Factors influencing implementation of integrated management of neonatal and childhood illness (IMNCI) strategy at public sector primary health care facilities in Matiari district, Sindh

Date of Award


Document Type


Degree Name

Master of Science in Health Policy & Management (MSc Health Policy & Mgmt)


Community Health Sciences


Study Title: Factors influencing implementation of Integrated Management of Neonatal and Childhood Illnesses (IMNCI) strategy at public sector primary health care facilities in Matiari district, Sindh. Background: IMCI strategy was launched by World Health Organization (WHO) and United Nations International for Children Education Fund (UNICEF) in 1995. IMCI is a single effective comprehensive strategy that targets five most prevalent causes of deaths among under five year children including; diarrhea, acute respiratory infection, measles, malaria and malnutrition. Experiences of IMCI implementation in developing countries evidenced more emphasis on capacity building of health care provider without adequately strengthening health system to support its implementation. Pakistan adopted IMCI strategy in 1998. Currently, Pakistan is in expansion phase of implementation i.e., expanding IMCI strategy to other districts in the country. Objective: To determine the factors influencing (constraining and supporting) implementation of IMNCI strategy at public sector primary health care facilities at three levels including: health sector policy and management level i.e., stakeholders responsible for implementation; health care providers level (trained IMNCI doctors) and at the level of primary health care facilities; in Matiari district, Sindh. Methodology: Duration of the study was July 09-Sep 09. The study involved concurrent mix method design; i.e., use of qualitative and quantitative data collection approaches. Qualitative part included in-depth interviews, utilizing semi-structured interview guideline, with provincial and district level stakeholders involved in IMNCI implementation process and IMNCI trained doctors posted at PHC facilities. Purposive sampling was used for the selection of key personnel and IMNCI trained doctors. Universal sampling was done to conduct survey of all primary health facilities (BHUs, RHCs and government dispensaries) in order to assess the health facility support to implement IMNCI strategy. WHO health facility IMCI survey checklist was utilized for health facility survey? Findings: Study involved 16 interviews (8 stakeholders and 8 IMNCI trained doctors) and surveyed 16 PHC facilities in the district. Among the major factor supporting IMNCI implementation at health sector policy and management (stakeholder level) was the clear understanding and believe in IMNCI strategy by majority of stakeholders; however their contribution in the implementation process was found constrained by lack of policy and planning initiatives for IMNCI implementation and communication gap among provincial and district level. Majority of health care providers (IMNCI trained doctors) exhibited their willingness and motivation to implement the strategy and their clear understanding and believe in significance of the strategy; which was considered as a major support factor at health care provider level but their practice to implement the strategy was found restricted by increase time consultation due to IMNCI strategy and inadequate health care system support to practice IMNCI strategy. Factors supporting IMNCI implementation at PHC facility level was only the presence of IMNCI trained doctors as inadequate logistic and managerial support i.e., inadequacy of essential supplies; equipment and IMNCI drugs in majority of PHC facilities were constraining implementation process. Moreover, inefficient referral and monitoring system also acted a major hurdle in implementation of IMNCI strategy. Study also reflected three major challenges; 1. IMNCI not considered a priority intervention. 2. IMNCI strategy perceived as a new culture. 3. Influence of pharmaceutical industries. The findings obtained from the interviews were supported by health facility survey and vice versa and some discrepancies were also reported. Conclusion: Matiari being the first district in implementing IMNCI strategy lacked adequate health care system support to implement IMNCI strategy by trained doctors. Health Department Sindh need to streamline IMNCI implementation in the district by assisting provincial and district health management in strategic direction and leadership in developing policy initiatives for IMNCI implementation and strengthening the health system support to implement IMNCI strategy.

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