactic Vitamin A, Iron-Folic Acid
Supplementation, and Deworming Status by ANM
11.5
0
26.9
30.8
88.5
100
73.1
69.2
0 10 20 30 40 50 60 70 80 90 100
Results of the assessment of paleness recorded
Correct assessment technique applied to check…
Conditions of assessing palmar paleness
Palmar pallor or some pallor
Assessment for Anemia (N=26)
Not Checked (%) Checked (%)
69.2
7.80 0
30.8
92.2100 100
0
10
20
30
40
50
60
70
80
90
100
Immunization Prophylactic Vitamin ASupplementation status
Iron and Folic acidsupplementation status
Deworming status
Checking Immunization, Prophylactic Vitamin A, Iron-Folic Acid Supplementation, and Deworming Status (n=26)
Checked % Not Checked %
Page | 42
In MO observations, Immunization status was checked for the actual case. Vitamin A
supplementation status, prophylactic Iron and Folic Acid Supplementation status and child’s
deworming status were not checked by any MO.
In 37.5% (09) cases ANMs asked questions about child’s food intake. Out of these cases, all the
ANMs (100%) asked questions about the child’s usual diet and diet during disease and 33.3% (3)
ANMs compared the mother’s response to the recommendations for age-specific feeding given in the
FOOD box on the IMNCI COUNSEL THE MOTHER chart (Table B4.7.2).
Table B4.7.2: Observation of ANM on Child Feeding Assessment
IMNCI Baseline 2020 N =9 (Multiple choice)
Asked the questions about food intake correctly Percent of cases (%)
Asked questions about the child’s usual diet and diet during disease 100.0
Compared the mothers response to the recommendations for age-
specific feeding
33.3
In 65.4% (17) cases ANMs counselled the mothers for feeding practices according to the food box
mentioned in the IMNCI chart. However, only in 7.7% (02) cases ANMs consulted the food box of
the counsel the mother table in the IMNCI chart probably due to chart’s unavailability during
observation. Although charts were available in only 7.7% (2) cases, however, in 65.4% (17) cases
ANM gave feeding advice as per the food box given in the Counsel the mother table. Out of these,
94.1% (16) cases ANMs demonstrated good communication skills and in same percentage of cases
sufficient adequate advice was provided to mothers (Table B4.7.3).
Table B4.7.3: Observation of Feeding Advice
IMNCI Baseline 2020 N = 17 (Multiple choice)
Asked to feed the child as described in the food box of the Counsel
the mother table, demonstrating:
Percent of cases (%)
Good Communications skills 94.1
Giving adequate advice 94.1
Only 3.9% (01) ANMs observed child’s mouth for oral thrush and in 38.5% (10) cases ANM correctly
assessed the child’s other problems. Both the MOs asked about child’s other problems and also asked
about food correctly. In both observations, MOs asked to feed the child as per the food box of the
Counsel the Mother table of IMNCI chart demonstrating good communication skills and by giving
adequate advice. As IMNCI charts were unavailable, none of the MOs consulted the Food box of the
counsel the mother table.
The Table B4.7.4 shows the list of tasks not performed during both the MO observations.
Page | 43
Table B4.7.4: List of tasks not performed during both MO observations
IMNCI Baseline 2020 (n=2)
1. Checking for child having measles within last 3
months
9. Checking ear problem
2. Looking for signs of measles 10. Checking for tender swelling behind
ear,
3. Looking or feeling for stiff neck 11. Looking and feeling for oedema of
both feet
4. Prescribing RDT test 12. Measuring the child’s weight
5. Looking for bacterial cause of fever 13. Measuring the length/height of child
6. Looking for mouth ulcers. 14. Measured MUAC
7. Looking for pus draining from the eyes. 15. Prescribing for Hb testing.
8. Checking for clouding of cornea
B4.8. CLASSIFICATION, IDENTIFYING TREATMENT AND COUNSELLING BY ANMs
FOR 2 MONTHS to 5 YEARS CHILDREN
Fig. B4.8.1: Classification performed by ANMs
Only in 11.5% (03) cases, ANMs were able to
correctly classify the ailment based on child’s
assessment. All 11.5% (3) cases were classified as
only cough or cold (no pneumonia) by ANMs as
shown in the Fig. B4.8.1.
Out of 11.5% (3) cases whose classification was
made, 66.6% (2) ANMs advised for home care for
cough or cold while 33.3% (1) ANM did not advice
for the same. In 46.2% (12) cases, counselling was
provided to mothers wherever required. MO
assessing the actual case was able to correctly
classify Cough and Cold (no pneumonia) as the
classification (table B4.8.2). The MO advised home
remedies, advised the mother when to return immediately and asked the mother to follow up in 5 days
if the child does not improve. Both the ANMs counselled the mother/ caregiver wherever required.
None of the MOs followed the assessment sequence as per the IMNCI guidelines.
Table B4.8.2: Status of Classification done by MO
IMNCI Baseline 2020 N = 1
What was the classification? Cough or cold (No Pneumonia)
Treatment given as per the IMNCI protocol? Yes
Did MO classify correctly? Yes
Counselled the mother where required Yes
84.6
11.5
3.9Classification (%)
No classification done
Only cough and cold (No Pneumonia)
Any other
Page | 44
B5. ILLNESS ANALYSIS AND ADHERENCE TO ASSESSMENT:
According to the IMNCI guidelines, ANM have to perform some tasks for doing Assessment of
infants/children. While some tasks are required to be performed with all children, many of them are
“conditional” tasks which are to be included in the calculation of the adherence index only if the
condition was met. For example, if the ANM asked a mother of 0-2 months’ age infant that whether
the infant has diarrhoea and she replies ‘no’, the ANM does not need to perform three more tasks-
looking for infant’s general condition, looking for sunken eyes, and doing the skin pinch test. In this
case, the applicable task would be one with applicable score as 1. If the mother would have said ‘yes’,
the applicable task would have been 4 with applicable score as 4 (1 score for each task). This way,
number of applicable tasks and number of performed tasks were calculated for each ANM per ailment
and at the end, score is calculated for overall adherence to assessment.
Percentage is calculated for obtained tasks against applicable tasks and the percentage is classified.
Here class interval is used to interpret the ailment analysis and adherence to assessment which is
performed by the ANM in 37 observations. Class interval table B5.1 tells us that what percentage of
applicable tasks (for assessment) for assessing different signs were performed by what percentage of
ANMs. The class interval for tasks performed is given in four categories- 0-25%, 26-50%, 51 to 75%
and 76 to 100%. These four ranges are the percentage of tasks completed for each ailment and at the
end the overall adherence to assessment is calculated.
As shown in Table B5.1 below, for the ANM who managed 0 to 2 months’ infants, only 54.5% (6)
ANMs were able to perform 25% or less of applicable tasks while 36.4% (4) ANM were able to
perform 26 to 50% of applicable tasks for assessing PSBI/ LBI. 100% (11) ANM could only perform
25% or less applicable tasks to assess severe Jaundice/ jaundice and Severe/ some dehydration. 27.3%
(3) ANM could perform 25% or less applicable tasks and remaining 72.7% (8) ANM could perform
26-50% tasks to assess low weight and feeding problem. Only for assessment of immunization, 36.4%
(4) ANMs could perform 76 to 100% of tasks, the remaining 63.6% (7) could perform 50% or less
tasks.
In observations where ANM managed 2 months to 5 years old children, majority of ANM (80.8%)
could only perform 25% or less tasks to assess General danger signs. In 61.5% (16) and 38.5% (10)
respective observations, ANMs could perform 25% or less and 26 to 50% applicable tasks
respectively to assess Severe Pneumonia or Very Severe Disease/ Pneumonia. In none of the
observations (0) ANMs could perform more than 25% tasks for assessing severe/ some dehydration
and Very Severe Febrile Disease/ Malaria. In only 3.8% (1) observation ANM performed 51 to 75%
of applicable tasks to assess malnutrition; in 73.1% (19) observations ANM could only perform 25%
or less tasks to assess malnutrition, while remaining 23.1% (7) could perform 26 to 50% tasks.
Only 30.8% (8) ANMs could perform tasks 76 to 100% for assessing Severe Anaemia/Anaemia,
remaining 69.2% (18) could only perform 25% or less tasks. Only 23.1% (6) ANMs could perform
76 to 100% tasks to assess immunisation status. Only 3.8% (1) ANM could perform 76 to 100% tasks
to assess prophylactic Vitamin A. In all the observations ANMs could only perform 25% or less tasks
to assess Iron- Folic Acid supplementation status and Deworming status.
Page | 45
With regard to overall adherence to assessment index for all 37 ANMs who managed 0 months to 5
years old children, in 67.6% (25) observations ANMs could only perform 25% or less applicable
tasks of assessment. In the remaining observations 32.4% (12) ANMs could perform only 26 to 50%
of applicable tasks for assessment.
Table B5.1: Ailment wise analysis and adherence to assessment byANMs
0 TO 2 MONTHS: ANM (N=11)
Applicable tasks performed (in class interval)
0 -25% 26-50% 51-75% 76-100%
PSBI/LBI Number 6 4 1 0
Percentage 54.5 36.4 9.1 0.0
SEVERE JAUNDICE/
JAUNDICE
Number 11 0 0 0
Percentage 100 0 0 0
SEVERE/ SOME
DEHYDRATION
Number 11 0 0 0
Percentage 100 0 0 0
VERY/LOW WEIGHT AND
FEEDING PROBLEM
Number 3 8 0 0
Percentage 27.3 72.7 0.0 0.0
IMMUNIZATION Number 2 5 0 4
Percentage 18.2 45.5 0.0 36.4
ADHERENCE TO
ASSESSMENT
Number 5 6 0 0
Percentage 45.5 54.5 0.0 0.0
2 MONTHS TO 5 YEARS: ANM (N=26)
GENERAL DANAGER SIGN Number 21 5 0 0
Percentage 80.8 19.2 0.0 0.0
SEVERE PNEUMONIA OR
VERY SEVERE DISEASE/
PNEUMONIA
Number 16 10 0 0
Percentage 61.5 38.5 0.0 0.0
Page | 46
SEVERE DEHYDRATION/
SOME DEHYDRATION
Number 26 0 0 0
Percentage 100 0 0 0
VERY SEVERE FEBRIE
DISEASE/ MALARIA
Number 26 0 0 0
Percentage 100 0 0 0
SAM /MAM Number 19 6 1 0
Percentage 73.1 23.1 3.8 0.0
SEVERE ANAEMIA/ANAEMIA Number 18 0 0 8
Percentage 69.2 0.0 0.0 30.8
IMMUNIZATION Number 7 13 0 6
Percentage 26.9 50.0 0.0 23.1
PROPHYLACTIC VIT.A Number 24 0 1 1
Percentage 92.3 0.0 3.8 3.8
IFA Number 26 0 0 0
Percentage 100 0 0 0
DEWORMING Number 26 0 0 0
Percentage 100 0 0 0
ADHERENCE TO
ASSESSMENT
Number 20 6 0 0
Percentage 76.9 23.1 0.0 0.0
0 TO 5 YEARS: ANM (N=37)
OVERALL ADHERENCE TO
ASSESSMENT BY ANMs
Number 25 12 0 0
Percentage 67.6 32.4 0.0 0.0
The illness-wise assessment and overall adherence to assessment for MOs is shown in Table B5.2.
The illness wise assessment is also not satisfactory in case of MOs. Only task performed 76 to 100%
was for assessing the immunization status in the actual case observation. The overall adherence to
assessment index for MOs shows that 2 MOs could perform 26 to 50% applicable tasks of overall
Page | 47
assessment while 1 MO performed 25% or less applicable tasks of assessment. However, owing to
the small sample size of MOs, this finding cannot be very conclusive.
Table B5.2: Adherence to Assessment by MOs
0 TO 5 YEARS: MOS (N=3)
OVERALL ADHERENCE TO
ASSESSMENT BY MOs
Number 1 2 0 0
Percentage 33.3 66.7 0.0 0.0
B6. TREATMENT, REFERRAL AND CONSELLING ANALYSIS
B6.1. TREATMENT, REFERRAL AND COUNSELLING BY ANMS FOR 0-2 MONTHS
INFANTS:
This section of report discusses the treatment prescribed by health workers for the ailment classified
by them. For infants 0 to 2 months of age managed by ANMs, 27.3% (3) were only able to classify
the cases as No Feeding problem and only 9.1% (1) ANM provided right prescription for children
below 2 months. As none of the remaining ailments like PSB/ LBI, Severe dehydration/ some
dehydration was classified, their treatments could not be assessed for ANMs (Table B6.1.1).
Table B6.1.1: Adherence to prescription for 0-2 months’ infants managed by ANM
For infant aged below 2 months
Adherence on prescription (based on classification of health workers)
Type of
ailments
Correct
prescription
Actual prescription
provided by ANM
Remarks
Possible serious
bacterial
infection
Oral Amoxicillin and IM
Gentamicin (pre referral)
NA ANMs did not classify
any of these ailments
Local bacterial
infection
Amoxicillin NA
Severe
dehydration/
Some
dehydration
Oral Amoxicillin, IM
Gentamicin and ORS (pre
referral)
NA
No dehydration
(Diarrhoea
reported)
ORS and Zinc Supplement NA
Page | 48
As ANMs did not classify any of the ailments given in table 11.1 and there was no case referral
required for infants to hospital, therefore, adherence to referral could be assessed. Adherence to
counselling was found to be 45.5% (5) as the same proportion of ANMs provided counselling to
mothers of 0 to 2 months’ infants wherever required (Table B6.1.2). In none (0%) of the observations,
correct sequence as per IMNCI chart was followed.
Table B6.1.2: List of Indicators on Adherence to Prescription and Counselling for infant aged
below 2 months
B6.2. TREATMENT, REFERRAL AND COUNSELLING BY ANMS FOR 2 MONTHS TO 5
YEARS OLD CHILDREN
Out of all observations of ANM who managed 2 months to 5 years old children, 7.7% (2) of ANMs
did right classification for children aged between 2 months to 5 years. The classification was Cough
or cold (no pneumonia). As none of the ANMs classified for Severe pneumonia, or very severe
disease, pneumonia, Severe/ some dehydration, and very severe febrile disease/ Malaria; therefore,
the assessment of prescription provided by ANMs applicable for these ailments could not take place
(Table B6.2.1)
Table B6.2.1: Adherence to Prescription for 2 months to 5 years’ children managed by ANM
For children aged between 2 months to 5 years
Adherence to Prescription (based on classification of health workers):
Type of ailments Correct prescription Actual prescription
provided by ANM
Remarks
Severe pneumonia or
very severe disease
Oral Amoxicillin and IM
Gentamicin (pre referral)
NA The ANMs did
not classify any
of these ailments Pneumonia Cotrimoxazole or
Amoxicillin
NA
Severe dehydration/
Dysentery
ORS (pre referral) NA
Some dehydration ORS and Zinc Supplement NA
Indicators
1. 27.3% (3) ANMs did classification of ailment
2. 9.1% (1) ANM did right classification of ailment
3. 9.1% (1) ANMs provided right prescription as per the classification done by herself
4. 45.5% (5) ANMs provided counselling
Page | 49
No dehydration
(Diarrhoea reported)
ORS and Zinc Supplement NA
Very severe febrile
disease
Oral Amoxicillin and IM
Gentamicin (pre referral)
NA
Malaria Antimalarial as per NAMP
guideline
NA
Malaria Unlikely One dose of paracetamol (if
temp is above 38.5 C)
NA
Referral was not required in any observation (0%) for 2 months to 5 years old children. 46.2 % (12)
ANMs counselled the mothers of 2 months to 5 years old children wherever required. Table B6.2.2
is the list of indicators applicable for treatment and counselling by ANMs for age group of 2 months
to 5 years’ children. In none (0%) of the observations, correct sequence as per IMNCI chart was
followed.
Table B6.2.2: List of indicators on adherence to Prescription and Counselling for children aged
2 months to 5 years
Table B6.2.3: List of indicators on adherence to Prescription and Counselling for children aged
below 5 years
In the observation of MOs, one of the two MOs who managed actual case correctly classified the
ailment as Cough and cold (No Pneumonia), prescribed the treatment correctly and counselled the
mother wherever required.
SECTION C – MOTHERS/ CAREGIVERS UNDERSTANDING OF HEALTH FOR THEIR
UNDER 5 YEARS CHILD
Indicators
1. 11.5% (3) ANMs did classification of ailment
2. 7.7% (2) ANMs did right classification of ailment
3. 9.1% (1) ANMs provided right prescription as per the classification done by herself
4. 45.5% (5) ANMs provided counselling
Indicators
1. 16.2% (6) ANMs did classification of ailment
2. 8.1% (3) ANMs did right classification of ailments
3. 8.1% (3) ANMs provided right prescription as per the classification done by herself
4. 46% (17) ANMs provided counselling for children aged below 5 years
Page | 50
C1 – Demographic findings
Majority of mothers of under-5 children interviewed visited nearby health facility within last six
months. 60% mothers belonged to scheduled tribe, 35% to scheduled caste and only 5% (2) belonged
to general category (Annex Table C1). A majority of mothers were found to have received formal
school education and above. 32.5% mothers attended high school and above, 37.5% attended between
class 8 to 10, 10% attended class 4 to 7 and only 20% have had no schooling (Annex Table C1.1).
The proportion of mothers who had one under-5
children was 75% and those who had two under-5
children were found to be 25%. Out of 40, 39
mothers had Maternal and Child Protection (MCP)
card with status of routine vaccination of their child.
All the mothers informed that their children were
timely vaccinated. 82.5% (33) under-5 children of
interviewed mothers’ fell sick during last 6 months
(Fig. C1.2). 61% mothers’ reported that their
children suffered from fever, 58% from cough, 24%
from Diarrhoea, 15% from skin infections, 9% from
cold and 3% from stomach pain (Table C1.3). 70%
mothers reported that their children had more than
one type of illnesses mentioned above.
Table C1.3 – Distribution of Respondents according to type of Illness U5 children had in last 6
months
IMNCI_Baseline 2020 N = 40 (multiple choice)
Type of illness U5 child had in last 6 months Percent of cases
Fever 60.61
Cough 57.58
Diarrhoea 24.24
Skin Infections 15.15
Cold 9.09
Stomach pain 3.03
C2 - Mothers seeking healthcare:
For medical consultation and treatment for their
children’s illnesses, it was found that community
largely relied on public health facilities. Out of 34
mothers (33 whose children fell ill during last six
months +1 for consultation), 91% sought
consultation and treatment from ASHAs, health
sub-centre, Primary health centre, and Sadar
hospital. Remaining 9% mothers sought care from
private clinic. A further break up of mothers who
sought support is given in Fig. C2.1. 8 mothers out of 40 mentioned that their children suffered from
82.50%
17.20%
Under-5 children fell sick during last 6 months
U5 children fellsick during last6 months
Fig. C1.2 – Distribution of respondents according
to under 5 children illness during last 6 months
9.09
60.61
18.189.09 6.06
0
20
40
60
80
Fig. C2.1: Percentage of mothers seeking support
Page | 51
diarrhoea during last six months. 75% (6) reported that they had given Oral rehydration salt (ORS)
during episodes of diarrhoea; and 87.5% (7) also fed homemade gruel to their children (Annex. Table
C2). They also reported that information related to home-based management of diarrhoea was given
by ANMs during community visits (Annex. Table C4)
The information about immunisation status of
under-5 children was assessed. It was found that
39 out of 40 mothers (97.5%) have had
undergone age-appropriate immunisation for
their children from the health facility (Fig. C3.6).
One caregiver mentioned that her child did not
receive any immunisation (the child was 1 month
old and was low birth weight. As per her mother,
the baby was in NICU for 15 days after birth)
To understand further about immunisation coverage, age of youngest child was asked and was
confirmed from the MCP card. 55% of mothers’ youngest children were below 18 months of age,
35% children were between 19 to 36 months of age and only 10 % caregiver’s children were above
36 months (Annex. Table C5). Vaccination of Polio and BCG was complete for all young children,
90% for ROTA vaccine and 87% each for Hepatitis and Pentavalent vaccines were given to youngest
child of the household. 74% youngest children were immunised with MR/Measles vaccine and
provided with Vitamin A (Table C3.7).
Table C3.7 - Distribution of Respondents according to type of Vaccines child received till date
IMNCI_Baseline 2020 N=39 (multiple choice)
Type of vaccines child received till date Percent of cases
Polio 100.00
BCG 100.00
ROTA 89.74
Hepatitis 87.18
Pentavalent 87.18
MR/Measles 74.36
Vitamin A 74.36
C3 - Service Rating
There were 20 mothers who received services only from health sub-centres (HSC). The satisfaction
is understood from the intent of availing the health service it in future. Majority of mothers said to
prefer the same sub-centre because of ease of access (90%), good behaviour of staff (80%) and
affordable service (80%). Availability of medical staff (55%) and provision of effective medicines
(15%) were other stated reasons for opting the same health sub-centre in future (Table C3.2).
Table C3.2 - Perceived reason for preference for Sub Centre in future
IMNCI_Baseline 2020 N = 20 (multiple choice)
Reason for preferring sub-centre in future Percent of cases (%)
95.50%
2.50%
Fig. C3.6: Children who received age-appropriate immunisation (n=40)
Children whoreceivedimmunisation
not received ageappropriateimmunisation
Page | 52
Ease of access 90.00
Availability of medical staff 55.00
Good behaviour 80.00
Affordable service 90.00
Provide effective medicines 15.00
Where access and affordability are not a great issue in the context of community-based health services
with regard to health sub-centre level. The main challenge lies with availability of staff, their
behaviour and receiving effective medication. Hence the overall satisfaction is calculated with the
affirmative response on their indicators.
The analysis of overall satisfaction (with intent of future visits in the same facility) with respect to
three parameters (availability of staff, their behaviour and receiving effective medication) is
represented in Table C3.3. Satisfaction of mothers one parameter was 35%; satisfaction on two
parameters for mothers was half (35%) and that on all three parameters together was only 15%. No
satisfaction on any of the three parameters was 15%.
Table C3.3: Overall satisfaction based on availability of staff, their behaviour and receiving
effective medication)
Overall satisfaction (based on availability of staff, their behaviour and receiving effective
medication) (N=20)
Satisfaction on all three important parameters 15
Satisfaction on just two parameters 35
Satisfaction on only one parameter 35
Not satisfied on any parameter 15
SECTION D: AVAILABILITY STATUS OF MEDICINES AND EQUIPMENTS IN HEALTH
FACILITIES
The study also tried to assess the availability of essential equipment and medicines in HSC, HWC
and PHCs in the blocks of Ratu, Namkum and Angara. Health facilities visited per block is shown in
the Fig below
Fig. D.1: Distribution of Health Facilities
Information about availability of
equipment and medicines in 52 health
facilities of these blocks was collected
through the scoping exercise conducted
in November 2020. The Table D.2
below represents the list of 11 essential
equipment in these facilities and their
status.
Table D.2: Equipment available in HSCs, HWCs AND PHCs of three blocks.
32.7
30.8
36.5
% Distribution of health facility (n=52)
Ratu
Namkom
Angara
Page | 53
IMNCI Baseline Available Functional
Sl.
No
Equipment Number Percent
(%)
Number Percent
(%)
1 Stethoscope 51 98 45 87
2 BP Apparatus- table model 52 100 51 98
3 Glucometer (to measure glucose) 52 100 51 98
4 Stadiometer (to measure height) 13 25 12 23
5 Length measuring board 23 44 20 38
6 Weighing scale 50 96 49 94
7 Test/Kits for essential laboratory
investigations
46 88 46 88
8 Thermometers 48 92 40 77
9 Kidney trays 52 100 48 92
10 Torch with batteries 36 69 29 56
11 Pulse Oximeter 17 33 17 33
NOTE: Weighing scale is for adults not for
infants/child.
It was observed that basic instruments like stethoscope, BP Apparatus- table model, Glucometer,
weighing scale (adults), test kits for essential laboratory investigations and kidney trays are available
and functional in more than 85% facilities. However, important anthropometry measurement devices
like stadiometer and length measuring boards are only available in 25% (13) and 44% (17) of facilities
respectively. Weighing scales for infants and children were unavailable in every facility visited during
the scoping exercise. Pulse oximeter, an important device to measure capillary oxygen which has
gained importance during COVID-19 pandemic is only available in 33% (17) health facilities.
Most basic device Torch with batteries was found to be unavailable in 31% (16) health facilities.
Across all the equipment, it was noted that the percentage of functional equipment was less than
available equipment. In fact, 8- 19% of more than half of available equipment (55%) in these facilities
are available but non-functional. These are Stethoscope (12% non-functional), stadiometer (8% non-
functional), length measuring board (13% non-functional), thermometer (17% non-functional),
kidney trays (8%) and torch with batteries (19%). There is only 11.5% (6) facilities where all the
essential equipment enlisted above is available.
Availability of important medicines used for treatment of 0 to2 months old infants and 2 months to 5
years’ infant/ children was assessed. In case of availability of medicines for 0 to 2months infant, 8
listed medicines (anti-microbial and ORS solution) were listed out. The Table D.3 below shows its
status. It was found that majority of health facilities (71.2%) had Amoxicillin availability and only
23.1% (12) health facilities only had Gentamycin which is used as essential drug. Other important
drugs like Ampicillin, Diazepam, Ceftriaxone, and Cefotaxime were unavailable in 98.1 to 80.8%
Page | 54
facilities. Phenobarbital was unavailable in any facility. Also, ORS solution used to treat diarrhoea in
young infants was unavailable in 32.7% (35) health facilities.
Table D.3: Availability of Medicines for 0 to 2 months’ infants in Health Facilities
IMNCI Baseline 2020 N=52
Amoxicil
lin
Ampicil
lin
Gentami
cin
Diazep
am
Ceftriax
one
Phenobarb
ital
Cefotaxi
me
ORS
Solutio
ns
Number of health
facility
37 6 12 3 10 0 1 35
Percentage of
health facilities
with availability
71.2 11.5 23.1 5.8 19.2 0.0 1.9 67.3
In case of 2 months to 5 years old children, availability of 21 medicines was assessed. As
demonstrated in Table D.4, It was found that in more than 90% of health facilities, Diazepam,
Phenobarbiturate, Cefotaxime, Ampicillin, nalidixic acid, Trimethoprim, Sulfadoxine-
pyrimethamine, Quinine and tetracycline eye ointment were unavailable. In 50-89% facilities,
essential drugs like Amoxicillin, Gentamycin, Cotrimoxazole, Ceftriaxone, Doxycycline, and
Chloramphenicol were unavailable. Also, other important drugs like ORS solution, Vitamin A syrup,
and Iron-Folic Acid syrup were unavailable at 40-49% facilities. 71% or more facilities only had
Paracetamol and Chloroquine. There is no facility where all the medicines prescribed in IMNCI
protocol is radially available.
Table D.4: Availability of Medicines for 2 months to 5 years’ children in Health Facilities
Drug Name Number
of
facilities
Percentage of
health
facilities with
availability
Drug Name Number
of
facilities
Percentage of
health
facilities with
availability
Amoxicillin 26 50.0 Paracetamol 51 98.1
Ampicillin 3 5.8 Chloroquine 37 71.2
Gentamicin 11 21.2 Sulfadoxine -
pyrimethamine
3 5.8
Diazepam 1 1.9 Primaquine 15 28.8
Cotrimoxazole 26 50.0 Quinine 2 3.8
Page | 55
Ceftriaxone 11 21.2 ORS Solution 30 57.7
Doxycycline 15 28.8 Zinc Sulphate 18 34.6
Chloramphenicol 9 17.3 Vitamin A
Syrup (Bottle)
30 57.7
Nalidixic Acid 0 0.0 IFA Syrup 28 53.8
Trimethoprim 4 7.7 Tetracycline eye
ointment
2 3.8
Sulphamethoxazole 2 3.8
CONCLUSION
IMNCI protocols comprise of assessment, classification, identifying and providing treatment,
counselling, giving follow up and referral of under-5 children by trained ANMs and medical officers.
The findings from round 1 survey of healthcare workers suggested all the ANMs had received IMNCI
training but long back without any refresher training in recent years. The most recent training
received by a few ANMs was also before year 2017. As majority of surveyed ANMs had received
training in 2011 with no refresher till today and so expecting a great quality of IMNCI implementation
for under 5 children from them would be not fair. Similar situation is with MO/MOICs/ANM
supervisors who received their IMNCI training around 10 years back. The doctors who are from
different speciality like physicians and gynaecology also pointed out to the fact that their speciality
is not in new-born and child health and there is no training provided for new-born and childcare.
Despite the fact that ANMs have received training long back, still they still believed that they have
the knowledge of IMNCI which can be enhanced through refresher training and rigorous practice and
supportive supervision.
While the ANMs showed confidence in IMNCI related knowledge while appearing in face to face
interviews and focus group discussions, the actual situation related to IMNCI practice in health
facilities was revealed by clinical observations. The observation of clinical management by HW
demonstrate that practice of IMNCI protocols is almost at non-existing stage in the health facilities.
There is unavailability of IMNCI charts in 72.5% facilities while in remaining 27.5% facilities, it is
not being referred appropriately. This is indicated from the finding that sequence of assessment is not
followed by any HW while managing 0 to 5 years old children. There is low-adherence to assessment
protocols. Majority of the healthcare workers did not check important applicable tasks of asking and
looking or feeling the signs of major ailments while assessing 0 to 2 months’ children. Signs of
PSBI/LBI, Jaundice/ dehydration and low-weight were missed by majority of the healthcare workers
Similarly, important tasks of IMNCI assessment for ailments like general danger signs, severe
pneumonia, dehydration, very severe febrile disease/ malaria, malnutrition, Anaemia and
immunization related tasks were missed by majority of HWs for 2 months to 5 years old children.
With regard to overall adherence to assessment for all 37 ANMs who managed 0 months to 5 years
old children, in 67.6% (25) observations ANMs could only perform one-fourth or of the less
applicable tasks of assessment. In the remaining observations, 32.4% (12) ANMs could perform only
Page | 56
26 to 50% of applicable tasks of assessment. The ailment wise assessment is not satisfactory in case
of MOs too. With regard to 0 to 2 months infant, in none of the observations MO performed 76-100%
of applicable tasks for assessing any listed ailment in IMNCI chart. For 2 months to 5 years old
children, both the MOs performed 25% or lesser applicable tasks for assessing the illnesses. The
overall adherence to assessment for MOs shows that 2 MOs could perform 26 to 50% applicable tasks
of overall assessment while 1 MO performed 25% or less applicable tasks of assessment. However,
owing to the small sample size of MOs, the findings may not hold statistical significance, but such
observations suggest that real situation may not be much different from these findings. Out of 40
observations of clinical management, only 15% (6) healthcare workers were able to classify the
ailment, while only 12.5% (5) were correctly classified them. Counselling to mothers was performed
by about half the ANMs. The overall adherence to protocols by MOs was low. MOs were able to
correctly classify the ailment but could not adhere to IMNCI protocols. None of the health workers
followed the assessment sequence as given in the IMNCI chart.
The study through a scoping exercise also assessed the availability of equipment and medicines in 52
health facilities (HSC, HWC and PHC) of the three blocks, as status of equipment and medicines
have a direct implication on providing treatment as per the IMNCI protocols. It was observed that
basic instruments like stethoscope, BP Apparatus- table model, Glucometer, weighing scale (adults),
test kits for essential laboratory investigations and kidney trays are available and functional in more
than 85% facilities. But, important anthropometry measurement devices like stadiometer and length
measuring boards are only available in 25% and 44% facilities respectively. Weighing scales for
infants and children were unavailable in every facility visited during the scoping exercise. Pulse
oximeter, an important device to measure capillary oxygen which has gained importance during
COVID-19 pandemic were only available in 33% health facilities. The concerns on ANMs on lack
of medicines and instruments also needs to be addressed on priority.
Most basic device like Torch with batteries was found to be unavailable in 31% health facilities.
Across all the equipment, it was noted that the percentage of functional equipment was less than
available equipment. In fact, 8- 19% of more than half of available equipment (55%) in these facilities
were available but non-functional. Availability of important medicines used for treatment of 0 to2
months old infants and 2 months to 5 years’ infant/ children was assessed. It was found that majority
of health facilities (71.2%) had Amoxicillin availability and only 23.1% (12) health facilities only
had Gentamycin which is used as essential drug. Also, ORS solution used to treat diarrhoea in young
infants was unavailable in 32.7% (35) health facilities. In case of 2 months to 5 years old children,
availability of 21 medicines was assessed. In 50-89% facilities, essential drugs like Amoxicillin,
Gentamycin, Cotrimoxazole, Ceftriaxone, Doxycycline, and Chloramphenicol were unavailable.
Also, other important drugs like ORS solution, Vitamin A syrup, and Iron-Folic Acid syrup were
unavailable at 40-49% facilities. 71% or more facilities only had Paracetamol and Chloroquine. The
findings suggest that in order to contribute to better health assessment through IMNCI, equipment
and medicine supply side of health facilities need to be strengthened.
The study recommends IMNCI training for all the cadres possibly including the technological
platform is one of the areas which immediately needs to be addressed. Currently the ANMs are
usually not using digital platform till now, hence they need a strong training and handholding for
using e-IMNCI application. The current pandemic situation emphasizes the need of urgent
implementation of technological friendly application with the easy to use devices that could work
offline (keeping hard to reach areas and no internet accessibility in mind). This will also strengthen
Page | 57
real time reporting of IMNCI. ANMs outlined that they would like to get feedback about their
performance so that they could improve their skills for professional development. Although they do
receive it sometimes but from outside partners and not from their own supervisors/ seniors. A little
appreciation from within the system is expected to give better results in the future. The health workers
will also require handholding support while practicing IMNCI and so there is a need to create a pool
of IMNCI supervisors to especially support the ANMs.
Mothers of under 5 children shared overall good feedback about ANMs working in their areas. But
the complains like low stock of medicines was evident problem for their children, sometimes it also
led to severity of illness as they could not receive urgent attention. Also, in the last 6 months 82.5%
respondent’s children fall sick and received care, out of which 61% sought care from HSCs and 28%
from PHC and ASHAs. Immunisation was hampered during lockdown period due to COVID-19, but
now it’s almost like previous time and Mothers responded that more than 90% children received it
timely. From the mothers’ perspective also, improvement is needed on the account of availability of
staff, their behaviour and receiving effective medication.
While concluding, the felt needs which should be highlighted for better implementation of IMNCI
and improving child survival and child health are, refresher training on IMNCI, reporting
streamlining, orientation to digital innovations on IMNCI (e-IMNCI) and introduction of e-IMNCI,
maintaining the stock of medication and instruments in health facilities, and timely supportive
supervision to make sure the adherence to IMNCI guidelines. These are expected to improve the
quality of care that community receives at local level. Also, working on improving community
awareness for timely healthcare seeking behaviour and operationalisation of techno friendly
platforms to minimalize the use of paper and data loss are the important things that need urgent
attention and action research.
Conducting a cross-sectional study within limited time frame, covering 80 health sub-centre area has
been slightly challenging process. Due to ongoing COVID-19 situation and issues like containment
zones, unavailability of participants for longer time period, ongoing cultural festivals made data
collection difficult within a short time period. Finding and interviewing mothers/mothers of under 5
children who meet the inclusion criteria during the pandemic was another challenge that the team was
able to overcome. Also, due to additional COVID-19 duties, Medical Officers and ANMs were
overburdened with their work but still agreed to participate in the study and provide handsome amount
of time, was nothing less than an achievement.
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ANNEXURES
Section A
Table A1
IMNCI_Baseline 2020 N = 40
Facility Type Percentage (%)
Sub Centre/ HSC 95.0
Primary Health Centre 5.0
Community Health Centre 0.0
Table A2
IMNCI_Baseline 2020 N = 40
Offering services in Health Facility Percentage (%)
Yes 100.0
No 0.0
Table A3
IMNCI_Baseline 2020 N = 40
Heard the term IMNCI Percentage (%)
Yes 100.0
No 0.0
Table A4
IMNCI_Baseline 2020 N = 40
Knowledge about IMNCI deals with the category of Percentage (%)
Adults 0.0
Pregnant Woman 2.5
Couples 0.0
Children under 5 years of age 95.0
Children above 5 years of age 0.0
Page | 60
All of the above 2.5
Table A5
IMNCI_Baseline 2020 N = 40
Last attending training year Percentage (%)
2005 15.0
2006 5.0
2008 10.0
2009 27.5
2010 20.0
2011 5.0
2012 7.5
2015 2.5
2016 5.0
2017 2.5
Table A6
IMNCI_Baseline 2020 N = 40
Training being helpful for improving IMNCI services Percentage (%)
Not much helpful 5.0
Helpful to some extent 15.0
Very much helpful 80.0
Table A7
IMNCI_Baseline 2020 N = 40
Average U5 children treated under IMNCI in the facility in
last week
Percentage (%)
None 2.5
Less than 5 children 67.5
5 to 10 children 20.0
More than 10 children 10.0
Table A8
Survey 2020 N =40 (multiple response)
Reasons for parents take their children to facility Percentage (%)
Common illness (cold/ cough/ fever/ diarrhoea etc.) 100.0
Causality / Emergency 42.5
Counselling 82.5
Page | 61
Examining 70.0
Vaccination 80.0
Medical Certificates 12.5
Malnutrition 70.0
Infection 2.5
Table A9
IMNCI_Baseline 2020 N = 40
ANMs have manual for hospital care on IMNCI Percentage (%)
Yes 95.0
No 5.0
Table A10
IMNCI_Baseline 2020 N = 40 (multiple response)
ANMs knowledge about types of IMNCI Medicines Percentage (%)
Amoxicillin 100.0
Ampicillin (Inject-able) 72.5
Artemisinin combination therapy 2.5
Artesunate (Parental) 27.5
Benzyl penicillin 25.5
Ceftriaxone 40.0
Ciprofloxacin 80.0
Cotrimoxazole 95.0
Gentamycin 80.0
New standard/Low osmolarity ORS 100.0
Salbutamol inhaler 35.0
Zinc tablets 97.5
Paracetamol 5.0
Table A11
IMNCI_Baseline 2020 N = 40
Knowledge on sings of bacterial infection Percentage (%)
Child have very sluggish movements 17.5
Convulsions 0.0
Fast breathing (60 breaths per minute or more) 0.0
Infected umbilical wound 25.0
Skin pustules 57.5
Table A12
IMNCI_Baseline 2020 N = 40
Knowledge on signs of anaemia (understanding pallor) Percentage (%)
Severe Anaemia 100.0
Severe dehydration 0.0
Page | 62
Malaria 0.0
Dysentery 0.0
Table A13
IMNCI_Baseline 2020 N = 40 (multiple response)
Place for referral Percentage (%)
Never Refer 6.4
Other ANM / Sub Center (HSC)/ PHC 0.0
CHC / Sadar 78.7
Private clinic 2.1
Medical college / district hospital 12.8
Table A14
IMNCI_Baseline 2020 N = 40
Using technological platform Percentage (%)
Yes 0.0
No 97.5
Don’t know 2.5
Section B
Table 1.1 Health workers included in the observation of clinical case management
Ratu Health
Worker
observed
Namkum Health
Worker
observed
Angara Health
Worker
observed
CHC Ratu 1 CHC Namkum 1 CHC Angara 1
PHC Nagri 2 HWC Arabaram 1 PHC Getalsud 1
HSC Adchero 1 HWC Hardag 2 PHC Johna 1
HSC Barkatoli 1 HWC Rampur 1 HSC Bisa 1
HWC Lalgutuwa 2 HSC Sodrol 1 HWC Chatra 1
HWC Nayasarai 1 HWC Tatisilwe 2 HWC Childag 1
HWC Purio 1 HSC Jamchunwa 1 HWC
Hesalpidhi
1
HSC Pundag 1 HSC Upardahu 2 HWC
Maheshpur
1
HWC Tiril 1 HWC
Narayansoso
1
HWC Tundul 1 HWC
Nawaharh
1
HWC Tusmu 1 HSC Paika 1
Page | 63
HSC Nacheyatu 1 HSC Rajadera 1
HSC
Tatisingari
1
HSC Guridih 1
HSC Dimra 1
14 11 15
Table B3.4.3: Assessing feeding problem or low weight for age
IMNCI Baseline 2020 Number of MOs (n= 1)
Breastfeeding question asked to mother Yes
Breastfeeding history asked (when, how much etc.) Yes
Breastfeeding assessment done Yes
Weight checked and recorded Yes
weight for age determined No
Checked if the infant is able to attach No
Checked if the infant was suckling effectively No
Looked for Oral thrush Yes
Section C
Annex. Table C1 – Distribution of Respondents according to caste
IMNCI_Baseline 2020 N = 40
Caste Percentage (%)
Scheduled Tribe (ST) 60.0
Other Backward Class 35.0
General 5.0
Table C1.1 – Distribution of respondents according to level of formal education
IMNCI_Baseline 2020 N = 40
Highest standard of schooling Percentage (%)
No Schooling 20.0
Class 4 to Class 7 10.0
Class 8 to Class 10 37.5
More than Class 10 32.5
Table C2 – Distribution of respondents according to Home based management of Diarrhoea
Page | 64
IMNCI_Baseline 2020 (N=8) Percentage
Child given ORS during diarrhoea 75% (6)
Child given homemade gruel during diarrhoea 87.5% (7)
Table C3 – Distribution of respondents according to preference for sub-centre for treatment in future
IMNCI_Baseline 2020 N = 20
Preference for sub-centre for treatment in future Percentage
Yes 100%(20)
No 0%
Table C4.1 – Distribution of Respondents according to caregiver’s knowledge on symptoms of
malnutrition in a child
IMNCI_Baseline 2020 N=40 (multiple choice)
Mothers knowledge on symptoms of malnutrition in a child Percent of cases
Lack of energy/ weakness 75.00
Frequent episodes of illness 50.00
Loss of weight/Thinness 90.00
Growth faltering in children 65.00
Becomes polio 2.50
Don’t know/Can’t say 10.00
Table C4.2 - Distribution of Respondents according to caregiver’s knowledge on how to prevent
malnutrition in children
IMNCI_Baseline 2020 N=40 (multiple choice)
Mothers knowledge on how to prevent malnutrition in children Percent of cases
Giving sufficient food to eat 92.50
Giving diverse foods to eat each day 67.50
Frequent feeding 50.00
Continued feeding during illness 42.50
Additional feeding during recovery from illness 37.50
Regular growth monitoring 50.00
Giving mother healthy diet 2.50
Don’t know/Can’t say 5.00
Table C5 - Distribution of Respondents according to age of youngest child
IMNCI_Baseline 2020 N=40
Age of youngest child (Grouping) Percentage (%)
Below 6 months 17.5
6 to 12 months 25.0
13 to 18 months 12.5
19 to 24 months 12.5
25 to 30 months 10.0
31 to 36 months 12.5
Above 36 months 10.0
Page | 65
Table C6 – Distribution of Respondents according to caregiver’s knowledge of signs of illness
in her child when she seeks care/treatment
IMNCI_Baseline 2020 N=40 (multiple choice)
Caregiver’s knowledge of ‘signs of illness’ in child for seeking
care/treatment
Percent of cases
High Fever (Malaria) 75.00
Cough 92.50
Grunting or difficulty breathing 55.00
Diarrhoea 82.50
Cold and Fever 77.50
Skin infections 52.50
Eye infections 35.00
Chest in drawing 40.00
Pustules 55.00
Poor suckling 62.50
Sluggish 40.00
Ear pain 2.50
Stomach pain 2.50
Table C7 - Distribution of Respondents according to caregiver’s knowledge of making
homemade food more nutritious
IMNCI_Baseline 2020 N=40 (multiple choice)
Mothers knowledge of making homemade food more nutritious Percent of cases
By adding animal source food 97.50
By adding pulses and nuts 70.00
By adding fruits and vegetables 90.00
By adding green leafy vegetables 95.00
By adding extra oil/fat 20.00
Table C8 - Distribution of respondents according to breastfeeding frequency during illness
IMNCI_Baseline 2020 N = 40
Breastfeeding frequency during illness Percentage (%)
Same as usual 27.5
Less than usual 27.5
More than usual 40.0
Stopped breastfeeding during illness 2.5
child could not drink due to illness 2.5
Table C9 - Distribution of Respondents according to mothers’ knowledge on minimum age for
continuation of breastfeeding
IMNCI_Baseline 2020 N=40
Mothers knowledge on minimum age for continuation of breastfeeding Percentage (%)
Up to 6 months 15.0
Up to 1year 2.5
Page | 66
At least till 2 years 77.5
Don’t know 5.0
Table C10 - Distribution of Respondents according to time at which breastfeeding was initiated.
IMNCI_Baseline 2020 N=40
Time at which breastfeeding was initiated Percentage (%)
Within 1 hour of birth 57.5
After 1 hour but within same day 42.5
After 1 day but within 3 days 0.0
Table C5.3 – Distribution of Respondents according to child ever fed with a bottle
IMNCI_Baseline 2020 N = 40
Child ever fed with a bottle Percentage (%)
Yes 15.0
No 85.0
Table C5.4 - Distribution of Respondents according to age of start of the complementary feeding
IMNCI_Baseline 2020 N=31
Age of start of the complementary feeding (grouping) Percentage (%)
Before 6 months 25.8
At 6 months 58.1
After 6 months 16.1
Table C5.5 - Distribution of Respondents according to hand washing practices
IMNCI_Baseline 2020 N=40 (multiple choice)
Hand washing practices Percent of cases
After defecation 95.00
Before feeding child 90.00
After helping a child who has defecated 95.00
Before preparing food 92.50
After handling cow dung or dirt 85.00
Table C5.6 - Distribution of Respondents according to place of cooking
IMNCI_Baseline 2020 N=40 (multiple choice)
Place of cooking Percentage (%)
In the same room where they sleep or spend time 10.0
In a separate room/ kitchen 87.5
Outdoors 2.5
Page | 67
Table Q1
IMNCI_Baseline 2020 N = 40
Presence of supervisor during interview with
ANM
Number of
Respondent
Percentage (%)
Yes 12 30.0
No 28 70.0
Table Q2
IMNCI_Baseline 2020 N = 40
Presence of supervisor during interview with
mothers
Number of Respondent Percentage
(%)
Yes 07 17.5
No 33 82.5
