An Evaluation of the Quality of IMCI Assessments among
IMCI Trained Health Workers in South Africa
Christiane Horwood1*, Kerry Vermaak1, Nigel Rollins2, Lyn Haskins1, Phumla Nkosi1, Shamim Qazi3
1Centre for Rural Health, University of KwaZulu-Natal, Durban, South Africa, 2Department of Paediatrics and Child Health, University of KwaZulu-Natal, Durban, South
Africa, 3Department of Child and Adolescent Health and Development, World Health Organisation, Switzerland, Geneva
Background: Integrated Management of Childhood Illness (IMCI) is a strategy to reduce mortality and morbidity in children
under 5 years by improving case management of common and serious illnesses at primary health care level, and was
adopted in South Africa in 1997. We report an evaluation of IMCI implementation in two provinces of South Africa.
Methodology/Principal Findings: Seventy-seven IMCI trained health workers were randomly selected and observed in 74
health facilities; 1357 consultations were observed between May 2006 and January 2007. Each health worker was observed
for up to 20 consultations with sick children presenting consecutively to the facility, each child was then reassessed by an
IMCI expert to determine the correct findings. Observed health workers had been trained in IMCI for an average of 32.2
months, and were observed for a mean of 17.7 consultations; 50/77(65%) HW’s had received a follow up visit after training.
In most cases health workers used IMCI to assess presenting symptoms but did not implement IMCI comprehensively. All
but one health worker referred to IMCI guidelines during the period of observation. 9(12%) observed health workers
checked general danger signs in every child, and 14(18%) assessed all the main symptoms in every child. 51/109(46.8%)
children with severe classifications were correctly identified. Nutritional status was not classified in 567/1357(47.5%)
Conclusion/Significance: Health workers are implementing IMCI, but assessments were frequently incomplete, and children
requiring urgent referral were missed. If coverage of key child survival interventions is to be improved, interventions are
required to ensure competency in identifying specific signs and to encourage comprehensive assessments of children by
IMCI practitioners. The role of supervision in maintaining health worker skills needs further investigation.
Citation: Horwood C, Vermaak K, Rollins N, Haskins L, Nkosi P, et al. (2009) An Evaluation of the Quality of IMCI Assessments among IMCI Trained Health Workers
in South Africa. PLoS ONE 4(6): e5937. doi:10.1371/journal.pone.0005937
Editor: Jacqueline Ho, JARING, Malaysia
Received January 31, 2009; Accepted April 28, 2009; Published June 17, 2009
Copyright: ? 2009 Horwood et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: All funding was provided by Department of Child and Adolescent Health and Development of the World Health Organization, Geneva. http://www.
who.int/child_ adolescent_health/ Dr. Qazi from WHO provided support throughout the process of designing the study, analysing the results and writing the
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: Christiane@telkomsa.net
In developing countries 9.7 million children under five years of
age die every year , most deaths are from preventable and easily
treatable diseases , and in a small number of developing
countries . It is estimated that over 60% of global child deaths
could be prevented by available and affordable interventions ,
and their effective delivery is critical for achieving the Millennium
Development Goal for child survival . Integrated Management
of Childhood Illness (IMCI) is a child survival strategy developed
by the World Health Organisation (WHO) and United Nations
Children’s Fund (UNICEF) . IMCI aims to improve coverage
of essential child health interventions by improving case
management skills of first level health workers, strengthening the
health system for effective management of sick children, and
promoting good community child care practices . South Africa
adopted IMCI as the standard of care for children in 1997, and is
one of 43 African countries to do so .
IMCI case management training equips health workers with
skills to manage children for a combination of illnesses, identify
those requiring urgent referral, administer appropriate treatments,
and provide relevant information to child carers. WHO
recommends that newly trained IMCI practitioners receive
follow-up visits from IMCI supervisors, starting 4–6 weeks after
training, to assist them in transferring their newly acquired skills to
the workplace . IMCI implementation has been shown to
improve the quality of management of sick children [10,11,12],
and IMCI trained health workers communicate better with care-
However, previous reviews have not described healthworkers’
assessments of children in detail, and have used the observed child
as the unit of analysis. In this article we report the results of an
evaluation of the performance of IMCI trained health workers,
conducted in two provinces in South Africa. We undertook a large
number of observations overall, and for each health worker, so we
are able to use the health worker as the unit of analysis and
describe in detail how health workers assess and classify sick
children. This provides a comprehensive picture of IMCI
implementation in routine clinical practice, from which we are
able to identify gaps in implementation, and suggest solutions.
PLoS ONE | www.plosone.org1 June 2009 | Volume 4 | Issue 6 | e5937
Study site and population
IMCI guidelines in South Africa were adapted to include a
component for management of HIV infected children, and
evaluation of this component was a primary objective of this
study. IMCI trained health workers (HW’s) working in first level
health facilities in Limpopo and Kwazulu-Natal (KZN) provinces,
South Africa, were randomly selected for inclusion in the study.
Health workers without IMCI training were excluded. IMCI
implementation began in 1998, and at the time of our study 1325
health workers had been trained in Limpopo Province and 1300 in
KZN, comprising 47% and 32% of health workers seeing sick
children in PHC clinics respectively.
Training and Data Collection
Two IMCI experts visited facilities to collect data in each
province. They were trained in study methods for two weeks by the
investigators (CH, KV); data collection tools and methodology were
piloted in two health facilities. All IMCI experts had previously
attended the 11 dayIMCI training courseand the IMCI facilitators’
course, and were experienced IMCI course directors.
The consultation by the health worker was observed by one
IMCI expert who recorded the activities and findings without
intervening. Activities recorded included whether the health worker
be expected if IMCI was being implemented correctly. During an
IMCI consultation, health workers assess first for general danger
signs, they then assess the four main symptoms (cough or difficult
breathing, diarrhoea, fever, ear pain) and nutritional status. A
classification is then made for each main symptom present,
according to the signs identified during the assessment of the child.
Thereafter, the second IMCI expert assessed the same child
independently, and these findings were considered to be the gold
standard for analysis of health worker performance. If the
management of the child was incorrect, this was changed by the
second IMCI expert as appropriate. Each health worker was
observed for 20 consultations with sick children aged 2–59 months
presenting consecutively to the health facility, or for 3 days if 20
observations had not been completed in that time.
The IMCI experts used standardized data collection instru-
ments to record data about health workers’ previous training and
supervision; assessments by the health worker and the IMCI
expert; and resources available at the clinic to support IMCI
implementation. To monitor quality during data collection, the
principal investigator visited the teams at least monthly, and all
completed forms were checked for quality and completeness.
Consent and ethical approval
Written informed consent was obtained from carers of children
for observation of the consultation with the health worker, and for
the second assessment of the child by the IMCI expert. Health
workers and observed children were allocated codes and no
identifying information was recorded.
The study was conducted in partnership with the South African
Department of Health (DOH), and all first level health workers in
the two provinces were informed by the DOH that a survey of
child health practices was to be undertaken. Participants were not
told ahead of time that they had been selected, or that IMCI in
particular was being evaluated, and because they were employed
by the DOH they were required to participate.
Ethical approval was obtained from the Biomedical Research
Ethics Committees of the University of KwaZulu-Natal Medical
School, Durban, and WHO, Geneva.
A major objective of this study was to assess implementation of the
assumption that 80% (+/210%) of health workers would correctly
classify for HIV in all 20 cases they assessed, compared to the IMCI
expert. The sample was calculated as 62 health workers. IMCI
trained health workers wererandomly selected from a list of all IMCI
trained health workers in each province using computer generated
random numbers . Sampling was stratified by province with
equal numbers of health workers selected from each province.
However, an interim analysis found that only 26% (+/210%) of
health workers had correctly classified all children, the sample was
therefore recalculated and increased to 77 health workers. The
results of the HIV implementation assessment are reported
Data management and analysis
Pre-coded data were double entered, cleaned and validated
using Epi-info (version 6.04). Analysis was conducted using SPSS
(version 13.0) and Stata (version 9). The proportion of health
workers who referred to the chart booklet and how frequently, was
used as an indicator of whether observed health workers were
implementing IMCI. To determine the performance of observed
health workers, their assessments were compared to those made by
the IMCI experts, which were considered to be ‘correct’ for
purposes of analysis. To assess the performance of each health
worker during the period of analysis, the proportion of observed
children correctly assessed for each main symptom was calculated
for each health worker. Using the child as the unit of analysis, we
then calculated the proportion of children with each main
symptom who were assessed correctly, assessed incorrectly or not
assessed at all, by observed health workers. We then calculated the
proportion of children with each IMCI classification that were
correctly classified by observed health workers, using the child as
the unit of analysis. 95% confidence intervals were calculated for
all performance indicators.
The consultations of 77 IMCI trained health workers working in
74 primary health care clinics in KZN and Limpopo provinces
were observed between May 2006 and January 2007. Each health
worker was observed for a mean of 2.7 days and 17.7
Training of observed health workers
All observed health workers were registered nurses with a
minimum of 3 years nursing training, and had attended an 11day
IMCI training course, but most had no other special training in
child health. The time since being trained in IMCI was an average
of 32.2 months. Most health workers had received at least one
follow up visit following IMCI training (table 1).
The average number of nurses on the staff establishment at
clinics where we undertook our observations was 6, and on
average 74% of these had been trained in IMCI. In 50/74 (67%)
clinics visited, more than 60% of nurses were IMCI trained.
Performance of observed health workers during the
31/77(40%) health workers referred to the IMCI chart booklet
during every observed consultation, 35(45%) did so during some
observed consultations, and only one health worker never referred
to the chart booklet during the period of observation.
Evaluation of IMCI Assessments
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During the period of observation, 9 (12%) health workers asked
about three general danger signs (unable to drink or breastfeed,
vomiting everything,and convulsionswiththis illness) inevery child,
and 14 (18%) asked about all four main symptoms in every child. 7/
9 (78%) health workers who checked the danger signs in every child
also checked all main symptoms in every child. Only 17 (22%)
health workers plotted the weight of all children. Depending on the
presenting complaints of children presenting to the facility, each
observed health worker assessed children with different symptoms
and signs. Table 2 shows the performance of each health worker in
classifying the children assessed during the observation period.
No association was found between health worker performance
and whether the health worker had received a follow up visit by a
supervisor, or the time since being trained in IMCI (data not
shown). However the number of health workers in the sample was
insufficient to exclude such an association.
Classification of observed children by health workers
During the 1357 observed consultations, health workers asked
about three general danger signs in 795(58.6% CI: 49.8%–66.9%),
and the four main symptoms in 815(60.1% CI: 51.0%–68.5%)
children. Health workers did not ask about cough in 123(9.1% CI:
6.3%–12.9%) children, diarrhoea in 297(21.9% CI: 15.7%–
29.6%) children, fever in 310(22.8% CI: 17.1%–29.8%) children,
and ear problems in 409 (30.1% CI: 23.0%–38.3%) children. The
performance of health workers in classifying observed children for
each main symptom is shown in table 3.
Of 112 children assessed as having a severe classification or a
danger sign by the IMCI expert, 52 (46.4% CI: 35.5%–57.7%)
were also given a severe classification by the health worker. Health
workers’ performance in identifying each IMCI classification is
shown in table 4.
Health workers either did not assess, or did not classify, for
malnutrition in 567/1357(41.8% CI: 34.2%–49.8%) children
(table 3), but the weight was plotted correctly on the growth chart
in 1060/1357(78.1% CI: 72.9%–82.5%) children. The findings
were explained to the mother in only 624(58.9% CI: 52.7%–
IMCI requires that all children under 2 years, and any who are
low weight for age, should have a feeding assessment. Of 944
children required a feeding assessment according to these criteria,
this was completed in 630 (66.7% CI: 60.1%–72.8%) children.
Our findings show that IMCI is being widely implemented in
clinics in South Africa several years into the expansion phase. Most
clinics visited had good coverage with IMCI trained health workers,
and despite the averagetime since training being almostthree years,
all but one health worker used the IMCI guidelines during observed
consultations. However the IMCI assessment was not applied
consistently and comprehensively, and activities not related directly
to the presenting complaint were frequently omitted.
Table 1. Training of observed health workers.
Months since training in IMCI (n=77)Number (%)
1–11 12 (16)
12–23 10 (13)
24–35 22 (29)
48 or more17 (22)
Additional training in child health
None 55 (71)
IMCI facilitator1 (1)
IMCI supervisor1 (1)
Primary health care diplomaa
Expanded programme of immunisation 10 (13)
Anti-retroviral treatment for children 1 (1)
Tuberculosis treatment for children1 (1)
Number of IMCI follow-up visits
0 27 (35)
1 34 (44)
2 13 (17)
3 3 (4)
aOne year course includes paediatric module.
Table 2. Proportion of children with each main symptom assessed correctly by health workers’ during the observation period.
Main symptom n=77a
No of observed
No of health workers who
assessed .80% children
correctly (%) (95% CI)
No of health workers who
assessed 60–80% children
correctly (%) (95% CI)
No of health workers who
assessed ,60% children
correctly (%) (95% CI)
Cough or difficult breathing77 9 (12) (6–21) 35 (46) (35–57)33 (43) (32–54)
20 (28) (18–40)21 (29) (20–41)31 (43) (32–55)
14 (18) (11–29)9 (12) (6–22) 53 (70) (58–79)
10(16) (9–27)5 (8) (3–18) 49 (77) (64–86)
Nutritional assessment (all children) 77 4 (5) (2–13) 10 (13) (7–23) 63 (82) (71–89)
Any severe classification54f
14 (26) (8–24)3 (6) (5–20) 36 (68) (54–80)
aUnit of analysis is the health worker.
bObserved health workers saw a different number of children with each of the main symptoms.
cExcludes 5 health workers who did not see any child with diarrhoea.
dExcludes 1 health worker who did not see any child with fever.
eExcludes 13 health workers who did not see any child with an ear problem.
fExcludes 24 health workers who did not see a child with any severe classification.
Evaluation of IMCI Assessments
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More observations were done in this study, both in total and of
each health worker, than previous IMCI evaluations, allowing us
to describe health worker performance in more detail. Health
workers’ performed best in assessing cough and dehydration, but
even with these symptoms, only a small proportion of health
workers assessed more than 80% of children correctly. The most
common reason for health workers’ not classifying correctly was
failure to ask about the symptom or to make a classification at all,
rather than making an incorrect classification. Few health workers
consistently asked about all main symptoms, particularly later in
IMCI assessment, indicating that incomplete assessments rather
than simply lack of skills often leads to poor IMCI implementation.
Health workers’ performance in identifying different classifica-
tions shows that health workers frequently fail to identify children
with moderate or severe classifications, and perform best at
identifying common, mild illnesses where no specific treatment is
required. Less than half of severely ill children who required
urgent referral to hospital were identified by IMCI trained health
workers. Correct assessment of moderate or severe classifications
depends on health workers’ ability to identify specific signs,
whereas mild classifications are usually based on the absence of
these signs. For example, when assessing a child with a cough,
identification of fast breathing or chest indrawing leads to a
classification of pneumonia or severe pneumonia, whereas failure
Table 3. Health worker (HW) performance in classifying children with each of the main symptoms.
Cough (%) n=1076b
Fever (%) n=789b
Ear problem (%)
Symptom not reported to HWd
38 (3.5) (2.4–5.1) 25 (8.0) (5.2–12.2) 125 (15.8) (12.5–19.9)31 (20.5) (14.9–27.6) n/a
HW did not ask about symptom30 (2.8) (1.9–4.1) 14 (4.5) (2.4–8.2) 121 (15.3) (11.3–20.5)21 (13.9) (8.7–21.5)130 (10.7) (7.2–15.6)
HW asked about symptom and/or
assessed child but did not classify
106 (9.8) (7.1–13.5)46 (14.8) (10.9–19.7)212 (26.9) (20.9–33.8) 22 (14.6) (9.6–21.5)437 (36.1) (29.8–42.8)
Incorrectly classified by HW 245 (22.8) (20.3–25.4)29 (9.3) (6.3–13.6) 1 (0.1) (0.0–0.9)23 (15.2) (10.2–22.2) 177 (14.6) (11.2–18.6)
Correctly classified by HW 645 (59.9) (56.0–63.8)195 (62.7) (56.6–68.4) 312 (39.5) (31.9–47.8)51 (33.8) (26.0–42.5) 446 (36.8) (30.7–43.4)
aUnit of analysis is the child.
bA total of 1357 consultations were observed but different numbers of children presented with each main symptom.
cExcluded 145 children where there was no chart available from the mother documenting weight for age.
dCarer reported symptom to IMCI expert but not to the health worker when asked.
Table 4. Proportion of classifications correctly identified by health workers.
Correct Classification (from IMCI expert)
Number of children with
Number correctly identified by
health worker (%) 95% Confidence intervals
Cough or difficult breathing (n=1076a)
Severe pneumonia or very severe disease69 33(47.8)34.6–61.4
Pneumonia 360146(40.6) 34.1–47.4
Cough or cold 645466(72.2) 67.4–76.7
Severe dehydration3 1(33.3)4.1–85.5
Some dehydration37 14 (37.8)22.0–56.8
No visible dehydration 270180 (66.7) 59.7–73.0
195 (62.9) 56.6–68.4
Suspected meningitis11 4 (36.4) 12.5–69.5
Fever other cause776 308 (39.7) 31.8–48.2
Severe malnutrition 185(27.8)12.2–51.5
Not growing well478 145(30.3)24.1–37.4
Growing well 715296 (41.4)32.8–50.5
446 (36.8) 30.7–43.4
adenominator different for each main symptom according to the number of observed children with that symptom.
d1missing, 145 could not be classified because there was no chart documenting weight for age.
Evaluation of IMCI Assessments
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to identify these signs would lead to the mild classification of no
pneumonia: cough or cold. It may be a lack of skills in identifying
those specific signs required to make severe classifications that
leads to poor performance, so those children most at-risk do not
receive appropriate treatment.
Nutritional assessments were also poorly implemented; many
children were not assessed for nutrition, most children with
malnutrition were not identified, and feeding advice was
frequently not given where indicated. Interventions and advice
about nutrition, particularly promotion of breastfeeding and
counselling about complementary feeding, have been shown to
substantially improve child mortality . Thus, failure to
implement this aspect of IMCI will have a major impact on the
potential for the IMCI strategy to improve child survival. A review
of training materials and methods related to nutrition and
identification of children with severe illnesses, could improve
performance in these important areas of practise.
IMCI has been shown to improve care of children at first level
[10,11,12], but poor adherence to IMCI guidelines has been
repeatedly described [12,16,17,18]. If IMCI implementation is to
achieve sufficient coverage to make a difference to child mortality,
it is critical that strategies are developed to achieve and maintain
high quality health worker performance. Our results suggest that
strategies to encourage health workers to apply the IMCI
assessment comprehensively, including the nutritional assessment,
would lead to an improvement in health worker performance.
Our results also highlight the importance of health workers’
achieving competency at identifying signs of severe disease during
IMCI training. Previous evaluations have shown that health
worker performance is adversely affected when the amount of
clinical practice included in IMCI training is reduced , as may
occur when training is decentralised. So interventions to improve
health worker performance should include ways of ensuring that
competency in identifying the severe signs used in the IMCI
assessment is achieved and maintained. A formal assessment could
be introduced for IMCI practitioners on completing the training,
and regular updates for IMCI practitioners could ensure that these
skills are maintained, as well as providing support for practitioners
in the workplace. Other methods of improving implementation
like awarding clinics ‘IMCI excellent’ accreditation could be used
to motivate practitioners.
The strengths of this study are that we observed large numbers
of health workers and for more consultations than previous
evaluations of IMCI implementation, so that analysis could be
done at the health worker level. All our IMCI experts were
experienced IMCI facilitators, and able to provide a reliable gold
standard. The influence of the observer’s presence on health
worker performance was minimised by the large number of
observations conducted over several days, so subject bias was
reduced by habituation. Limitations of the study include not
evaluating health workers’ ability to identify particular signs, or
treatments given to children, and no measure was taken of inter-
rater reliability. We were also unable to determine reasons for
poor performance in sufficient detail, including any relationships
that may have existed between health worker performance and
IMCI supervision, or time since training.
Further research is required to investigate the factors leading to
a lack of knowledge and skills. Health workers often find it difficult
to transfer new skills to the work place, and to maintain these skills,
especially as IMCI consultations take longer . Implementing
and sustaining IMCI follow up after training has been shown to be
difficult in several previous evaluations of IMCI [11,12,16,20].
However, supervision has been shown to improve performance 
and may also improve motivation and job satisfaction. The role of
IMCI supervision in IMCI implementation and different models for
provision of supervision should be investigated further.
In conclusion, IMCI can improve quality of care for sick
children, and is being implemented in those countries where most
child deaths occur. In our setting almost all IMCI trained health
workers were using IMCI to assess children, but incomplete
implementation means IMCI is failing to achieve maximum
benefits for child survival. Improvements in training and
supervision can go some way to addressing these problems, but
further research is required to fully understand the determinants of
health worker performance, both in the long and short term and
strategies for maintaining IMCI skills over time should be
evaluated. Effective solutions to the problem of scaling up IMCI,
and other public health interventions, are needed to bridge the
gaps between knowledge and practise, and to achieve universal
coverage of critical interventions to improve child survival.
We are grateful for the support of the child and adolescent health sub-
directorate of the South African department of health, in particular
Ntombi Mazibuko. Thanks to Beatrice Mlati and Janet Dalton, maternal
and child health program managers from Limpopo and KZN provinces for
their very valuable help with logistics. Thanks also go to Steve Reid from
the Centre for Rural Health, Ann Robertson and Steve Donohue from
Limpopo Department of Health, and Ruth Bland from the Africa Centre
for Health and Population studies.
We would like to thank the data collection teams who worked so hard,
the staff of the participating clinics for their support, and all the mothers
and infants who agreed to participate.
Shamim Qazi is a staff member of the World Health Organization. The
expressed views and opinions do not necessarily express the policies of the
World Health Organization.
Conceived and designed the experiments: CMH KV SAQ. Performed the
experiments: CMH KV LH PN. Analyzed the data: CMH KV NR LH PN
SAQ. Wrote the paper: CMH KV NR LH PN SAQ.
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