Improving the quality of primary care delivery and health worker performance in rural Rwanda using the W.H.O. Integrated Management of Adolescent & Adult Illness (IMAI) guidelines

To-­‐date primary care delivery – defined here as first-­‐contact patient care delivered at the first level of health systems -­‐ in low-­‐ and middle-­‐income countries (LMICs) has been an under-­‐ researched topic, with researchers tending to focus on specific diseases or vulnerable groups (e.g. children,pregnant women). Yet as verticalprograms have evolved and expanded inthe past two decades, interest in primary care has been renewed, specifically as operational challenges to delivering integrated care have surfaced. There is also growing recognition that vertical interventions benefit from a basic foundation of general clinical quality, which in turn, requires integration at the point-­‐of-­‐care.

One of the few notable, yet comparably under-­‐ researched,efforts to advance integrated primary care delivery in LMICs, is the World Health Organization (WHO)’s Integrated Management of Adolescent &Adult Illness (IMAI). IMAI consists of simplified protocols addressing common adult and adolescent illness and targeted at health workers at first-­‐level facilities. Unlike the better-­‐known Integrated Management of Childhood Illness (IMCI) for children under-­‐five, however, IMAI lacks an evidence base either for its validation or its impact on care. This thesis addresses this gap and describes an implementation research trial – using a pre-­‐ / post-­‐ intervention plausibility design -­‐ of the impact of IMAI training combined with a program of sustained mentoring and supervision, on the quality of care and on the performance of primary care nurses in one district in rural Rwanda.

The main finding of this trial is that IMAI training and sustained supervision leads to significant improvements in basic quality indicators and behaviors such as taking of vital signs and screening and counseling for priority conditions, while also resulting in a greater than two-­‐fold increase in the odds of agreement in diagnosis and treatment decisions by nurses, when compared to the reference standard. This effect remained for diagnosis with exposure to supervision alone, but in the absence of classroom-­‐based didactic IMAI training, highlighting the importance of sustained mentorship to improving health worker performance and quality.

This study is one of the first of its kind to focus specifically on the quality of integrated primary care delivery in itself,rather than through the lens of a specific proxy disease or population subgroup. It is also the first study to provide impact data on IMAI, and thus offers early evidence of its utility as an organizing protocol to improve integrated primary care delivery in LMICs.