Long and Short Integrated Management of Childhood Illness (IMCI) Training Courses in Afghanistan: A Cross-sectional Cohort Comparison of Post-Course Knowledge and Performance

Document Type : Original Article


1 School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada

2 BASICS/Afghanistan and Centre for Health Services, Management Sciences for Health, Medford, MA, USA

3 BASICS/Afghanistan, Ministry of Public Health, Great Massoud Circle, Kabul, Afghanistan

4 Child and Adolescent Health Department, Ministry of Public Health, Kabul, Afghanistan


In 2003 the Afghan Ministry of Public Health (MoPH) adopted the Integrated Management of Childhood Illness (IMCI) for delivering child health services in primary care facilities. Key problems were subsequently identified: high cost of training, frequent health worker turnover and poor quality of IMCI implementation by those trained – specifically in the use of job aids and protocols for assessment, classification, treatment and counselling. The high financial, human resources and opportunity costs of implementing IMCI spurred the MoPH to prioritize developing a shortened IMCI course of comparable quality to the 11-Day training.
This cross-sectional evaluation compared knowledge before and after training, and health worker performance in assessment, classification and treatment of sick children in two similar cohorts, eight months post-training.
The mean increase in knowledge scores of the thirty 7-Day course trainees was 29 [95% Confidence Interval (CI): 24, 34] compared to 23 (95% CI: 18, 28) in the 31 trained in the 11-Day course. During assessment visits, mean scores in the 7-Day course trainees and the 11-Day course trainees were 93% (95% CI: 91, 95) versus 94% (95% CI: 91, 96) in assessment; 95% (95% CI: 89, 100) versus 96% (95% CI: 91, 100) in classification; 95% (95% CI: 92, 100) versus 97% (95% CI: 95, 100) in treatment; and 81% (95% CI: 76, 86) versus 80% (95% CI: 75, 85) in counselling. The 7-Day course was 36% less expensive than the 11-Day course. For each course opportunity costs, measured as numbers of children who potentially received poorer care than usual during trainee absence, were 3,160 for the 11-Day course and 2,016 for the 7-Day course. This measure was chosen because trainee absence commonly resulted in higher patient volumes per remaining provider or complete closure of a health facility with one single health worker.
Given similar performance and knowledge of health workers trained in both courses, potential cost savings, the possibility of training more health workers and the relative ease with which health workers in remote settings might participate in a shorter course, it seems prudent to standardize the 7-Day course in Afghanistan where child mortality rates remain unacceptably high.




Watch the Video Summary here



Main Subjects

Additional File 1 (Download)

Additional File 2 (Download)



    1. Salama P. Status of the health and nutrition sector in Afghanistan: progress and challenges 2001-2003. Kabul: UNICEF; 2003. Unpublished presentation by the Chief Health and Nutrition Officer of UNICEF.
    2. The United Nations Children's Fund (UNICEF). Best Estimates of Social Indicators for Children in Afghanistan. New York City: UNICEF; 2005.
    3. Gove S. Integrated management of childhood illness by outpatient health workers: technical basis and overview. The WHO Working Group on Guidelines for Integrated Management of the Sick Child. Bull World Health Organ 1997; 75 Suppl 1: 7-24. 
    4. Afghan Ministry of Public Health (MoPH). Basic Package of Health Services. Kabul: Afghan Ministry of Public Health; 2005.
    5. Goga AE, Muhe LM. Global challenges with scale-up of the integrated management of childhood illness strategy: results of a multi-country survey. BMC Public Health 2011; 11: 503.  doi: 10.1186/1471-2458-11-503
    6. Goga AE, Muhe LM, Forsyth K, Chopra M, Aboubaker S, Martines J, et al. Results of a multi-country exploratory survey of approaches and methods for IMCI case management training. Health Res Policy Syst 2009; 7: 18.  doi: 10.1186/1478-4505-7-18
    7. Nguyen DT, Leung KK, McIntyre L, Ghali WA, Sauve R. Does integrated management of childhood illness (IMCI) training improve the skills of health workers? A systematic review and meta-analysis. PLoS One 2013; 8: e66030.  doi: 10.1371/journal.pone.0066030
    8. World Health Organization (WHO). Report of technical consultation on IMCI training approaches and pre-service IMCI: 19-23 November, 2007. Geneva: WHO; 2008.
    9. Hansen PM, Peters DH, Niayesh H, Singh LP, Dwivedi V, Burnham G. Measuring and managing progress in the establishment of basic health services: the Afghanistan health sector balanced scorecard. Int J Health Plann Manage 2008; 23: 107-17.  doi: 10.1002/hpm.931
    10. Edward A, Kumar B, Niayesh H, Naeem AJ, Burnham G, Peters DH. The association of health workforce capacity and quality of pediatric care in Afghanistan. Int J Qual Health Care 2012; 24: 578-86.  doi: 10.1093/intqhc/mzs058
    11. Chopra M, Patel S, Cloete K, Sanders D, Peterson S. Effect of an IMCI intervention on quality of care across four districts in Cape Town, South Africa. Arch Dis Child 2005; 90: 397-401.  doi: 10.1136/adc.2004.059147
    12. Bryce J, Victora CG, Habicht JP, Vaughan JP, Black RE. The multi-country evaluation of the integrated management of childhood illness strategy: lessons for the evaluation of public health interventions. Am J Public Health 2004; 94: 406-15. 
    13. Rowe AK, Rowe SY, Holloway KA, Ivanovska V, Muhe L, Lambrechts T. Does shortening the training on Integrated Management of Childhood Illness guidelines reduce its effectiveness? A systematic review. Health Policy Plan 2012; 27: 179-93.  doi: 10.1093/heapol/czr033
    14. Bishai D, Mirchandani G, Pariyo G, Burnham G, Black R. The cost of quality improvements due to integrated management of childhood illness (IMCI) in Uganda. Health Econ 2008; 17: 5-19.  doi: 10.1002/hec.1231
    15. Rowe AK, Osterholt DM, Kouame J, Piercefield E, Herman KM, Onikpo F, et al. Trends in health worker performance after implementing the Integrated Management of Childhood Illness strategy in Benin. Trop Med Int Health 2012; 17: 438-46.  doi: 10.1111/j.1365-3156.2012.02976.x
    16. Tavrow P, Kekitiinwa Rukyalekere A, Maganda A, Ndeezi G, Sebina-Zziwa A, Knebel E. A comparison of computer-based and standard training in the Integrated Management of Childhood Illness in Uganda. Bethesda, Maryland: United States Agency for International Development (USAID) through the Quality Assurance Project; 2002.
    17. Afghan Ministry of Public Health (MoPH). Mid-Term Review of Facility-based Integrated Management of Childhood Illness Implementation in Afghanistan. Kabul: MoPH Afghanistan/USAID; 2008.
    18. Afghan Ministry of Public Health (MoPH). Integrated Management of Childhood Illness Situational Analysis. Kabul: BASICS/USAID; 2008.
    19. Lind A, Edward A, Bonhoure P, Mustafa L, Hansen P, Burnham G, et al. Quality of outpatient hospital care for children under 5 years in Afghanistan. Int J Qual Health Care 2011; 23: 108-16.  doi: 10.1093/intqhc/mzq081
    20. Edward A, Dwivedi V, Mustafa L, Hansen PM, Peters DH, Burnham G. Trends in the quality of health care for children aged less than 5 years in Afghanistan, 2004-2006. Bull World Health Organ 2009; 87: 940-9.  doi: 10.2471/BLT.08.054858
    21. Peters DH, Noor AA, Singh LP, Kakar FK, Hansen PM, Burnham G. A balanced scorecard for health services in Afghanistan. Bull World Health Organ 2007; 85: 146-51. 
    22. Huicho L, Scherpbier RW, Nkowane AM, Victora CG. How much does quality of child care vary between health workers with differing durations of training? An observational multicountry study. Lancet 2008; 372: 910-6.  doi: 10.1016/S0140-6736(08)61401-4
    23. Mitchell M, Hedt-Gauthier BL, Msellemu D, Nkaka M, Lesh N. Using electronic technology to improve clinical care - results from a before-after cluster trial to evaluate assessment and classification of sick children according to Integrated Management of Childhood Illness (IMCI) protocol in Tanzania. BMC Med Inform Decis Mak 2013; 13: 95.  doi: 10.1186/1472-6947-13-95
    24. Mitchell M, Getchell M, Nkaka M, Msellemu D, Van Esch J, Hedt-Gauthier B. Perceived improvement in integrated management of childhood illness implementation through use of mobile technology: qualitative evidence from a pilot study in Tanzania. J Health Commun 2012; 17 Suppl 1: 118-27.  doi: 10.1080/10810730.2011.649105
    25. World Health Organization (WHO). Integrated Management of Childhood Illness - Self-study modules. Geneva: WHO; 2014.
    26. Lehmann U, Dieleman M, Martineau T. Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention. BMC Health Serv Res 2008; 8: 19.  doi: 10.1186/1472-6963-8-19
    27. Quality Assurance Project. Evaluation of an IMCI Computer-based Training Course in Kenya. Bethesda, Maryland, USA: Published for the U.S. Agency for International Development (USAID) by the Quality Assurance Project; 2006.
    28. Afghan Ministry of Public Health (MoPH). Afghanistan Health Sector Balanced Scorecard 2008. Kabul: MOPH; 2008.