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LEADERSHIP THEORIES

LEADERSHIP THEORIES

LEADERSHIP THEORIES

Interest in leadership increased during the early part of the twentieth century. Early leadership theories focused on what qualities distinguish between leaders and followers, while subsequent theories looked at other variables such as situational factors and skill level.

While many different leadership theories have emerged, most can be classified as one of five major types:

  1. Great Man Theories.
  2. Trait Theories.
  3. Behavioral Theories.
  4. Contingency Theories.
  • Fiedler’s Least Preferred Co-worker (LPC) Theory
  • Path-Goal 

5. Situational Theories.

  • Hersey and Blanchard’s Situational Theory
  • House’s Path Goal Theory
  • Leader Participation Model
Great-Man-Theory

Great Man Theory

This theory is associated with the historian Thomas Carlyle and was introduced in the 19th century (1840s) when history was believed to be primarily shaped by the influence of extraordinary individuals or heroes, suggesting that great leaders are inherently born, not made.

  • Carlyle significantly shaped this leadership theory, once expressing that, “The history of the world is essentially the collective biographies of great men.” In his work “On Heroes, Hero-Worship, and the Heroic in History,” he drew comparisons among various heroes.
  • This theory was called “great man” because it focused on identifying the innate qualities and characteristics possessed by great social, political, and military leaders.
  • According to this theory, capacity for leadership is inborn, that is, a person is a natural born leader. These born leaders are highly influential individuals, gifted with divine inspiration and the right characteristics like charisma, intelligence, wisdom, political skills etc. with a capability to have a decisive historical impact.
  • According to the great man theory of leadership, leadership calls for certain qualities like commanding personality, charm, courage ,intelligence, persuasiveness and aggressiveness.

Assumptions of Great Man Theory

The Great Man Theory centers on two main assumptions: 

  1. Great leaders are born possessing certain traits that enable them to rise and lead. The theory assumes that the traits of leadership are intrinsic. That simply means that great leaders are born… they are not made. This theory sees great leaders as those who are destined by birth to become a leader.
  2. Great leaders will arise when there is a great need. The belief was that great leaders will rise when confronted with the appropriate situation.

Criticism: Herbert Spencer, a noted philosopher, sociologist, biologist and political theorist of the Victorian era, countered that the Great Man Theory was childish, primitive and unscientific. He believed leaders were products of their environment or the society in which they lived. He advocated that before a “great man” can remake his society, that society has to make him.

Trait Theory

Trait Theory

Trait Theories assume that some people have certain characteristics or personality traits that make them better leaders than others. 

  • Similar in some ways to “Great Man” theories, trait theory assumes that people inherit certain qualities and traits that make them better suited to leadership. 
  • Trait theories often identify particular personality or behavioral characteristics shared by leaders. 
  • But if particular traits are key features of leadership, how do we explain people who possess those qualities but are not leaders? This question is one of the difficulties in using trait theories to explain leadership. 

The trait theory is based on the great man theory, but it is more systematic in its analysis of leaders. Like the great man theory, this theory assumes that the leader’s personal traits are the key to leadership success.

Leadership Traits include;

Ambition and energy

Honesty and integrity

Intelligence 

The desire to lead

Self-confidence

Job-relevant knowledge

Leadership Skills include;

Clever (intelligent) 

Honesty and integrity

Intelligence 

Diplomatic and tactful

Conceptually skilled

Creative 

Knowledgeable about group task

Fluent in speaking

Socially skilled

Assumptions of Traits Theory  

  • People are born with inherited traits.  
  • Some traits are particularly suited to leadership.  
  • People who make good leaders have the right (or sufficient) combination of traits. 

Behavioural Theory 

In contrast with trait theory, behavioral theory attempts to describe leadership in terms of what leaders do, while trait theory seeks to explain leadership on the basis of what leaders are.

  • Leadership according to this approach is the result of effective role behaviour. Leadership is shown by a person’s acts more than by his traits.
  • It suggests that effective leadership can be learned through observation, imitation, and reinforcement. Behavioral theories identify two main leadership styles: task-oriented (focused on achieving specific goals) and people-oriented (focused on building relationships and supporting team members).
  • Theory proposes that specific behaviors differentiate leaders from non leaders.
  • Behavioral theories of leadership are based upon the belief that great leaders are made, not born. 
  • Rooted in behaviorism, this leadership theory focuses on the actions of leaders, not on mental qualities or internal states.
  • According to this theory, people can learn to become leaders through teaching and observation.
  • Successful leadership is based in definable, learnable behaviour.
CONTINGENCY THEORY (Fred Fiedler)

Contingency Theories

According to this theory, no leadership style is best in all situations. Success depends upon a number of variables, including the leadership style, qualities of the followers, and aspects of the situation. For example, an authoritarian style might be most appropriate in a situation where the leader is the most knowledgeable and experienced member of a group. In other instances where group members are skilled experts, a democratic style would be more effective.

There are basically three steps in the model;

  1. Identifying Leadership Style: Fiedler believes a key factor in leadership success is the individual’s basic leadership style, So he created the Least Prefer Co-worker (LPC) Questionnaire . LPC:-An instrument that tells to measure whether a person is task or relationship oriented. Low LPC score(57 or less) means task oriented, high LPC score(64 or above) means relationship oriented.
  2. Defining the Situation: Fiedler identified three contingency dimensions that define the key situational factors, i.e Leader-member relations, Task structure and Position Power.
  3. Matching leaders and situations: After knowing the leadership style through LPC and defining all the situations, we will choose the leader who will fit for the situation. Two ways in which to improve leader effectiveness, 1. Change the leader to fit the situation or  2. Change the situation to fit the leader

Several contingency approaches were developed concurrently in the late 1960s, such as the Path-Goal Theory (1971) and the Vroom and Yetton’s DecisionMaking Model (1973). 

  • Path-Goal theory was developed by House (1971) to describe the way that leaders encourage and support their followers in achieving the goals they have been set by making the path that they take clear and easy.  According to the Path-Goal Theory, an effective leader guides his employees to help them attain shared goals: he or she supports employees in order to ensure that their goals and collective goals coincide (Langton & Robbins, 2007). 
Situational Theories

Situational Theories

Hersey and Blanchard (1977), developed a Situational theory of leadership. Situational theories propose that leaders choose the best course of action based upon situational variables. Different styles of leadership may be more appropriate for certain types of decision making.  These theories emphasize the importance of leaders being able to adapt their style and approach to different circumstances in order to be successful. 

Such Factors are:

  • Consider the Relationship: Social and interpersonal factors between leaders and group members.
  • Consider the Task: The nature and complexity of the task.
  • Consider the Level of Authority: The leader’s power and influence over group members.
  • Consider the Level of Maturity: The maturity level of each individual group member

Then choose the best leadership style appropriate.

  • Telling (S1): The leader tells people what to do and how to do it.
  • Selling (S2): This style involves more back-and-forth between leaders and followers. Leaders “sell” their ideas and message to get group members to buy into the process.
  • Participating (S3): The leader offers less direction and allows group members to take a more active role in coming up with ideas and making decisions.
  • Delegating (S4): This style is characterized by a less involved, hands-off approach to leadership. Group members make most of the decisions and take most of the responsibility.

An example of situational leadership would be a leader adapting their approach based on the needs of their team members. One team member might be less experienced and require more oversight, while another might be more knowledgeable and capable of working independently.

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leadership

LEADERSHIP INTRODUCTION

LEADERSHIP INTRODUCTION

Leadership does not mean dominating the subordinates as it is the case with leadership; however, the leader’s job is to get work done by other people, and make people willingly want to accomplish something. So effective leadership means effective and productive group performance.

Leadership is the process of influencing the thoughts and actions of other people to attain the desired objectives.

Leadership is the ability to influence and secure the cooperation of others to work to achieve certain goals without use of force.

Leading means influencing and inspiring people in such a way that they feel motivated to do their jobs. People find it easier to follow a leader. Following the orders of a manager is something that is done as a part of one’s job, but following a leader is something that is done more willingly by people.

Thus, every manager must aim at becoming a good leader. A leader focuses on interpersonal relations with each employee and constantly motivates them to perform better. By creating a positive working environment a leader can effectively help improve the employees’ job performance and hence their morale.

A leader is an individual who is able to direct activities of other people because he or she possesses the qualities and skills that the followers may not have.

OR

A leader is an influential person who has the ability to lead a group or department without necessarily holding a formal position.

An Effective Leader is a person who can induce followers to contribute voluntarily to the achievement of group tasks in a given situation.
kinds of leadership

Kinds of leadership.

A leader may be formal or informal.

  • Formal leadership: A leader is formal if he has legitimate authority conferred to him by position in organization and described in job description.
  • Informal leadership: leadership is informal when a staff member who does not have a specified management role, not appointed, exercises leadership.

An effective and efficient leader or manager

  • Effectiveness  is the degree to which an objective is being or has been achieved. e.g. if a health unit sets 100 children to be immunized against measles in a particular week and achieves 95%, we shall say the work has been managed effectively. The effective manager is one who achieves the set objective or target.
  • Efficiency  is the measure of the relationship between the results obtained (output) and the effort-resources (input) expended. This concept has a focus on people, or human resources, and on the way they work. It also involves time put in and money and other resources to perform a particular task. Efficiency can also mean the ability to produce satisfactory results with an economy of effort and a minimum wastage. We can simply put it that an efficient manager is one who achieves his targets/objectives with the planned available resources. The more minimal the resources (input) the manager uses to achieve the maximum results (output) the more efficient he is.

Factors that affect efficient leadership

Factors that affect efficient leadership can be both internal and external.

  • Lack of devotion on the part of the leader: A leader who lacks dedication and commitment to their role may struggle to inspire and motivate their team. Devotion is important for effective leadership as it sets an example for others to follow.
  • Task/position-centered approach: Leaders who focus solely on completing tasks and meeting goals without considering the needs and expectations of their team members may hinder efficient leadership. A leader should prioritize building relationships, understanding individual strengths, and providing support to ensure the team’s success.
  • Conflicts between needs and expectations: Conflicts can arise when there is a mismatch between the needs and expectations of the leader and their team members. It is important for leaders to be aware of these conflicts and find ways to address them through effective communication, collaboration, and compromise.
  • Failure to get feedback: Leaders who do not actively seek feedback from their team members may miss out on valuable information and perspectives. Feedback is important for growth and improvement, and leaders should create a culture that encourages open and honest feedback.
  • Inflexibility in decision-making: Leaders who are rigid and unwilling to adapt their decision-making approach may hinder efficient leadership. It is important for leaders to be open to new ideas, consider different perspectives, and be willing to adjust their decisions based on changing circumstances.
  • Unwillingness to accept criticism: Leaders who are resistant to criticism may create a negative work environment and hinder efficient leadership. Constructive criticism helps leaders identify areas for improvement. Leaders should be open to feedback and view criticism as an opportunity for growth.
  • Ineffective delegation: Leaders who struggle with delegation often take on too much themselves, which can lead to burnout and hinder their ability to focus on strategic projects. Effective delegation involves identifying tasks that can be delegated and providing the necessary support and guidance to team members.
  • Poor communication: Communication is essential for effective leadership. Leaders need to establish open and transparent communication channels, listen to their team members, and address any concerns or issues. Without effective communication, shared goals may not be reached, and misunderstandings can occur.
Qualities of a Good Leader

Qualities of a Good Leader

  1. Authenticity: A great leader is genuine and stays true to who they are, showing their best qualities and building trust with others.
  2. Curiosity: Great leaders have a mindset of curiosity, constantly seeking new experiences, perspectives, and possibilities.
  3. Analytical power: Leadership requires the ability to break down complex problems, identify root causes, and make informed decisions based on data and expertise.
  4. Adaptability: Good leaders are able to adjust to ever-shifting demands and embrace new opportunities and challenges.
  5. Creativity: Leaders cultivate an environment that nurtures creativity in others and recognizes the value of different perspectives and innovative ideas.
  6. Resilience: Successful leaders exhibit resilience, i.e they withstand and recover quickly from difficulties and seek input from others to stay on course.
  7. Empathy: Understanding and connecting with others on an emotional level is a key trait of strong leadership, improving relationships and building trust.
  8. Flexibility: Good leaders are adaptable and open to change, willing to adjust their plans and strategies as needed.
  9. Vision: Leaders have a clear vision of where they want to go and inspire others to work towards that vision.
  10. Confidence: A good leader exudes confidence, inspiring trust and providing reassurance to their team.
  11. Competence: Leaders possess the necessary skills and knowledge to effectively lead and guide their team.
  12. Credibility: Good leaders are trustworthy and have a track record of delivering on their promises.
  13. Action-oriented: Leaders take initiative and are proactive in driving progress and achieving goals.
  14. Hopeful: Effective leaders instill hope and optimism in their team, even in challenging times.
  15. Ability to lead and follow: Good leaders know when to take charge and lead, but also recognize the importance of listening and following others’ expertise.
  16. Trustworthiness: Leaders are reliable and trustworthy, creating an environment of trust and transparency.
  17. Optimism: Positive leaders maintain an optimistic outlook, inspiring and motivating their team.
  18. Caring: Good leaders genuinely care about the well-being and success of their team members.
  19. Ability to bring out the best in people: Effective leaders have the ability to recognize and develop the strengths of their team members, bringing out their full potential.
POWER AND AUTHORITY IN LEADERSHIP 

POWER AND AUTHORITY IN LEADERSHIP 

For effective leadership, one should exercise power and authority.

Power:

  • Is the ability to induce people to accept your orders. 
  • It is the potential ability to influence others in order to achieve goals.

Legitimacy:

  • Is the acceptance of the exercised power.

Authority: = Power+ Legitimacy

  • That is to say; Authority= power (The potential ability to induce people to accept orders) + legitimacy (The acceptance of the exercised power-acting on the orders given);
  • Authority is a right(legitimacy) to give orders and the power to exert obedience. It is a legitimate right to give orders and the power to exert obedience.

TYPES OF POWER/BASES OF POWER

There are mainly five types of powers divided into two categories namely: Position Powers and Personal Powers. Each of these also has subsets of powers.

A Person in a Managerial Position has:

  • Legitimate power.
  • Coercive power.
  • Reward power.

Personal powers which include:

  • Expert power
  • Referent power

1. Legitimate power. It refers to the power and influence derived from formal positions in the organizational hierarchy. It is based on the belief that individuals in certain positions have the right to exert authority and make decisions that affect others within the healthcare setting. This power is granted through organizational structures and job titles. This means that you have technical power to treat patients and manage resources that are within the health facility. No other person has this power except you in the health profession. It is usually associated with the job and rank in the organization hierarchy e.g staff will always comply with the in-charge or supervisors’ directives such as keeping time, not missing duty etc. Because they know she/he is their boss.

2. Coercive power. Coercive power is a type of power that relies on the use of force, threats, or punishment to influence others and achieve desired outcomes. This means a manager may exercise some force when you see that certain tasks are not being performed as expected. For instance; cleaning the health facility every morning. Another example is when a health worker is always late for duty, you as the Incharge may use coercive power to discipline such a health worker.

3. Reward power. Reward power in healthcare refers to the ability of a leader to reward or protect their followers from negative consequences. It is a type of formal power that can be used to motivate and incentivize healthcare professionals. You may exercise reward power to motivate staff that are performing very well in their tasks. For example giving bonuses, recognition programs, time off and vacation benefits, offering flexible work schedules, recommending staff for promotions or going for further studies etcetera.

4. Expert power. Expert power in healthcare refers to the influence and authority that individuals possess due to their specialized knowledge, skills, and experience in a particular area. It is a type of power that is derived from expertise and is often recognized and respected by others. Expert power is personal power, which a health worker like you may have. For example a midwife has a technical know-how on how to handle a woman in labour.  Experienced healthcare professionals, such as doctors, nurses, and specialists, who have accumulated years of expertise in their respective fields, possess expert power.

5. Referent power. Referent power in healthcare refers to the influence a leader or healthcare professional has based on their personal qualities, charisma, and the admiration and respect they receive from others. It is derived from the attractiveness of the leader’s personality, values, or beliefs, rather than their formal position or expertise. Referent power refers to the influence that a manager has over others. The In-charge needs to have influence over other team members through good practices that may attract them to stay on and work for the organization.

Importances of Power/Reasons Why Power is Used

Power is the ability to influence others and achieve desired outcomes. The most common reasons why power is used include:

1. To Gain a Competitive Advantage: Power can provide an edge over competitors in the market, allowing organizations to secure resources, market share, and influence.

2. To Acquire Information: Power can facilitate access to valuable information that is not readily available.

3. To Motivate People: Power can be used to inspire, motivate, and influence others to achieve desired goals.

4. To Communicate: Power can amplify the impact of communication, ensuring that messages are heard and understood. 

5. To Improve Performance and Enhance Processes: Power can drive organizational change, improve efficiency, and enhance processes.

6. To Acquire Resources: Power can facilitate access to essential resources, such as funding, talent, and technology. 

  • To Protect Interests: Power can be used to safeguard the interests of individuals or groups.
  • To Maintain Control: Power can help maintain order and stability within organizations and societies.
  • To Influence Policy: Power can be used to shape public policy and advocate for specific causes.
  • To Enhance Reputation: Power can enhance an individual’s or organization’s reputation and credibility.
  • To Achieve Personal Goals: Power can be used to fulfill personal ambitions and aspirations.

Rules for Using Power in Organizations

  1. Use the least amount of power you can to be effective in your interactions with others. It is important to avoid excessive or unnecessary use of power. Instead, focus on achieving your goals while maintaining positive relationships with others.
  2. Use power appropriate to the situation. Different situations may require different levels or types of power. Assess the situation and consider the potential impact of your power on others before using it. 
  3. Learn when not to use power. Recognize that there are situations where using power may not be the most effective or appropriate approach. For example, in collaborative or team-based settings, it may be more beneficial to rely on influence and persuasion rather than asserting power.
  4. Focus on the problem, not the person. When using power, direct it towards addressing the issue at hand rather than targeting individuals. 
  5. Make polite requests, never arrogant demands. When exercising power, communicate your needs or expectations in a respectful and considerate manner. Arrogant demands can create resistance and damage relationships, while polite requests are more likely to be received positively.
  6. Use coercion only when other methods do not work. Coercive power should be a last resort and used sparingly. Exhaust other options, such as persuasion or negotiation, before resorting to coercion. This helps maintain trust and minimize negative consequences.
  7. Keep informed to retain your credibility when using your expert power. Expert power is obtained from knowledge and expertise. To effectively use this power, it is important to stay updated and informed in your field. Continuously develop your skills and knowledge to maintain credibility and influence others.
Types of Authority in Organizations

Types of Authority in Organizations

Structural Authority/Bureaucratic/Rational/Legitimate Authority: This type of authority is derived from the position one holds within the structure of the organization. It is based on job descriptions, responsibilities, rank, seniority, and formal organizational hierarchy.

Expert Authority: Expert authority is derived from an individual’s knowledge, skills, and experience in a specific area. It is based on the perception that the person has specialized expertise and can provide valuable information.

Moral Authority: Moral authority is obtained from an individual’s behaviors, integrity, respect, and goodness. A leader with moral authority is able to influence and inspire others through their ethical conduct and values.

Charismatic Authority: Charismatic authority is based on an individual’s personality and natural powers of leadership. Leaders with charismatic authority have the ability to inspire and motivate others through their charisma and charm.

Other Types of Authority:

  • Physical Authority: Authority based on physical superiority of an individual.

  • Parental Authority: God-given authority based on the relationship between parents and their children.

  • Clerical Authority: Authority based on the relationship between religious leaders and the laymen.

  • Economic Authority: Authority based on the ability to control money or material possessions.

DIFFERENCE/SIMILARITIES AND RELATIONSHIP BETWEEN MANAGEMENT AND LEADERSHIP

Leadership/Leaders

Management/Managers

A leader may or may not have an official appointment.

Appointed officially to the position.

Leaders have the power and authority to enforce decisions as long as followers are willing to be led.

Managers have power and authority to enforce decisions using their position.

Leaders influence others either formally or informally. Use interpersonal skills to achieve results/goals.

Managers carry out predetermined policies, rules, and regulations. Use rules, policies to achieve results/goals.

Take risks and explore new ideas. Maintain an orderly, controlled, rational, and equitable structure. / Risk-averse.

Maintain an orderly, controlled, rational, and equitable structure. / Risk-averse.

Relate to people personally in an emphatic manner.

Relate to people according to their roles or work expectations.

Leaders feel rewarded from personal achievements.

Managers feel rewarded when fulfilling organizational goals or mission.

Leaders may or may not be successful as a manager. They are managers as long as they hold the appointment.

N/A

Addresses “why”, “What” What should be done and why? – Why are things done and going on that way, Why such results?

Addresses “how” and “when”. When and How can the activity/work be done, results be achieved?

Leadership inspires, motivates, and influences people.

Management controls and clarifies to people.

Leadership is service and people-focused.

Management is profit and result-focused.

Leadership is strategy-focused. Concerned with bigger, long-term objectives.

Management is focused on short-term objectives, day-to-day operations/activities.

Leadership is concerned with fulfillment of goals.

Management is concerned with performance of activities that lead to fulfillment of goals.

Leadership is concerned with versatility/creativity of employees.

Management is concerned and preoccupied by consistency to standards of operations and procedures.

Leadership is concerned with alignment of whatever goes on in the organization to policy and set standards and goals.

Management is concerned with accountability to the leadership of what is achieved and whether it’s achieved to the required standard and expectation.

Leadership is concerned with aligning the people brought in the organization to the organizational policies, mission, and vision.

Management plans and staffs the organization.

Leadership is more people-focused.

Management is more task-focused and achievement of work targets.

Leadership originates.

Management Initiates.

Similarities

  • They both share success and failure.
  • They both work with focus, and communication is vital to both.
  • They both typically evaluate employees.
  • They are both accountable for results.
  • They use metrics to measure performance.
  • They both follow a vision and make their people follow that vision.

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KEY GOVERNMENT POLICIES

KEY GOVERNMENT POLICIES

KEY GOVERNMENT POLICIES

A policy is a comprehensive set of guidelines that outlines the desired direction of actions and operations. 

A key government policy is a statement or set of statements that define the desired direction of operations or actions by a government.

 It outlines the interests and values of the people it is meant to serve and provides guidance for present and future actions. Government policies are designed to address specific issues, challenges, or goals and often involve multiple sectors and stakeholders.

Government policies can cover a wide range of areas, including healthcare, education, economic development, environmental protection, social welfare, and more. They serve as a framework for decision-making, resource allocation, and the implementation of programs and initiatives.

Example of Key Government Policies realted to Health

1. National Health Policy (1999, 2010): The National Health Policy sets out the overall vision, goals, principles and strategies for the health sector in Uganda. It provides guidance on issues such as health service delivery, health financing, human resources for health, and health infrastructure development. This policy aims to improve the health status of Ugandans by promoting equitable access to quality healthcare services, empowering communities, and addressing health disparities. It emphasizes primary healthcare, disease prevention, and health promotion.

2. National Policy on Public-Private Partnership in Health (2012): This policy encourages collaboration between the government and private sector to enhance healthcare delivery. It aims to harness the strengths of both sectors to improve access, quality, and efficiency in healthcare provision. It outlines the framework for partnerships, including roles, responsibilities, and mechanisms for monitoring and evaluation.

3. Uganda National HIV and AIDS Policy (2011): This policy provides a comprehensive approach to combating HIV and AIDS in Uganda. It focuses on prevention, treatment, care, and support for affected individuals and communities.

4. Policy Guidelines for Prevention of Mother-to-Child Transmission of HIV (2006): These guidelines aim to reduce the transmission of HIV from mothers to their children during pregnancy, labor, and breastfeeding. They outline effective interventions, such as antiretroviral therapy and counseling.

5. Guidelines for Management of Private Wings of Health Units in Uganda (2010): These guidelines regulate the establishment and operation of private wings within public health facilities. They ensure quality standards, ethical practices, and accountability in the provision of healthcare services.

6. Safe Male Circumcision Policy (2010): This policy promotes safe male circumcision as an effective HIV prevention measure. It outlines the procedures, training requirements, and quality assurance mechanisms for circumcision services.

7. Uganda HIV Counseling and Testing Policy (2011): This policy provides guidance on the voluntary and confidential provision of HIV counseling and testing services. It emphasizes the importance of informed consent, confidentiality, and linkage to care and support.

8. Local Government Sector Workplace Policy on HIV/AIDS (2009): This policy addresses HIV/AIDS in the workplace, promoting prevention, awareness, and support for affected employees. It outlines the roles and responsibilities of employers and employees in creating a supportive and inclusive work environment.

9. Ministry of Education, The Education Sector HIV and AIDS Workplace Policy: This policy aims to reduce the impact of HIV/AIDS on the education sector. It provides guidance on prevention, care, and support for students, teachers, and staff.

10. Guidelines for HIV/AIDS Coordination at Decentralized Levels in Uganda (2013): These guidelines strengthen the coordination of HIV/AIDS services at the local level. They outline the roles and responsibilities of various stakeholders, including district health teams, local governments, and community organizations.

11. Village Health Team Strategy and Operational Guidelines: These guidelines provide a framework for engaging and utilizing Village Health Teams (VHTs) in community-based healthcare delivery. VHTs play a important role in promoting health education, disease surveillance, and access to healthcare services in rural areas.

National Health Policy and Health Sector Strategic Plan (HSDP)

National Health Policy and Health Sector Strategic Plan (HSDP)

The National Health Policy (NHP) and HSDP are formulated within the framework of the Constitution of the Republic of Uganda (1995) and the Local Government Act (1997), which decentralized governance and service delivery. They are also guided by the National Health Sector Reform Programme, the National Poverty Eradication Programme, and the Alma Ata Declaration of Health for All (HFA).

Mission Statement of the NHP:

“The overall goal of the health sector is the attainment of a good standard of health by all people in Uganda in order to promote a healthy and productive life.”

Objectives of the NHP:

  • Reduce mortality, morbidity, and fertility, and the disparities therein
  • Ensure access to the minimum healthcare package

Key Priorities of the NHP:

  • Control of communicable diseases (malaria, STIs/HIV/AIDS, tuberculosis).
  • Integrated management of childhood illnesses (IMCI).
  • Sexual and reproductive health rights (antenatal and obstetric care, family planning, adolescent reproductive health, violence against women).
  • Other public health interventions (immunization, environmental health, health education and promotion, school health, epidemic and disaster prevention, nutrition, eradication of diseases such as guinea worm, river blindness, polio, neonatal tetanus, and measles).
  • Strengthening mental health services.
  • Essential clinical care (injuries, non-communicable diseases, disabilities, rehabilitative health, palliative care, oral/dental health).

Guiding Principles of the NHP:

Primary Health Care (PHC) as the basic philosophy and strategy for national health development;

  • Equitable distribution of health services throughout the country.
  • Cost-effective, quality healthcare interventions.
  • High efficiency and accountability in health system management.
  • Health promotion, disease prevention, and community empowerment.
  • Attention to emerging health problems, including healthcare for the elderly
  • Strengthened partnerships between public and private sectors, NGOs, and traditional practitioners.
  • Inter-sectoral cooperation and coordination for health development.
  • Gender-sensitive and responsive health system.
  • Sustainable additional health financing mechanisms.

HSDP Priorities:

The government will prioritize cost-effective health services that have the greatest impact on reducing mortality and morbidity.

  • These include interventions to address malaria, STIs/HIV/AIDS, tuberculosis, diarrheal diseases, acute lower respiratory tract infections, perinatal and maternal conditions, vaccine-preventable childhood illnesses, malnutrition, injuries, and physical and mental disability. 

These interventions will be integrated into the Uganda National Minimum Healthcare Package, which will be regularly reviewed.

HEALTH SECTOR DEVELOPMENT PLAN (HSDP)

RATIONALE FOR HSDP:

Locally:

  • Part of the overall health sector planning framework.
  • Provides strategic focus for the sector in the medium term.
  • Contributes to the implementation of the National Development Plan (NDP II) and the National Health Policy (NHP II).
  • Guided by the NDP II, which sets Uganda’s medium-term strategic direction and development priorities.

Regionally:

  • Formulated in recognition of the Common African Position (CAP) of the African Union.
  • Emphasizes universal and equitable access to quality healthcare, with a focus on vulnerable groups and strengthening health systems.

Internationally:

Aligned with Uganda’s global commitments, including:

  • Implementation of the International Health Regulations.
  • Ouagadougou Declaration on Primary Health Care and Health Systems.
  • International Health Partnerships (IHP+) on Aid Effectiveness.
  • Post-MDG 2015 agenda (UN Social Development Goals).
  • International Human Right agreements.

STRATEGIC DIRECTION:

Medium-term plan (5 years) guiding the health sector towards achieving NHP II objectives

AIM:

To achieve Uganda Vision 2040 of a healthy and productive population contributing to socioeconomic growth and national development

STRATEGY:

  • Implementing the Uganda National Minimum Health Care Package
  • Client-centered approach
  • Focus on both supply and demand side of healthcare

GOAL:

To accelerate movement towards Universal Health Coverage (UHC), ensuring that all people receive essential and good quality health services without financial hardship.

GUIDING PRINCIPLES:

  • Equity and non-discrimination
  • Participation and accountability
  • The right to health elements of availability, accessibility, acceptability, and quality

PRIORITY AREAS OF INTERVENTION:

  • Health promotion, environmental health, disease prevention, and community health interventions.
  • Prevention, management, and control of communicable diseases.
  • Prevention, management, and control of non-communicable diseases.
  • Maternal and child health.

HSDP INVESTMENT FOCUS:

  • Health governance and partnerships.
  • Service delivery systems.
  • Health information.
  • Health financing.
  • Health products and technologies.
  • Health workforce.
  • Health infrastructure.
THE UGANDA’S NATIONAL HEALTH SYSTEM/SECTOR.

THE UGANDA’S NATIONAL HEALTH SYSTEM/SECTOR. 

WHO defines a health care system as –

“All the activities whose primary purpose is to promote, restore and/or maintain health”. 

It incorporates the people, institutions and resources, arranged together in accordance with established policies, to improve the health of the population they serve, while responding to people’s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health. 

This definition encompasses Health actions and Non-Health actions within and outside the Health Sector that lead to desired health results.

The World Bank defines health systems more broadly to include factors interrelated to health, such as poverty, education, infrastructure and the broader social and political environment. 

Well-functioning health systems are critical in the achievement of the Sustainable Development Goals (SDGs) by 2030.

The Ugandan National Health Care System is a well-organized one built on a decentralized framework. Health care services are delivered through a referral system. In the provision of health services in Uganda, districts and Health Sub Districts (HSDs) are playing a key role in the delivery and management of health services at those levels. The district health structure is responsible for all the structures except the regional referral hospitals where they exist.

COMPONENTS:

The National Health System (NHS) is made up of the public and private sectors.

Public Sector:

  • All GoU health facilities under the MOH.
  • Health services of the Ministries of Defense (ARMY), Education, Internal Affairs (police and prisons), and Ministry of Local Government (MoLG).

Private Sector:

  • Private Not for Profit (PNFPs) providers
  • Private Health Practitioners (PHPs)
  • Traditional and Complementary Medicine Practitioners (TCMPs)

PUBLIC HEALTH SECTOR UNDER MOH:

The public health sector under MOH is structured directly from MOH headquarters, the national services (National Referral Hospitals (NRHs) and Regional Referral Hospitals (RRHPs), General Hospitals, District health headquarters (District health team), Health Centre (HC) IVs, HCIIIs, HCIIs, and community health services (community health centers and workers, households, Village Health Teams (VHTs-HCIs).

MOH HEADQUARTERS AND NATIONAL LEVEL INSTITUTIONS:

The core functions of the MOH headquarters are as follows:

  • Policy analysis, formulation, and dialogue
  • Strategic planning
  • Setting standards and quality assurance
  • Resource mobilization
  • Advising other ministries, departments, and agencies on health-related matters
  • Capacity development and technical support supervision
  • Provision of nationally coordinated services including health emergency preparedness and response and epidemic prevention and control
  • Coordination of health research
  • Monitoring and evaluation of overall health sector performance
National, Regional and general Hospitals:
  • General Hospitals: provide preventive, promotive, curative, maternity, in-patient services, surgery, blood transfusion, laboratory and medical imaging services, and clinical support services, training, consultation and operational research in support of the community-based health programmes.
  • Regional Referral Hospitals: offer specialist clinical services such as psychiatry, Ear, Nose and Throat (ENT), ophthalmology, higher surgical and medical services, and clinical support services(laboratory, medical imaging and pathology).They are also involved in teaching and research. This in addition to services provide by General hospitals.
  • National Referral Hospitals: Provide comprehensive specialist services and are involved in health research and teaching in addition to providing services offered by general hospitals and RRHs.

The Ministry of Health and National Level Institutions

The Ministry of Health (MOH) is the central authority responsible for health care in Uganda. Its core functions include:

  • Policy analysis, formulation, and dialogue: Developing and reviewing health policies and strategies.
  • Strategic planning: Setting long-term goals and objectives for the health sector.
  • Setting standards and quality assurance: Establishing and monitoring standards for health services to ensure quality and safety.
  • Resource mobilization: Securing funding and other resources for the health sector.
  • Advising other ministries, departments, and agencies on health related matters: Providing guidance and expertise on health issues to other government entities.
  • Capacity development and technical support supervision: Training and supporting health workers to improve their skills and knowledge.
  • Provision of nationally coordinated services: Managing national health programs, such as emergency preparedness and response, and epidemic prevention and control.
  • Coordination of research: Facilitating and supporting health research activities.
  • Monitoring and evaluation of the overall health sector performance: Tracking and assessing the progress and impact of health interventions.
National Autonomous Institutions

To enhance efficiency and effectiveness, the MOH has delegated some of its functions to autonomous institutions. These institutions include:

Specialized Clinical Services

  • Uganda Cancer Institute: Provides specialized cancer care.
  • Uganda Heart Institute: Provides specialized heart care.

Specialized Clinical Support Services

  • Uganda Blood Transfusion Services (UBTS): Manages the national blood supply.
  • Uganda Virus Research Institute: Conducts research on viruses and infectious diseases.
  • National Medical Stores: Procures and distributes essential medicines and medical supplies.
  • National Public Health Laboratories: Provides laboratory testing and surveillance services.

Regulatory Bodies / Authorities

  • National Drug Authority: Regulates the importation, distribution, and use of drugs.
  • Medical and Dental Practitioners Council: Regulates the practice of medicine and dentistry.
  • Allied Health Professional’s Council: Regulates the practice of allied health professions.
  • Pharmacy Council: Regulates the practice of pharmacy.
  • Nurses and Midwives Council: Regulates the practice of nursing and midwifery.

Other National Level Institutions

  • Uganda National Research Organization (UNHRO): Coordinates national health research activities.
  • Health Service Commission: Manages human resources for health.
  • Uganda AIDS Commission (UAC): Guides the multi-sectoral response to HIV/AIDS.

District Health Systems:

The constitution (1995) and local Government Act (1997) mandate the local Governments (LGs) to plan, budget, implement health policies and health sector plans. The LGs have the responsibility of: 

  • recruitment, deployment, development and management of human resource (HR) for district health services. 
  • Development and passing of health-related by-laws and monitoring of the overall health sector performance. 
  • LGs manage public general hospitals and HCs also supervise and monitor all health activities (including those in the private sector) in their respective areas of responsibility. The public private partnership at district level is still weak.

Health sub-District system: The HSDs are mandated with planning, organization, budgeting and management of the health services at this and lower health centre levels. HSDs carry an oversight function of overseeing all curative, preventive, promotive and rehabilitative health activities including those carried out by the PNFPs and PFP service providers in the health sub-district. The headquarters of the HSD will and remain a HCIV or a selected general hospital.

Health centres III, II and village Health Teams (HCI): HCIIIs provide basic preventive, promotive and curative care. They also provide support supervision of the community and HCIIs under their jurisdiction. There are provisions for laboratory services for diagnosis, maternity care and first referral cover for the sub-county. The HCIIs provide the first level of interaction between the formal health sector and the communities. HCIIs only provide out patient care, community outreach services and linkages with the village Health Teams(VHTs).

According to HSDP 2015/016 the community health services will be delivered by training 15000 community health extension workers(CHEWS) distributed among 7500 parishes at community health centers. These will supervise and work with VHTs that are accountable for the health of certified model households/families. The ministry targets 300,000 model households in place by 2020.Eventually the entire country’ population/households should have a VHT who looks after their health, VHT reports to an assigned trained CHEW. Currently, CHEWS are being trained in pilot districts in eastern Uganda and this will spread out as planned by the sector.

A network of VHTs has been established in Uganda which is facilitating health promotion, service delivery, community participation and empowerment in access to and utilization of health services. The VHTs are responsible for:

  •  Identifying the community’s health needs and taking appropriate measures; 
  • Mobilizing community resources and monitoring utilization of all resources for their health. 
  • Mobilizing communities for health interventions such as immunization, malaria control, sanitation and promoting health seeking behavior; 
  • Maintaining a register of members of households and their health status; 
  • Maintaining birth and death registration; and Serving as the first link between the community and formal health providers. 
  • Community based management of common childhood illnesses including malaria, diarrhea and pneumonia; and 
  • management and distribution of any health commodities availed from time to time. 

While VHTs are playing an important role in health care promotion and provision, coverage of VHTs is however still limited: VHTs by 2010 had been established in 75% of the districts in Uganda but only 31% of the districts had trained VHTs in all the villages. Attrition was quite high among VHTs mainly because of lack of emoluments. (HSSIP 2010/11-2014/15).

The District Health Officer and District Health Management Team

The district health services are led by the District Health Officer (DHO), a medical officer with additional management training. The DHO, along with other health officials in the district, is responsible for the overall management of district health services.

Members of the District Health Management Team

The District Health Management Team (DHMT) usually includes the following members:

  • District Biostatistician
  • District Health Educator
  • District Nursing Officer
  • District Stores Manager (Medical)
  • District Cold Chain Manager
  • District Environmental Health Officer
  • District Laboratory Focal Person
  • District Tuberculosis and Leprosy Supervisor
  • District Vector Control Officer
  • Heads/In-Charges of Health Sub-Districts (HSDs) in the district
  • Any other member deemed necessary by the DHO

Functions of the District Health Management Team

The DHMT, led by the DHO, is responsible for all health-related activities in the district, including:

  • District Planning: The DHO coordinates all health service planning in the district in collaboration with other district officials.
  • Supervision of District Health Activities: The DHMT supervises all government and private not-for-profit (PNFP) health facilities through regular visits. They provide guidance to staff and ensure that appropriate records are maintained. The DHMT also supervises special health programs such as the Expanded Programme on Immunization (EPI), Tuberculosis and Leprosy control, and family planning.
  • Training of Health Personnel: The DHO’s office coordinates basic training in the district. The DHO is also responsible for the continuing education of all health staff and supports the training of community-based health workers.
  • Clinical Work: The DHO may also participate in clinical work, particularly in situations where there is a shortage of health workers.

Health Care Setting Management Positions

In addition to the DHMT, various management positions exist within health care settings, including:

  • Ward: In-Charge
  • Special Clinic: In-Charge
  • Outreaches: Coordinator
  • Records Department: Director of Medical Reports
  • Nursing: Senior/Principal Nursing Officer

Summary: Organization of Health Services in Uganda

The Ugandan health care system is organized into eight levels:

1. Ministry of Health: Responsible for setting policies and standards, resource mobilization, capacity building, technical supervision, monitoring and evaluation, and overall regulation.

2. National Referral Hospitals Population:30,000,000: Provide comprehensive specialist services, teaching, and research.

3. Regional Referral Hospitals Population: 2,000,000: Serve a region of about 3 million people. Offer specialist services, teaching, and research.

4. District Hospitals Population: 500,000: Serve a district. Provide preventive, promotive, outpatient curative, maternity, inpatient health services, emergency surgery, blood transfusion, laboratory, and other general services.

5. Health Sub-Districts and HCIV: Population: 100,000

  • Plan and manage health services within the Health Sub-District (HSD).
  • Provide technical, logistical, and capacity development support to lower health units and communities.
  • The referral facility at HSD is HCIV, which can be government or PNFP.
  • HCIV provides basic preventive, curative, and rehabilitative care in the immediate catchment area and serves as a referral facility for lower-level units in the HSD.

6. Health Center 3 (HCIII)Population: 20,000

  • Offers continuous basic preventive, promotive, and curative care.
  • Provides support supervision to community and HCII facilities.

7. Health Center 2 (HCII)Population:5,000: Represents the first level of interaction between the formal health sector and communities.

8. Village Health Team (Health Centre I)Population: 1,000 

  • Facilitates community mobilization and empowerment for health action.
  • Each village has a VHT of 9-10 people selected by the village leadership.

KEY GOVERNMENT POLICIES Read More »

Management of equipment and supplies

Management of equipment and supplies

Management of equipment and supplies

Management of equipment and supplies refers to the processes and strategies implemented to effectively and efficiently handle and oversee the procurement, utilization, maintenance, and disposal of medical equipment and supplies within healthcare organizations.

 

It is important for ensuring the availability of necessary equipment and supplies, optimizing their utilization, and maintaining their quality and safety standards.

Phase of Equipment and Supplies Management.

  1. Planning: This involves assessing the healthcare facility’s needs, identifying the required equipment and supplies, and developing a strategic plan for their acquisition and utilization.
  2. Acquisition: This stage involves the procurement of equipment and supplies through processes such as tendering, vendor evaluation, and contract negotiation.
  3. Delivery and incoming inspection: Upon delivery, the equipment and supplies undergo an inspection to ensure they meet the specified requirements and are in proper working condition.
  4. Inventory and documentation: A comprehensive inventory is maintained, documenting details such as equipment descriptions, manufacturer information, purchase orders, warranty conditions, and service history.
  5. Installation and commissioning: Proper installation and commissioning of equipment are essential to ensure their safe and effective functioning. This may involve in-house technical staff or collaboration with suppliers.
  6. User training: Training programs are conducted to educate healthcare staff on the proper use and maintenance of equipment and supplies, reducing the risk of malfunctions and errors.
  7. Monitoring of use: Regular monitoring and performance evaluation of equipment and supplies are conducted to identify any issues, ensure optimal utilization, and address maintenance needs.
  8. Maintenance: Preventive and corrective maintenance activities are carried out to ensure equipment remains in good working condition, reducing the need for repairs and minimizing downtime.
  9. Replacement or disposal: When equipment reaches the end of its useful life or becomes obsolete, proper procedures for replacement or disposal are followed, considering environmental regulations and safety guidelines.
Management of Supplies

Management of Supplies

Supplies at a healthcare facility are stores of essential equipment, drugs and other supplies that you will need to use during your routine healthcare work.

There are two main types of supplies in your Health Post, referred to as non-consumables and consumables.

  1. Non-consumables are items of equipment that can be used for years, but may eventually have to be replaced or updated.
  2. Consumables are items that are used within a short period of time, so they need to be regularly replaced. They include all the medicines, drugs, vitamin supplements and infusion fluids (for intravenous use).

Category

Item

Description

Non-Consumables

 
 

Furniture

Desks, chairs, cabinets, examination tables, etc.

Equipment

Medical devices, diagnostic equipment, etc.

Vehicles

Ambulances, vans, motorcycles, etc.

Infrastructure

Buildings, fixtures, plumbing, electrical, etc.

Consumables

 
 

Medical Supplies

Bandages, dressings, syringes, gloves, etc.

Pharmaceuticals

Medications, drugs, vaccines, etc.

Laboratory Supplies

Test tubes, slides, reagents, etc.

Office Supplies

Paper, pens, folders, staplers, etc.

Cleaning Supplies

Disinfectants, detergents, mops, buckets, etc.

Fuel

Gasoline, diesel, propane, etc.

Maintenance Supplies

Lubricants, spare parts, tools, etc.

RATIONAL USE OF SUPPLIES

RATIONAL USE OF SUPPLIES

Rational medicine use: Refers to measures designed to avoid misuse of medicines, hence increases effectiveness, efficiency, and minimises waste and danger.

Or

This is the administration of the correct medications, for the appropriate patients, for the appropriate clinical needs, in doses and routes that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community.

 

Key Criteria for Rational Medicine Use:

  1. Correct Medicines: Ensuring that the prescribed medications are appropriate for the patient’s condition and are the most effective treatment available.
  2. Appropriate Indication: Prescribing medications based on sound medical considerations and in accordance with established treatment guidelines for the specific condition being treated.
  3. Medicine Suitability: Selecting medications that are suitable for the individual patient, taking into account factors such as age, gender, medical history, allergies, and other medications they may be taking.
  4. Dosage, Administration, and Duration: Ensuring that the prescribed dosage of medication is appropriate for the patient’s condition and age, that it is administered correctly, and that the duration of treatment is sufficient to achieve the desired therapeutic outcome.
  5. Patient Safety: Taking into consideration any contraindications or potential adverse reactions to the prescribed medication, and ensuring that the benefits outweigh the risks for the individual patient.
  6. Dispensing Accuracy: Ensuring that medications are dispensed accurately and that patients receive clear instructions on how to take them, including dosage instructions, frequency, and any special considerations.
  7. Patient Adherence: Encouraging and supporting patients to adhere to their prescribed medication regimen, including addressing any barriers or concerns they may have about taking their medications as directed.

Irrational Use of Medicine

Irrational medicine use can occur due to health worker wrong prescribing practices i.e.

  • Patients often take medicines in the wrong way, either by reducing the dose to make the treatment last longer or by increasing the dose in the hope of quick recovery.
  • They take the medicines at the wrong times or forget a dose.
  • Patients on long courses of treatment often stop taking medicines too soon.
  • Some patients do not understand the action of medicines in the body. As a result, they are sometimes not cured and the medicines are wasted.
  • Use of medicines when not needed e.g. use of antibiotics to treat mild ARI or diarrhea.
  • Wrong medicines e.g. the use of tetracycline for sore throat instead of penicillin.
  • Unsafe medicines e.g. Dipyrone (Novalgine).
  • Underuse of available effective medicines e.g. underuse of ORS for acute diarrhea.
  • Incorrect use of medicines e.g. giving patients only one or two days’ supply of antibiotics rather than the full course of therapy.
  • Wrong route of administration e.g. application of antibiotics directly on the wounds.
  • Polypharmacy – prescribing multiple medications without a clear medical indication.

10R’s for Proper Drug Administration

  1. Right Patient: Ensuring that the medication is administered to the correct patient by verifying their identity using at least two unique identifiers, such as their name, date of birth, or medical record number.
  2. Right Time: Administering the medication at the correct time intervals as prescribed, adhering to the prescribed schedule to maintain therapeutic effectiveness and prevent adverse effects.
  3. Right Dose: Providing the accurate dosage of the medication according to the prescribed amount, taking into account the patient’s age, weight, and other relevant factors.
  4. Right Route: Administering the medication via the appropriate route of administration, such as oral, intravenous, intramuscular, subcutaneous, or topical, as specified in the medication order.
  5. Right Drug/Medication: Ensuring that the medication administered is the correct drug as prescribed by the healthcare provider, matching the medication order and the patient’s condition.
  6. Right Formulation: Administering the medication in the correct formulation, such as tablets, capsules, liquid, or injectable, as specified in the prescription.
  7. Right Disposal: Properly disposing of expired or unused medications according to institutional protocols and regulatory guidelines to prevent environmental contamination and misuse.
  8. Right Storage: Storing medications appropriately under conditions such as temperature, humidity, and light to maintain their stability and efficacy, following manufacturer recommendations and regulatory requirements.
  9. Right Equipment: Using the appropriate equipment and devices for medication administration, such as syringes, infusion pumps, or inhalers, and ensuring they are clean, calibrated, and functioning properly.
  10. Right Site: Administering medications to the correct anatomical site or location as prescribed, particularly important for procedures such as injections, intravenous infusions, or topical applications, to avoid complications or adverse effects.

Common Problems in Handling Medical Supplies:

Theft

  • Lack of proper record to identify the culprits/detect theft.
  • Lack of security in the store where it’s accessed by everybody at any time making it difficult to detect theft cases and responsible person.
  • Lack or irregular stock cards not updated and items been picked/issued with requisitioning.
  • Fear by Incharges or store personnel to report theft cases due to fear of creating conflicts and enmity with staff.
  • Theft due to collusion between staff members.

Misuse

  • Lack of ownership/self-reliance among staff thinking it’s not their responsibility to control and economize since they are not the ones buying and lose nothing.
  • Irrational use of supplies by health workers, for example, using gloves as tourniquets, for hanging I.V fluids, etc.
  • Inadequate knowledge and skills in executing service delivery, for example, lack of skills in cannulation in children waste more cannulas.
  • Using expired or near-expired medical supplies due to improper stock rotation.

Lack of Record Keeping

  • Personal habit of “I don’t care” attitudes/behaviors of staff.
  • Knowledge gap among staff resulting in lack of and/or improper record keeping.
  • Absence of data collection tools.
  • Emerging technology may be challenging due to knowledge gap among the record handlers.
  • Inadequate training on inventory management leading to improper documentation and monitoring of medical supplies.

Others common problems in handling medical supplies include;

  1. Expired Supplies: Failure to monitor and manage inventory effectively can lead to the accumulation of expired medical supplies, which can result in wastage of resources and compromise patient care if used unknowingly.
  2. Stockouts: Inadequate inventory management practices may result in stockouts of essential medical supplies, leading to delays in patient care, compromised safety, and increased costs due to emergency procurement or alternative solutions.
  3. Poor Quality Control: Lack of quality control measures in the procurement and storage of medical supplies can result in the acquisition of substandard or counterfeit products, posing risks to patient safety and treatment effectiveness.
  4. Inefficient Ordering Process: Inefficient or inaccurate ordering processes, such as manual requisition systems or lack of forecasting methods, may lead to understocking or overstocking of medical supplies, impacting patient care and operational efficiency.
  5. Inadequate Storage Facilities: Improper storage facilities, such as inadequate space, inappropriate environmental conditions (e.g., temperature, humidity), or lack of security measures, can compromise the integrity and shelf life of medical supplies, leading to waste and reduced efficacy.
  6. Poor Distribution Practices: Inefficient distribution practices, such as lack of standardized procedures, improper handling, or delays in delivery, can result in discrepancies between supply availability and demand at healthcare facilities, affecting patient care and workflow efficiency.
  7. Inaccurate Documentation: Failure to maintain accurate and up-to-date documentation related to medical supplies, including procurement records, inventory logs, and usage reports, can lead to errors in decision-making, regulatory non-compliance, and financial losses.
  8. Inadequate Training: Insufficient training and education of healthcare staff involved in handling medical supplies may result in improper storage, handling, or administration practices, increasing the risk of errors, contamination, or adverse events.
  9. Lack of Standardization: Absence of standardized protocols and procedures for managing medical supplies across healthcare facilities within an organization or region can lead to inconsistencies, inefficiencies, and disparities in care delivery.
  10. Budget Constraints: Limited financial resources allocated for the procurement and maintenance of medical supplies may restrict access to essential supplies, compromise patient care quality, and impede efforts to address emerging healthcare needs or emergencies.

ROLES OF A NURSES IN EQUIPMENT AND SUPPLIES MANAGEMENT

  1. Inventory Management: Nurses are responsible for monitoring and managing inventory levels of medical supplies, including consumables (e.g., gloves, syringes, dressings) and non-consumables (e.g., equipment, instruments). This involves regular stocktaking, tracking usage patterns, and replenishing supplies as needed to prevent stockouts or overstocking.
  2. Ordering and Procurement: Nurses play a crucial role in the procurement process by assessing supply needs, preparing requisitions, and liaising with relevant departments or suppliers to ensure timely acquisition of required supplies. They may also participate in evaluating product quality and cost-effectiveness.
  3. Storage and Handling: Nurses are responsible for ensuring that medical supplies are stored appropriately to maintain their integrity, safety, and efficacy. This includes organizing storage areas, monitoring environmental conditions (e.g., temperature, humidity), and implementing proper handling procedures to prevent damage, contamination, or expiration of supplies.
  4. Distribution and Allocation: Nurses facilitate the distribution and allocation of medical supplies to various departments, units, or patient care areas within the healthcare facility based on demand, priority, and usage patterns. They ensure equitable distribution while optimizing resource utilization.
  5. Quality Control: Nurses are involved in ensuring the quality and safety of medical supplies through inspection, verification, and adherence to standards and regulations. They identify and report any issues related to product quality, packaging, labeling, or expiration dates to appropriate authorities.
  6. Education and Training: Nurses provide education and training to healthcare staff on proper procedures for handling, storing, and using medical supplies to promote patient safety, infection control, and resource conservation. They may conduct in-service sessions, orientation programs, or ongoing training to reinforce best practices.
  7. Documentation and Reporting: Nurses maintain accurate records and documentation related to supply management activities, including inventory records, usage logs, expiration dates, and incident reports. They generate reports and analysis to track trends, identify areas for improvement, and support decision-making.
  8. Collaboration: Nurses collaborate with multidisciplinary teams, including procurement personnel, clinicians, administrators, and support staff, to coordinate supply-related activities, address challenges, and implement effective solutions. They communicate effectively to facilitate seamless workflow and optimize patient care outcomes.
  9. Continuous Improvement: Nurses actively participate in quality improvement initiatives aimed at enhancing supply chain efficiency, reducing waste, and optimizing resource utilization. They contribute ideas, feedback, and suggestions for process improvement and innovation in supplies management practices.

Management of equipment and supplies Read More »

TRANSPORT MANAGEMENT

TRANSPORT MANAGEMENT

TRANSPORT MANAGEMENT 

Transport refers to the act or process of transferring or conveying people, goods, or materials from one place to another.

It involves the movement of individuals, objects, or substances by various means such as vehicles, vessels, or even through digital networks. 

 

Transport is essential for carrying out both, Facility-Based and Non-Facility-Based community health care services.  These include:- bicycles, motorcycles and vehicles depend on level of Health facility. For such transport means to be useful for the intended results, some minimal management procedures or instructions need to be instituted.

Procedures for Managing Bicycles, Motorcycles, and Vehicles in Health Service Transport

To ensure the effective management of bicycles, motorcycles, and vehicles in health service transport, it is important to implement certain procedures and instructions. While the specific procedures may vary depending on the level of the health facility.

Keeping an Updated Inventory Record:

  • Maintain a comprehensive inventory record of all bicycles, motorcycles, and vehicles used in health service transport. This record should include details such as the make, model, registration number, and condition of each vehicle.
  • Regularly update the inventory record to reflect any changes, such as additions or disposals of vehicles,  and identify any discrepancies or missing vehicles.
  • Use the inventory record to track the usage, maintenance history, and availability of each vehicle.

Servicing and Maintenance:

  • Establish a regular servicing and maintenance schedule for all bicycles, motorcycles, and vehicles. Such as oil changes, tire rotations, and brake checks to ensure the vehicles are in optimal condition.
  • Conduct routine inspections to identify any issues or defects that may affect the safety or performance of the vehicles.
  • Keep detailed maintenance records, including dates of service, performed tasks, and any repairs or replacements made.
  • Train staff members responsible for servicing and maintenance on proper procedures and safety protocols.
  • Address any reported issues or concerns to minimize downtime and ensure the vehicles are always available for use.

Transport policy: 

  • Every health care organization must make a transport policy that governs their transport. It should be adhered to by all workers and managers. 
  • Authorization and Use of Vehicles: The transport policy should clearly define who is authorized to use the organization’s vehicles and under what circumstances. It should specify the procedures for requesting and obtaining authorization to use a vehicle. The policy should outline any restrictions on carrying passengers or items in the vehicles.
  • Vehicle Maintenance and Disposal: The transport policy should include guidelines for the maintenance and upkeep of vehicles. It should specify the procedures for regular inspections, servicing, and repairs of vehicles. When disposing of old vehicles or purchasing new ones, the policy should adhere to relevant regulations, such as the Public Procurement and Disposal Authority (PPDA) Act 2014 for government and PNFPs.
  • Compliance and Training: All workers and managers should be made aware of the transport policy and their responsibilities in adhering to it. Regular training sessions should be conducted to ensure that employees understand and comply with the policy. The policy should be reviewed periodically to incorporate any necessary updates or changes.

Managing transport information:

In healthcare organizations, it involves keeping track of various documents and records related to vehicles, journeys, fuel usage, maintenance, and compliance. 

  • Vehicle Log Book: The logbook proves your ownership of a vehicle. In addition, the vehicle logbook works as a summary of the vehicle’s key statistics: make, model, engine, etc. Log book is a book in which someone records details and events relating to something for example a journey or period of their life or a vehicle
  • Vehicle Journey Cards: Some organizations use journey cards or a book to record all the journeys made by each vehicle. This helps in tracking the total distance traveled and the amount of fuel consumed for each journey.
  • Fuel and Maintenance Receipts: It is important to keep receipts for fuel purchases and maintenance repairs. These receipts provide evidence of expenses and can be used for accounting and auditing purposes.
  • Tax Licenses: Healthcare organizations must ensure that all vehicles have valid tax licenses. These licenses should be kept up to date and readily accessible for inspection.

Planned Preventive Maintenance

  • It involves periodic maintenance tasks such as replacing oil, fluids, and grease; inspecting for wear and tear on moving components; and replacing components according to the manufacturer’s recommendations and regular inspections.
  • Objectives: Investing in maintenance to avoid breakdowns, Increasing the reliability of vehicles and Reducing overall running costs.
  • Implementation: Planned preventive maintenance is achieved through daily checks, defect identification, and regular servicing.

Inventory of Transport:

Inventory refers to a detailed list of equipment, instruments, infrastructure, and buildings, including transport, available in a unit.

Information to Collect:

  • Make and model of the vehicle.
  • Year of manufacture.
  • Engine and chassis numbers.
  • Registration number.
  • Main use.
  • Activity or program it is allocated to.
  • Seating capacity.
  • Running condition.
  • Person responsible.

Importance of Carrying out Inventory of Transport:

  • Prevents misuse of transport.
  • Facilitates good supervision.
  • Aids in scheduling use.
  • Restricts use to named individuals.
  • Supports the use of log books.
  • Enables the enactment of enforceable policies on private use.
  • Ensures strict daily vehicle checks.

Importance of Transport Management in Health Facilitie

  1. Resource Optimization: Transport is a valuable resource that should be managed like any other asset. By efficiently managing vehicles, health facilities can maximize their utilization and achieve better outcomes without necessarily increasing the number of vehicles.
  2. Impact on Service Delivery: Well-managed transport systems ensure that vehicles are available when and where they are needed, enabling timely delivery of healthcare services to patients.
  3. Cost Considerations: Transport management can help minimize costs including purchase, maintenance, repairs, insurance, fuel, and replacement, freeing up resources for other needs of healthcare.
  4. Third Largest Cost: In many health service delivery settings, transport ranks as the third largest cost after staff and medicines. Proper management of transport can help optimize spending in this area and allocate resources more effectively.
  5. Protection of Vehicles and Equipment: Proper maintenance and use of vehicles extend their lifespan and reduce the need for repairs and replacements. This saves money and ensures that vehicles are always in good working condition.
  6. Time Savings: Improved transport management allows for more efficient use of vehicle time, reducing delays and improving overall service delivery timelines. 
  7. Safety: Good maintenance and respect to safety protocols not only save time and money but also save lives. Well-maintained vehicles are less prone to breakdowns, reducing the need for repairs and replacements.
  8. Reduced Liability: Effective transport management helps prevent accidents and injuries, reducing the risk of legal liability for health facilities.
  9. Accident Prevention: Effective transport management helps minimize the risk of accidents and injuries. This protects not only the vehicle operators and users but also pedestrians and other road users.
  10. Positive Public Image: Well-managed transport systems contribute to a positive public image for health facilities. On the other hand, poorly managed transport can lead to negative publicity and a loss of public trust.
  11. Compliance with Regulations: Transport management must comply with relevant laws and regulations to ensure the safety and well-being of all road users. This includes adhering to traffic regulations, maintaining proper documentation, and ensuring vehicles are in compliance with legal requirements.
  12. Divers responsinilities are respected: Ensuring the availability and use of safety equipment (e.g., warning triangles, first aid kits, fire extinguishers). Wearing high visibility clothing and other protective gear. Carrying essential tools and supplies (e.g., puncture repair kits, tow ropes, spare fuel)

Uses of Transport in Health Facilities

  1. Emergency Medical Services (EMS): Transport plays a critical role in emergency medical services, enabling rapid response and transportation of patients to hospitals or specialized care facilities. EMS vehicles, such as ambulances, provide life-saving transportation for individuals in critical condition.
  2. Medical Supply Delivery: Transport is important for the timely delivery of medical supplies, such as medications, vaccines, laboratory samples, and equipment, to healthcare facilities. Small quantities can be transported by foot or bicycle to community health workers. 
  3. Administrative Support: Use of public transportation for administrative tasks to conserve available vehicles for health service delivery.
  4. Supervision: Technical support, program inspections (e.g., sanitation, water source protection). 
  5. Training:Transport for facilitators and participants during field visits and study tours Delivery of training materials and equipment (e.g., computers, projectors)
  6. Health Outreach Programs: Transport is utilized in health outreach programs, where healthcare professionals and support staff travel to remote or underserved areas to provide medical services, health education, and preventive care. 
  7. Mobile Clinics: Transport is essential for mobile clinics, which are equipped vehicles that bring healthcare services directly to communities. These clinics provide primary care, screenings, vaccinations, and other essential services, particularly in rural or isolated areas.
  8. Patient Transfers: Transport is involved in transferring patients between healthcare facilities for specialized treatments, surgeries, or higher levels of care. 
  9. Meetings: Attendance at meetings at various levels (e.g., Ministry of Health, district, sub-district, community.

N.B: Walking remains the most reliable method of transportation for lower-level health facilities. Other means of transportation (e.g., bicycles, vehicles) are necessary for larger distances, bulk deliveries, and emergency situations.

MANAGING INFRASTRUCTURE 

The maintenance of the buildings that make up the unit is the responsibility of the in charge. 

Problems such as 

  • leaking roofs, 
  • broken toilets and repainting and repairs due’

should be reported to the local ministry of works representative or the person who is responsible for the actual repairs. 

Sometimes the ministry of works (MOW) is unable to carry out the necessary repairs and authority is then given for the work to be sub-contracted to commercial builders. 

Before such work can be carried out, it MUST be put out to tender. Tenders are offers by suitably qualified contractors to carry out the work with a statement of cost and of how long the work will take. Tenders are submitted in sealed envelopes. A tender committee, made up of various officers, opens all the tenders at the same time and compares them. The builder who best meets the requirements, even if the price is not the lowest, is awarded the contract and asked to carry out the work. 

The tender system is used to avoid corruption and favoritism and loss of government/organizational money through inflated estimates. Work awarded without tendering will not be paid for by the government/ most organizations even if it involves small amounts. Inspect all the buildings including staff quarters (if there are any), once a week or once a fortnight, with one or two other staff, to check on the general standard of cleanliness. Necessary maintenance can be considered at the same time. Fire risk should be considered. Buckets of sand should be available if there are no other extinguishers. 

Extinguishers need routine inspection to see if they are intact and up to date. Effective security is always difficult in health facilities. It (security) can be improved by limiting access to doors and gates and under observation by guards. After duty hours these doors must be closed and locked. Make sure the watch man/Askari knows who to inform in case of emergency. 

Importances of infrastructure management  in health facilities.

  1. Operational Efficiency: Well-managed infrastructure ensures that healthcare services and facilities operate efficiently and effectively. This includes planning and structuring the built environment, equipment, access, information technology systems, and processes to facilitate high-quality, accessible, responsive, and safe services.
  2. Emergency Preparedness: Infrastructure management becomes particularly important during times of crisis. Health facilities rely on vital resources such as electricity, water, and oxygen. Having backup plans in place, such as emergency generators, ensures continuity of care even during disruptions in the supply of essential resources.
  3. Patient Experience and Well-being: Well-planned and managed infrastructure supports improved standards of patient care and well-being. Factors such as the design of healing environments, access to green spaces, and consideration of the sensorial environment can positively impact patient experience, reduce stress, and contribute to better health outcomes.
  4. Staff Well-being: Infrastructure management should also prioritize the well-being of healthcare staff. Facilities that provide amenities like shops, cafes, prayer rooms, and access to green spaces can contribute to a positive work environment and support the well-being of staff, which is important for ensuring better healthcare.
  5. Sustainability: This can involve implementing energy-efficient technologies, utilizing real-time measurements and control systems, and reducing carbon emissions. Building sustainable healthcare infrastructure not only helps protect the environment but also optimizes operational costs and improves resource management.

TRANSPORT MANAGEMENT Read More »

FINANCIAL MANAGEMENT, BUDGETING & ACCOUNTABILITY

FINANCIAL MANAGEMENT, BUDGETING & ACCOUNTABILITY

FINANCIAL MANAGEMENT

Financial management is balancing income and expenditure to ensure that available money is used appropriately to meet ongoing needs.

Financial management has three crucial aspects:

  1. Quantity: This means that there must be enough money to meet the organization/health facility needs regardless of other factors. This applies particularly to cash.  It is not safe to have a large amount of cash at the health center as it may be stolen. For this reason, visible money is usually small in amount and is called “Petty cash”.
  2. Liquidity: Funds must be in the suitable form for the use for which they are intended. For Example diverting money meant for medicines to other expenditures in the health facility.
  3. Performance: Funds are allocated to the health facility based on its level of functionality and performance. For example: HCII, HCIII, HCIV and hospitals.
Importance of Financial Management at a Health Facility

Importance of Financial Management at a Health Facility

Raising and Safeguarding Funds: Proper management of health facility revenue and expenditure includes raising and safeguarding funds to ensure that the facility has sufficient financial resources to operate effectively. This involves:

  • Developing strategies to generate revenue from various sources, such as patient fees, insurance payments, government grants, and donations.
  • Implementing efficient systems for collecting and recording revenue, including the use of receipts and electronic payment methods.
  • Establishing secure storage facilities for cash and other financial assets to prevent theft or loss.

Efficient Resource Allocation: Effective management of revenue and expenditure allows health facilities to allocate their financial resources efficiently to optimize healthcare services. This involves:

  • Prioritizing essential expenses, such as salaries, medical supplies, and equipment maintenance.
  • Identifying areas where costs can be reduced or optimized without compromising the quality of care.
  • Investing in cost-effective interventions and technologies to improve patient outcomes.

Community Access to Services: Proper financial management ensures that health facilities have the resources to provide essential health services to the community. This includes:

  • Covering the costs of staff salaries, medical supplies, and equipment necessary to deliver healthcare services.
  • Establishing affordable payment options for patients, including fee waivers and payment plans.
  • Reaching out to underserved populations and providing access to healthcare services regardless of their ability to pay.

Informed Decision-Making: Effective management of revenue and expenditure provides health facility managers with accurate financial data to support informed decision-making. This includes:

  • Regular financial reporting that tracks revenue, expenditure, and financial performance.
  • Analysis of financial data to identify trends, forecast future needs, and make evidence-based decisions.
  • Using financial information to plan for future investments and service expansions.

Trust and Confidence: Transparent and accountable financial management builds trust among health staff and the community. This involves:

  • Maintaining accurate and up-to-date financial records.
  • Regularly reporting financial information to stakeholders, including staff, patients, and the community.
  • Addressing any concerns or questions about financial matters promptly and effectively.

Others include;

Ensuring Availability of Funds for Essential Purchases: Proper management ensures that sufficient funds are available to purchase high-priority items such as drugs, medical supplies, and equipment, which are essential for providing quality healthcare.

Preventing Financial Exhaustion: By managing revenue and expenditure effectively, health units can avoid running out of funds, which could lead to disruptions in healthcare services.

Tracking Expenses: Proper management allows health units to monitor how much they are spending on specific items, such as salaries, utilities, and maintenance. This information helps identify areas where costs can be optimized or reduced.

Determining Financial Status: Effective management provides a clear understanding of the health unit’s financial status, including the amount of money available at any given time. This information is essential for planning and decision-making.

Adhering to Budget: Proper management ensures that the health unit follows the approved budget in its spending, preventing unauthorized or excessive expenditures.

 

Financial Management Obligations for Managers

  • Budget Preparation: Develops a financial plan outlining income and expenses.
  • Financial Projections: Forecasts future financial needs and potential risks.
  • Cost Analysis: Compares costs of services to identify areas for improvement.
  • Reporting Compliance: Meets reporting requirements for donors and government agencies.
  • Data-Driven Decisions: Utilizes financial reports to make informed decisions that enhance healthcare operations.

Process of Financial Management in a health facility

  1. Collecting Money and Issuing Receipts: All revenue received, such as patient fees, insurance payments, and donations, must be collected and documented with official receipts.
  2. Recording Exemptions and Debtors: If any patients are exempted from paying fees or receive credit, their exemptions or debts must be recorded accurately.
  3. Safeguarding Funds: Money collected should be kept securely at the health unit or deposited in a designated bank account.
  4. Recording Transactions: All revenue received and deposited, as well as any exemptions or debts, must be recorded in the cashbook and bank book.
  5. Verifying Bank Statements: Bank statements should be regularly reconciled with the bankbook to ensure accuracy and prevent discrepancies.
  6. Reconciling Records: The total amount of money recorded in the health unit’s registers should match the amount in receipts, debtors, and exemption books to ensure accountability and prevent fraud.
Sources of Health Financing

Sources of Health Financing

Health financing can be categorized into two main sources:

  1. Public Funding: Funds coming from central and local Government, including funds from Health Development partners (HDPs) channeled through central and local Government budget support mechanisms, and through project mechanisms.
  2. Private Funding: Funds coming from private or non-Government sources, including out-of-pocket payments (payment from a sick person or relative’s pocket) for health services, Insurance Prepayment scheme premiums, donations and projects and programmes funded and implemented by and through NGOs.

Service Sectors

Public Funding Sources

Private Funding Sources

Government Health

– Government of Uganda.

– Development partners.

– Central budget support.

– District Budget support.

– Private wings.

– NGO-supported projects and programs

Private Services

-Facility-based Private Not for Profit (PNFP)

– Non-facility-based PNFPs

– Private health practitioners

– Traditional and complementary medicine practitioners

 

– Govt subsidies or cost support to private facilities, including infrastructure development

– Contractual arrangements with private providers

– Participation in Govt-funded programs

– Multilateral and bilateral

projects and program

channeled through

central or local Govt.

– Household (user fees)

– Insurance (employer-based, community-based, national-based, and private)

– Donations (internal and external)

– Income-generating activities

– Fundraising

– Commercial marketing strategies

– NGO-supported projects and programs

Primary Methods/Mechanisms of financing and funding health care systems 

  1. Direct or Out-of-Pocket Payments: Individuals make direct payments for healthcare services as they are received. This method involves paying at the point of service delivery, often from personal funds.
  2. General Taxation from Formal and Informal Sectors: Funding is generated through general taxation, encompassing contributions from both the formal and informal sectors. Examples include income tax (e.g., pay as you earn) and taxes levied on businesses.
  3. Social Health Insurance: Citizens contribute compulsory premiums from their income, mandated by government law. In Uganda, this mechanism is currently under discussion, reflecting ongoing considerations about its implementation.
  4. Voluntary, Community, or Private Health Insurance: This method involves individuals or employers paying premiums to insurance agencies for healthcare coverage. Examples include private insurers like AAR and UAP. Additionally, community health insurance models exist, where community members pool resources to collectively cover health risks and expenses for members or dependents facing illness.
  5. Donations: Healthcare systems may receive support in the form of grants or loans from development partners. These external contributions, whether financial aid or loans, play a role in improving healthcare infrastructure and services.

BUDGETING AND BUDGET CONTROL 

A budget is a quantitative statement, usually in monetary terms, of the plans and expectations of a defined area over a specific period of time. It addresses what to be done, where and when.

A budget is a financial statement which contains estimates of revenue and expenditure of an organization for a certain period of time in order to achieve predetermined objectives..

A budget is a plan of how to spend a certain amount of money for a specified period. It involves allocation of available funds to prioritized items and activities.

Terms Related to Budgeting:

  • Cost Centers: A cost center is a function within an organization that does not directly add to profit but still costs money to operate, such as accounting, HR, or IT departments.
  • Profit: Profit refers to the financial gain or positive difference between revenues and expenses. 
  • Fixed Costs: Fixed costs are expenses that do not vary with the level of production or activity. These costs remain constant regardless of the volume of goods or services produced.
  • Variable Costs: Variable costs fluctuate based on the level of production or activity. They increase as production volume increases and decrease as production volume decreases.
  • Direct Costs: Direct costs are expenses that can be easily traced to a specific product, department, or project. Examples include raw materials, labor, and distribution costs directly associated with production.
  • Indirect Costs/Overhead Costs: Indirect costs are expenses that are not easily traceable to a specific product, department, or project. These costs are incurred for the overall operation of the organization and cannot be directly allocated to a specific cost object.
  • Operating Expenses: Operating expenses are the ongoing costs incurred by a business to conduct its normal operations. These expenses include rent, utilities, salaries, and other day-to-day expenses necessary for running the business.
  • Budget Variance: Budget variance is the difference between the budgeted or planned amount and the actual amount incurred or achieved. Positive variance indicates that actual performance exceeded the budget, while negative variance suggests that actual performance fell short of the budget.
  • Cash Flow: Cash flow refers to the movement of money in and out of a business over a specific period. Positive cash flow indicates that the business is generating more cash than it is spending, while negative cash flow indicates that the business is spending more cash than it is generating.
  • Contingency Fund: A contingency fund, also known as a reserve fund, is a pool of money set aside to cover unexpected expenses or emergencies. It serves as a buffer against unforeseen events that could impact the organization’s financial stability.
  • Budget Cycle: The budget cycle is the process through which a budget is created, approved, executed, monitored, and evaluated within an organization. It follows a recurring timeline, such as monthly, quarterly, or annually, depending on the organization’s needs.
Importance of Budgeting

Importance of Budgeting

Budgeting is a crucial financial planning tool and It involves the systematic allocation of financial resources to achieve specific goals and objectives.

  1. Planning and Policy Making: Budgeting provides a framework for organizations to plan their operations and set policies. It helps them establish clear financial targets and allocate resources accordingly.
  2. Evaluating Performance: Budgets serve as benchmarks against which actual financial performance can be measured. By comparing actual results to budgeted amounts, organizations can identify areas where they are meeting or falling short of expectations.
  3. Determining Sources of Resources: Budgeting helps organizations determine the sources of financial resources they need to achieve their goals. This includes identifying potential revenue streams and exploring funding options.
  4. Determining Expenditure: Budgets establish limits on how much organizations can spend on various activities. This helps control expenses and ensures that resources are allocated efficiently.
  5. Authorizing Future Expenditure: Budgets provide authorization for future expenditures. Once approved, budgets give managers the authority to commit resources to specific projects or initiatives.
  6. Coordinating Activities of an Organization: Budgeting helps coordinate the activities of different departments and units within an organization. It ensures that all departments are working towards common financial goals.
  7. Regulating and Controlling Income and Expenditure: Budgets act as a regulatory mechanism to ensure that income and expenditure are managed responsibly. They help prevent overspending and ensure that resources are used effectively.
  8. Determining the Affordability of Programs: Budgeting helps organizations determine the affordability of new programs or initiatives. By comparing the costs of proposed programs to available resources, organizations can make informed decisions about which programs to pursue.
  9. Motivational Tool: It motivates individual members by serving as a target. Well defined goals and targets usually motivate individuals. But this needs participatory formulation of plans.

Qualities of a good Budget:

  1. Realistic: Achievable with the available resources.
  2. Balanced: Addresses all relevant needs in a well-proportioned manner.
  3. Plan-Based: Follows a structured work plan.
  4. Understood by Users: Clearly comprehensible to all users involved.
  5. Inclusive of All Revenue Sources: Encompasses all potential sources of revenue.
  6. Future-Bound: Forward-looking, considering future requirements.
  7. Reflects Teamwork and Consultative Effort: Demonstrates collaboration and input from the team.

Types/Kinds/Forms of Budgets:

1. Operating Budget: Also known as an Annual Budget, this is the organization’s statement of expected revenues and expenses for the coming year. It covers a specified 12-month period and is used to measure the operational and financial performance of the organization. The operating budget can be further broken down into smaller periods such as 6 months, 4 quarters, or even monthly periods.

  • Revenue Budget: Represents the expected income for the budget period, such as money from patients in a hospital.
  • Expense Budget: Consists of salary and non-salary items and should reflect the patient care objectives and activity parameters established for the nursing unit or hospital.

2. Personnel Budget: Also known as a Salary Budget, this budget projects the salary costs that will be paid and charged to the cost center in the budget period.

3. Supply and Non-salary Expense Budget: This budget identifies the input supplies needed to operate the business or organization. In the case of a hospital or nursing unit, it includes patient-related supplies needed for operations.

4. Capital Budget: This budget is made to meet the long-term goals of an organization, such as physical renovations, new constructions, or equipment replacements planned within the budget period.

budget process

The Budgeting Process/Budgeting Cycle.

Budgeting is a process of planning and controlling future operations by comparing actual results (actual budgetary performance) with planned expectations. 

Budgeting process preparation 

Before the preparation of any budget in an organization, the budget period, a budget manual, responsibility for the preparation of budget, and a budget committee have to be set or/and put in place.

Steps of Budgeting process:

1. Identification of Objectives: The first step in the budgeting cycle is to identify the organization’s objectives. These objectives should be aligned with the organization’s mission, vision, and strategic plan.

2. Determination of Resource Needs: Once the objectives have been identified, the organization must determine the resources that are needed to achieve those objectives. This includes both financial and non-financial resources, such as personnel, equipment, and supplies.

3. Pricing of the Requirements: The next step is to price the requirements. This involves estimating the cost of the resources that are needed to achieve the objectives.

4. Identification of Revenue Sources: The organization must then identify the revenue sources that will be used to fund the budget. This may include revenue from sales, grants, donations, or other sources.

5. Negotiation of Budget Allocation with Superiors: Once the budget has been developed, it must be negotiated with superiors. This may involve justifying the budget to superiors and making adjustments as necessary.

6. Prioritizing the Needs: The organization must then prioritize the needs that are included in the budget. This involves determining which needs are most important and which needs can be deferred.

7. Coordination and Consolidation into Master Budget: The individual budgets for each department or unit within the organization are then coordinated and consolidated into a master budget. The master budget is a comprehensive financial plan that outlines the organization’s expected revenues and expenses for the upcoming period.

8. Approval: The master budget must then be approved by the organization’s leadership. This may involve a vote by the board of directors or other governing body.

9. On-going Review: The budget is not a static document. It should be reviewed and updated on an ongoing basis to ensure that it remains aligned with the organization’s objectives and financial performance.

METHODS OF BUDGETING

Approaches or Methods or Classifications of budgeting.

The organization may choose various approaches or methods, or combination of them, for requesting departmental managers to prepare their budget requests.

1. Zero-based budget: ZBB requires starting the budgeting process from scratch, with every expense justified and evaluated. It does not rely on previous budgets and encourages a thorough review of all expenses. It assumes the base for projecting next year’s budget is zero. Managers are required to justify activities and programs as if they were being initiated for the first time.

A regional hospital, aiming to expand its services to meet the growing healthcare needs of the community, decides to implement zero-based budgeting for the upcoming fiscal year. The hospital administration identifies the need to provide new services, particularly in the maternity and emergency departments, and plans to hire additional medical staff, upgrade medical equipment, and renovate existing facilities.

Advantages:

  1. Strategic Focus: The hospital can strategically allocate resources to priority areas, ensuring the effective expansion of essential services.
  2. Resource Optimization: By starting with a clean slate, the hospital can allocate resources based on current needs, avoiding unnecessary expenses and optimizing resource utilization.
  3. Granular Visibility: Zero-based budgeting provides detailed visibility into each department’s requirements, allowing for a thorough examination of costs at a granular level.
  4. Cost Reduction: Identifying and justifying every money spent helps the hospital identify areas for potential cost reduction, contributing to overall financial efficiency.
  5. Adaptability to Changes: As the hospital aims for expansion, zero-based budgeting allows for easy adaptation to unforeseen changes in the healthcare landscape or community needs.
  6. Eliminates Tradition: ZBB eliminates the traditional approach of carrying over items from the previous budget, ensuring a fresh and relevant budget.
  7. Output Focus: The approach focuses on output in relation to value for money, aligning expenditures with measurable outcomes.
  8. Realistic Needs: Zero-based budgeting is more realistic to the current needs of the hospital, preventing the perpetuation of outdated budgetary items.
  9. Bottom-Up Approach: The involvement of lower cadres of staff in the budgeting process ensures a bottom-up approach, incorporating insights from those directly involved in patient care.
  10. Encourages Creativity: ZBB encourages creativity among lower-level staff as they actively participate in decision-making processes related to budgeting.

Disadvantages:

  1. Time-Consuming Process: The thorough line-by-line justification required for zero-based budgeting can be time-consuming, demanding extensive analysis and documentation.
  2. Costly Implementation: Implementing ZBB can be costly, involving significant expenses in terms of time, effort, and potentially hiring external expertise.
  3. Lower-Level Understanding: Lower-level cadres may find it hard to understand the complexities of zero-based budgeting, potentially hindering effective participation.
  4. Skilled Personnel Requirement: Successful implementation requires highly skilled personnel, and such individuals may be scarce, leading to recruitment challenges.
  5. Theoretical and Difficult: ZBB is very theoretical and can be difficult to apply in real-world scenarios, posing challenges in practical execution.
  6. Limited Frequency of Use: Due to its time-intensive nature, zero-based budgeting is often not employed frequently, potentially limiting its effectiveness in ongoing financial management.
  7. Trial and Error: The iterative nature of adjusting the budget may involve trial and error, especially for a healthcare facility navigating expansion plans.
  8. Resource Allocation Challenges: Allocating resources without historical reference may pose challenges in accurately estimating the needs of each department.

2. Incremental Budgeting: Incremental budgeting is a traditional budgeting method where the budget for the new period is prepared by making incremental changes to the previous period’s budget. This approach is based on the assumption that the current activities and costs are still needed, without thoroughly examining them. Also called Traditional Budgeting since it involves creating a budget based on historical data and previous spending patterns.

A well-established hospital with a focus on maintaining its current standards and services chooses the incremental budgeting method for the next fiscal year. The hospital administration, aiming for budgetary stability, believes that incremental changes in the existing budget are sufficient to meet the institution’s ongoing needs.

Advantages:

  1. Cost-Effectiveness: Incremental budgeting is a cost-effective choice for the hospital, as it doesn’t require extensive financial analysis or sophisticated calculations.
  2. Low Skill Requirement: The method is simple to prepare, requiring no highly skilled manpower. This simplicity facilitates a quick and efficient budgeting process.
  3. Ease of Understanding: Incremental budgeting is easy to understand, making it accessible to various staff members across different departments.
  4. Time Efficiency: The budgeting process takes a shorter time, allowing the hospital to swiftly allocate resources and plan for the upcoming fiscal year.
  5. Reduced Conflict: Since incremental changes are few, the approach minimizes conflicts during the budgeting process, fostering a smoother decision-making environment.
  6. Alignment with Long-Term Goals: Incremental budgeting is suitable for maintaining the hospital’s long-term goals, providing stability and consistency in resource allocation.

Disadvantages:

  1. Carrying Forward Deficiencies: Deficiencies from the previous year are carried forward, potentially bringing inefficiencies or misallocations.
  2. Lack of Questioning Spending Levels: The method does not encourage questioning of the previous level of spending, possibly leading to unnecessary resource allocation.
  3. Neglect of Specific Areas: Incremental budgeting may overlook specific areas of spending, hindering a detailed examination of each department’s needs.
  4. Potential for Inflated Expenditure: Current expenditure could be inflated or padded, leading to a distortion of the actual financial needs of the hospital.
  5. Disincentive to Innovation: The method may act as a disincentive to innovation or the generation of new ideas, as it tends to maintain existing spending patterns.
  6. Risk of Maintaining Inefficiencies: Incremental budgeting may keep inefficiencies in operations, especially if the operations based on the budget have not been thoroughly evaluated for effectiveness.
  7. Limited Scrutiny: The approach inhibits change and relationships between costs, benefits, and objectives are rarely subjected to searching scrutiny, potentially hindering organizational growth.
  8. Budget Maintenance Strategy: Managers may learn to spend the entire budget amount established for the current year to avoid budget cuts, creating a base for the next year that may not reflect the actual needs.

3. Program budgeting / Activity-based budget: An activity-based budget (ABB) is a financial budgeting approach that links activities to costs. Program-based budgeting requires objectives, outputs, expected results, and detailed costs to be provided for each activity or program. The budget is then prepared by combining all the budgets for different activities, resulting in a comprehensive program budget. This approach promotes transparency and accountability.

A specialized medical center, catering to a wide range of healthcare services and treatments, adopts the Activity-Based Budgeting (ABB) approach for the upcoming fiscal year. The complexity of services provided, including various medical procedures, diagnostics, and specialized treatments, makes ABB an ideal choice to gain a comprehensive understanding of resource allocation and cost distribution for each program or activity.

Advantages:

  1. Rational Framework for Decision Making: Program Budgeting provides a structured and rational framework for decision-making, ensuring that financial allocations align with the strategic goals of the health program.
  2. Cross-Functional Decision Making: It cuts across lines of responsibility, promoting collaborative decision-making that involves various departments and functions within the health program.
  3. Identification of Contradictions and Overlaps: Program Budgeting exposes contradictory or overlapping programs, allowing the health program to streamline its initiatives for better efficiency.
  4. Focus on Long-Term Effects: The method concentrates on the long-term effects of budget allocations, ensuring that resources are directed toward initiatives that contribute to sustained positive outcomes.
  5. Informed Decision Making: Program Budgeting provides valuable information on the likely impacts of alternatives, enabling the health program to make informed decisions based on comprehensive insights.
  6. Rational Choices through Cost-Benefit Analysis: It enables a rational choice through thorough cost-benefit analysis, ensuring that investments yield optimal returns in terms of program effectiveness.
  7. Identifying Overspending Areas: ABB helps the medical center identify areas of potential overspending by linking activities directly to costs, allowing for a more detailed financial analysis.
  8. Efficient Resource Allocation: The approach enables the medical center to allocate resources more efficiently, ensuring that each medical procedure or service is adequately funded based on its specific resource requirements.
  9. Setting Better Financial Goals: ABB allows for the setting of more precise financial goals, aligning budget allocations with the strategic objectives of the medical center.
  10. Progress Monitoring and Adjustments: The medical center can easily monitor its progress by assessing the budget against actual activities. This flexibility facilitates necessary adjustments to the budget in response to changing circumstances.

Disadvantages:

  1. Complex Process: Program Budgeting is considered a complicated process, requiring a deep understanding of the individual programs and financial implications.
  2. Limited Availability of Required Information: The information required for effective Program Budgeting may not always be readily available, potentially posing challenges in the decision-making process.
  3. Resource-Intensive: Implementing Program Budgeting may demand a significant amount of work, both in terms of data collection and analysis, making it resource-intensive.
  4. Centralization Requirement: Program Budgeting often needs a pyramidal structure for decisions to be taken at the top, potentially ignoring decentralization efforts within the health program.
  5. Time-Consuming and Resource-Intensive: Implementing ABB can be time-consuming and resource-intensive, requiring detailed assessments of various activities and their associated costs.
  6. Complexity and Specialized Training: Itmay be complex and necessitate specialized training for individuals responsible for creating and managing the budget. This can pose challenges in terms of understanding and implementation.
  7. Inflexibility in Plans: ABB may be inflexible and may not allow for changes in plans or activities as they occur, potentially limiting adaptability to unforeseen circumstances.
  8. Difficulty in Understanding and Using: The complexity of ABB can make it challenging for managers to understand and use the budget effectively, which may impact decision-making.

4. Value proposition budgeting: Value proposition budgeting, also known as priority-based budgeting, is an approach that focuses on analyzing and justifying the value of each item on an expenditure list. It involves reviewing costs and determining whether they contribute to the overall value and success of the company or hospital. By analyzing each cost item, value proposition budgeting helps identify areas where resources should be allocated to maximize value and eliminate unnecessary spending.

In a hospital setting, the management team is tasked with creating a budget for the upcoming fiscal year. With limited resources and increasing demands for healthcare services, they need a budgeting approach that ensures every dollar spent contributes to the hospital’s overall value proposition.

Advantages of Value Proposition Budgeting

  1. Rational Decision Making: Value proposition budgeting provides a rational framework for decision-making by focusing on the value created by each expenditure. This ensures that resources are allocated to initiatives that align with the hospital’s goals and objectives.
  2. Efficient Resource Allocation: By analyzing costs and determining their contribution to overall value, value proposition budgeting helps allocate resources more efficiently. This ensures that resources are directed towards activities that generate the highest return on investment for the hospital.
  3. Long-term Focus: Value proposition budgeting concentrates on the long-term effects of expenditures rather than short-term gains. This helps the hospital prioritize investments that will have a lasting impact on its success and sustainability.
  4. Cost-Benefit Analysis: Value proposition budgeting enables a cost-benefit analysis of each expenditure, allowing the hospital to assess whether the value derived from an activity justifies the cost incurred. This helps prevent unnecessary spending on low-value activities.
  5. Exposure of Contradictory Programs: Through the rigorous analysis of costs and value, value proposition budgeting exposes contradictory or overlapping programs within the hospital. This allows the management team to streamline operations and eliminate redundant activities.

Disadvantages of Value Proposition Budgeting

  1. Complex Process: Implementing value proposition budgeting can be a complex process, requiring significant time and resources to analyze and justify each expenditure. This complexity may deter some organizations from adopting this approach.
  2. Resource Intensive: Value proposition budgeting requires specialized training and expertise to effectively analyze costs and determine value. This may require additional resources and manpower, particularly for hospitals with limited financial capabilities.
  3. Inflexibility: The rigid focus on value may lead to inflexibility in budgetary decisions, overlooking important but intangible factors that contribute to the hospital’s success. This lack of flexibility may hinder the hospital’s ability to respond to changing market conditions or emerging opportunities.
  4. Difficulty in Understanding: Value proposition budgeting may be challenging for stakeholders, including staff and administrators, to understand and implement due to its complex nature. This could lead to resistance or reluctance to adopt this approach within the hospital.
  5. Limited Consideration of External Factors: Value proposition budgeting may overlook external factors such as changes in regulations or market conditions that could impact the hospital’s operations. This narrow focus may result in decisions that are not fully aligned with external realities.
limitations of budgeting

Limitations of Budgets and Budgeting:

  1. Inflexibility: Budgets are usually static and do not account for unforeseen circumstances or changes in business conditions. This can make it difficult to adapt to unexpected events or seize new opportunities.
  2. Time-Consuming: Budgeting is a time-intensive process that requires gathering data, analyzing trends, and making projections. This can divert resources away from other important activities.
  3. Inaccuracy: Budgets are based on estimates and assumptions, which can lead to inaccuracies. Actual results may deviate significantly from budgeted figures, making it difficult to assess performance and make informed decisions.
  4. Lack of Motivation: Budgets can be seen as constraints rather than motivators. Employees may become discouraged if they feel that their budgets are too restrictive or unrealistic.
  5. Political Bias: Budgets can be influenced by political or personal agendas, leading to decisions that may not be in the best interests of the organization.
  6. Limited Scope: Budgets do focus on financial aspects of the organization and may not consider other important factors such as market conditions, customer satisfaction, or employee morale.
  7. Over Reliance on Historical Data: Budgets often rely heavily on historical data, which may not be relevant in a rapidly changing environment. This can lead to outdated assumptions and missed opportunities.
  8. Lack of Accountability: If budgets are not properly monitored and enforced, they may become ineffective and fail to achieve their intended purpose.
  9. Budgetary Slack: Employees may intentionally overestimate expenses or underestimate revenues to create a buffer for unexpected events. This can lead to inefficiencies and wasted resources.
  10. Lack of Innovation: Budgets can discourage innovation by limiting resources for new initiatives or experimental projects. This can stifle creativity and hinder the organization’s ability to stay competitive.
  11. Too few controllers and owners: Budgets may be controlled by a small number of individuals, leading to a lack of ownership and accountability.
  12. Lack of good estimating: Budgets may be based on poor estimates, leading to inaccuracies and missed opportunities.
  13. Based more on history rather than needs: Budgets may be based on historical data rather than current needs and priorities.

Conditions Necessary for Successful Budgeting:

  1. Involvement and support of top management: Top management must be actively involved in the budgeting process and must demonstrate their support for the budget. This includes setting clear expectations, providing resources, and holding managers accountable for achieving their budget targets.
  2. Clearly stated objectives: The budget should be aligned with the organization’s long-term strategic objectives. These objectives should be clearly defined and communicated to all employees.
  3. Genuine and full involvement of managers: Line managers are responsible for implementing the budget and achieving the desired results. They must be fully involved in the budgeting process and must have a say in setting targets and allocating resources.
  4. An appropriate accounting and information system: The accounting and information system should provide accurate and timely data to support the budgeting process. This includes data on revenues, expenses, assets, and liabilities.
  5. Framework for regular revision of budgets and targets: Budgets should be reviewed and revised regularly to reflect changes in the business environment and the organization’s priorities. This ensures that the budget remains relevant and achievable.
  6. Flexibility in the administration of budgets: Budgets should be flexible enough to accommodate unforeseen events and changing circumstances. This may involve adjusting targets or reallocating resources as needed.
  7. Effective communication: The budget should be communicated clearly and effectively to all employees. This helps to ensure that everyone understands their role in achieving the budget targets.
  8. Training and development: Employees should be provided with training and development opportunities to help them understand the budgeting process and to develop the skills needed to effectively manage their budgets.
  9. Performance evaluation: Performance evaluations should be based on budget targets and achievements. This helps to hold employees accountable for their performance and to identify areas for improvement.
  10. Continuous improvement: The budgeting process should be continuously improved to ensure that it is effective and efficient. This may involve seeking feedback from employees and making adjustments as needed.
  11. Reward and recognition: Employees who achieve or exceed their budget targets should be rewarded and recognized. This helps to motivate employees and to reinforce the importance of budgeting.
accountability

ACCOUNTABILITY

Accountability refers to the responsibility and obligation of individuals or entities to justify and take ownership of their financial activities and decisions. 

 

It involves ensuring that financial resources are used efficiently, effectively, and in accordance with established policies, regulations, and ethical standards.

Key Financial Records in Financial Management

  1. Cash and bank books: These records track all cash and bank transactions, including deposits, withdrawals, and balances. They provide a detailed account of the facility’s cash flow and are essential for reconciling bank statements.
  2. Budget: The budget outlines the facility’s planned revenue and expenditure for a specific period, typically a year. It serves as a financial roadmap and helps managers allocate resources effectively.
  3. Cheques: Cheques are used to make payments to suppliers, staff, and other parties. They provide a secure and traceable method of transferring funds.
  4. Requisition forms: Requisition forms are used to request the purchase of goods or services. They typically include details such as the item being requested, the quantity, and the estimated cost.
  5. Vote books: A vote book is a memorandum accounts book intended to track government expenditures and verify that no money is spent outside of the budget. Vote books are used to track expenditure against specific budget lines. They help managers monitor spending and ensure that funds are being used as intended.
  6. Invoices: Invoices are issued to patients and other payers for services rendered. They provide a detailed breakdown of the charges and are used to track revenue.
  7. Payment receipts: Payment receipts are issued to patients and other payers upon receipt of payment. They serve as proof of payment and are used to reconcile revenue.
  8. Payroll records: Payroll records track employee salaries, benefits, and deductions. They are used to calculate payroll expenses and ensure that employees are paid accurately and on time.
  9. Inventory records: Inventory records track the quantity and value of medical supplies, equipment, and other assets on hand. They help managers optimize inventory levels and prevent overstocking or shortages.
  10. Financial statements: Financial statements, such as the balance sheet and income statement, provide a comprehensive overview of the facility’s financial position and performance. They are used for financial reporting, analysis, and decision-making.

Receipt Book

A receipt is a formal record of the transfer of money from one person to another. It serves as proof that money has been paid for a service or goods.

Importance of Receipts:

  • Proof of purchase: Receipts serve as evidence that a transaction has taken place. They provide proof of purchase, which can be useful for returns, exchanges, or warranty claims.
  • Expense tracking: Receipts help individuals and businesses track their expenses. By keeping receipts, you can accurately record and categorize your spending, making it easier to manage your budget and track your financial health.
  • Tax deductions: Receipts are crucial for claiming tax deductions. They provide documentation for deductible expenses, such as business expenses, medical expenses, or charitable donations. Without receipts, it may be challenging to prove these deductions to tax authorities.
  • Reimbursement: Receipts are often required for reimbursement purposes. Whether it’s for business expenses or personal reimbursements, having receipts ensures that you can provide evidence of the expenses incurred.
  • Warranty and insurance claims: Receipts are necessary for warranty and insurance claims. If a product needs repair or replacement under warranty, the receipt serves as proof of purchase. Similarly, for insurance claims, receipts can help substantiate the value of lost or damaged items.
  • Budgeting and financial planning: Receipts play a vital role in budgeting and financial planning. By keeping track of your expenses through receipts, you can analyze your spending patterns, identify areas where you can save money, and make informed decisions about your financial goals.
  • Audit and compliance: Receipts are essential for audit and compliance purposes. They provide documentation and support for financial transactions, ensuring transparency and accountability.

Storage of Receipts:

  • Receipts should be filled out in duplicate. The original is given to the person giving the money.
  • The duplicate remains in the receipt book and is used for financial reconciliation purposes.

Handling Partial Payments:

  • If a person cannot pay the full amount, they should be given a receipt for the amount paid, and the remaining balance should be recorded in the Debtors’ Book.

Cash Analysis Book/Cash book

A Cash Analysis Book is used to record income and expenditure, showing money received and spent.

Purpose:

  • Efficient cash management: The Cash Analysis Book allows businesses to effectively manage their cash by providing a clear record of all cash transactions. 
  • Budgeting and financial planning: Cash Analysis Book helps businesses create budgets and financial plans. It helps in forecasting future cash flows, setting financial goals, and ensuring that the organization is living within its means.
  • Financial reporting and compliance: The Cash Analysis Book serves as a reliable source of information for financial reporting and compliance purposes. It provides accurate records of cash transactions, which are necessary for preparing financial statements, tax returns, and other regulatory requirements.
  • Cash flow analysis: The Cash Analysis Book enables businesses to analyze their cash flow patterns over time,  assess the timing of cash receipts and payments, and make adjustments to improve cash flow management.
  • Internal control and fraud prevention: Maintaining a Cash Analysis Book helps in establishing internal controls and preventing fraudulent activities, making it easier to detect unauthorized cash withdrawals or discrepancies in cash balances.
  • Decision-making support: The Cash Analysis Book provides valuable financial information that can be used to make informed decisions,  businesses can identify areas where costs can be reduced, revenue can be increased, or investments can be made.

Categories in Cash Analysis Book:

  • IN (Income) categories include Inpatient User Charges, User Charges, Debt Recovery, Subventions, Medicines, Maternity.
  • OUT (Expenditure) categories cover Allowances, Functional expenses, Equipment and Maintenance, and Others.

Bank Deposits and Withdrawal forms

Bank deposit and withdrawal forms are used to deposit or withdraw money from the bank. They must be filled out accurately to reflect the transaction details.

Local Bank Statement: Provided by the bank, it summarizes the account’s transactions.

Bank Reconciliation: Compares transactions recorded in the Cash Analysis Book with those on the bank statement.

Quarterly Financial Report: Quarterly Financial Report summarizes monthly financial data copied into it at the end of each quarter.

Petty Cash Book: Petty cash (imprest) is a small amount of money kept for minor purchases, managed through a Petty Cash Book.

Petty Cash Requisition Voucher: Used to record petty cash expenditures, each voucher is numbered and filled out sequentially. Expenditures must be supported by receipts, and any balance should be noted for reconciliation.

 

MANAGING PETTY CASH

Managing money in a healthcare setting is handled by accountants or finance officers. However, in smaller health units like health centers, sometimes healthcare workers may need to manage the spending of money, known as petty cash.

Types of Money:

  1. Invisible Money (Budgetary Allocation): This is money allocated for specific purposes, such as purchasing drugs or equipment. It’s not physically handled but requires record-keeping.
  2. Visible Money (Cash or Petty Cash): This is physical money given to health workers for day-to-day expenses like transportation or minor purchases. It’s called petty cash and is kept in small amounts to minimize the risk of theft.

Keeping Track of Invisible Money:

An allocations ledger is used to record the spending of invisible money. This ledger details the allocated amount, purpose, and references to documents confirming the allocation. It helps ensure that money is spent only for its intended purpose.

Advantages of Allocations Ledger:

Advantages

Disadvantages

Helps track spending for specific purposes

Requires meticulous record-keeping

Ensures accountability and transparency

Time-consuming process

Using Petty Cash (Visible Money):

Petty cash, or small amounts of cash, is used for minor expenses that cannot be covered by allocations. The imprest system is commonly used to manage petty cash. In this system, a fixed amount of cash is given and replenished as needed, ensuring accountability.

Suppose that a health in charge (worker) is given an imprest of 40,000shs. He finds his office supplies are low, so he buys some stationery (carbon paper, paper clips, stamps, glue) all in one week. He spends a total of 30,000= leaving an unspent balance of 10,000=.

He then takes his receipts and petty cash book to his finance officer, who will give him 30,000= in cash to make the imprest up to 40,000= again. The imprest is now replenished. It may now take several weeks before he uses all the office supplies he bought, so that he may not need to replenish the imprest for a month or more.

Advantages of Imprest System:

Advantages

Disadvantages

Ensures accountability and control of petty cash

Requires careful documentation

Facilitates quick and small transactions

Risk of theft or misuse if not properly managed

Recording Petty Cash Transactions:

Petty cash transactions are recorded using petty cash vouchers. These vouchers detail the items purchased, amounts spent, and are accompanied by receipts. There are two methods of keeping petty cash records: the simple petty cash book and the columnar petty cash book.

Advantages of Petty Cash Vouchers:

Advantages

Disadvantages

Provides a record of petty cash transactions

Requires consistent and careful documentation

Prevents misuse of funds

  

Summary:

i. Financial documents such as proforma invoice, tax invoice, receipt, petty cash voucher, simple cash book, and columnar cash book are essential for managing healthcare finances. Each serves a specific purpose in tracking expenses and maintaining financial records.

ii. The two types of money used in a healthcare facility are invisible money (budgetary allocations) and visible money (petty cash).

iii. The imprest system involves providing a fixed amount of cash for petty expenses, which is replenished as needed, ensuring proper management and accountability.

FINANCIAL MANAGEMENT, BUDGETING & ACCOUNTABILITY Read More »

ASSESS AND CLASSIFY A SICK YOUNG INFANT 0-2 MONTHS

ASSESS AND CLASSIFY A SICK YOUNG INFANT 0-2 MONTHS

ASSESS AND CLASSIFY A SICK YOUNG INFANT 0-2 MONTHS

Young infants have special characteristics which must be considered when classifying their illness. They can become sick and die very quickly from serious bacterial infection but which may manifest themselves through general signs e.g. reduced movements, fever or even hypothermia, failure to breastfeed etc.

IMNCI PROCESS FOR THE SICK YOUNG INFANT

1. GREET THE CAREGIVER

ASK: Child’s age 

ASK : What are the infant’s problems?

ASK: Initial or follow-up visit for problems?

MEASURE: Weight and temperature

2. CHECK FOR
  • Possible serious bacterial infection (PSBI) or very severe disease
  • Pneumonia
  • Local Infection

All with severe disease require URGENT referral

3. ASSESS FOR MAIN SYMPTOMS

MAIN SYMPTOMS

  • Jaundice
  • Diarrhea
  • Feeding problem or LOW WEIGHT FOR AGE
  • Possible HIV INFECTION,
  • TB EXPOSURE
4. CLASSIFY

URGENT REFERRAL REQUIRED

• IDENTIFY and give pre-referral treatment

• URGENTLY REFER

TREAT IN CLINIC

• IDENTIFY TREATMENT

• TREAT

• COUNSEL caretaker

• FOLLOW-UP CARE

TREAT AT HOME

• IDENTIFY TREATMENT

• COUNSEL caretaker on home treatment

• FOLLOW-UP CARE

Signs of severe disease

  1. Not feeding.

  2. Severe chest indrawing or Fast breathing.

  3. Convulsions.

  4. No movement/Lethargy.

  5. Temperature too high or too low.

ASSESS, CLASSIFY AND TREAT THE YOUNG INFANT

DO QUICK ASSESSMENT OF ALL SICK YOUNG INFANTS BIRTH UP TO 2 MONTHS*

ASK THE MOTHER WHAT THE YOUNG INFANT’S PROBLEMS ARE

  • Determine if this is an initial or follow-up visit for this problem
  • If initial visit, assess the child and classify as follows:

pneumonia

CHECK FOR POSSIBLE SERIOUS BACTERIAL INFECTION OR VERY SEVERE DISEASE, PNEUMONIA AND LOCAL INFECTION

ASSESS:

ASK

LOOK, LISTEN AND FEEL

  • Is the infant having difficulty in feeding?
  • Has the infant had convulsions (fits) or twitching?

 

ASK and LOOK: 

  • Is the infant not able to feed or breastfeed? 
  • Is there blood in the stool?
  • Look for breathing: is the baby gasping or not breathing at all even when stimulated 
  • Count the breaths in one minute. Repeat the count if elevated. 
  • Look for severe chest indrawing
  • Look and listen for grunting or wheezing. 
  • Look for nasal flaring.
  • Look for central cyanosis and pulse oximetry where available 
  • Look and feel for bulging anterior fontanelle. 
  • Look at the umbilicus. Is it red or draining pus? Look for severe abdominal distension. Measure axillary temperature (or feel for fever or low body temperature) 
  • Look for skin pustules. 
  • Look For high pitched cry.
  • Look at the young infant’s movements

(Young infant must be Calm)

 

CLASSIFY AND IDENTIFY TREATMENT

SIGNS

CLASSIFY AS

IDENTIFY TREATMENT

Any of the following signs:

  • Respiratory rate less than 20 breaths per minute or 
  • Convulsions or convulsing now or
  • Not able to feed or breastfeed or 
  • Fast breathing (more than 60 breaths per minute) or 
  • Severe chest indrawing or
  • Grunting or wheezing or
  • Nasal flaring or
  • Bulging anterior fontanelle or 
  • Pus draining from the ear or 
  • Fever (37.5º C* or above or feels hot) or 
  • Very low body temperature (less than 35.5º C* or Feels cold) or 
  • Movement only when stimulated or 
  • No movements at all. 
  • Blood in stool.
  • Severe abdominal distension
  • High pitched cry 
  • Oxygen saturation <90%

POSSIBLE

SERIOUS

BACTERIAL

INFECTION

OR VERY

SEVERE

DISEASE

• Immediately resuscitate using a bag and mask if the baby: 

 – Is gasping or not breathing

– Has a respiratory rate less than 20 breaths per minute 

• If convulsing now, give Phenobarbitone  

• Give the first dose of Benzylpenicillin & Gentamicin. 

• Treat to prevent low blood sugar 

• Admit or refer URGENTLY to hospital**

 • Advise mother how to keep the infant warm on the way to the hospital. 

• Screen for possible TB disease and check for HIV 

• If oxygen saturation is less than 90%, start oxygen therapy and refer or admit 

• IF REFERRAL NOT POSSIBLE (see pg 37)

  • Red umbilicus or draining pus or 
  • Skin pustules. And none of the signs of very severe disease

LOCAL

BACTERIAL

INFECTION

• Give Flucloxacillin Syrup

• Teach the mother to treat local infections at home.

• Advise mother to give home care for the young infant. 

• Follow-up in 2 days 

• Screen for possible TB disease and check for HIV. 

• Advise mother when to return immediately

  • Fast breathing (60 breaths per minute or more) in infants 7 to 59 days old

PNEUMONIA

• Give amoxicillin for 7 days

• Advise mother to give home

care for the young infant

• Follow up on day 4 of treatment

  • Temperature between 35.5ºC to 36.4ºC

LOW BODY

TEMPERATURE

• Re-warm the young infant and reassess after 1 hour. (kangaroo warming)

• Treat to prevent low blood sugar

• Advise mother to give home care for the young infant 

• Advise mother when to return immediately

None of the signs of Very Severe Disease or Local Bacterial Infection

INFECTION

UNLIKELY

• Advise mother to give home care for the young infant

• Screen for possible TB disease and check for HIV. 

• Advise mother when to return immediately.

JAUNDICE

THEN CHECK FOR JAUNDICE

Physiological Jaundice:

  • Physiological jaundice emerges between 48 to 72 hours after birth.
  • It reaches its peak intensity on days 4 and 5 in term babies and day 7 in preterm infants.
  • Generally, it disappears by day 14.
  • Physiological jaundice does not extend to the palms and soles, requiring no treatment.
  • If jaundice appears on the first day, persists for 14 days or more, and extends to palms and soles, it is considered severe jaundice and demands urgent attention.

Pathological Jaundice:

  • Jaundice onset within the first day of life characterizes pathological jaundice.
  • It lasts longer than 14 days in term infants and 21 days in preterm infants.
  • Jaundice accompanied by fever raises concerns.
  • Deep jaundice, where the palms and soles of the baby exhibit a profound yellow hue, signifies a more severe condition.
ASSESS JAUNDICE 

ASK

LOOK

  • Does the young infant have yellow discoloration of eyes, palms or soles? 
  • If yes, for how long?
  • Look for jaundice (yellow eyes or skin) 
  • Look at the young infants’ palms and soles. Are they yellow?

Classify Jaundice

SIGNS

CLASSIFY AS

IDENTIFY TREATMENT

  • Any jaundice if age less than 24 hours or 
  • Yellow eyes, palms and soles at any age 
  • Any visible yellowness in a pre-term baby regardless of when it appears

 

SEVERE

JAUNDICE

• Treat to prevent low blood sugar: 

• Refer URGENTLY to the hospital.

• Advise mother how to keep the infant warm on the way or the Hospital.

• Screen for possible TB disease

  • Yellowness appearing after 24 hours of age 
  • Yellowness in the eyes & skin 
  • Palms and Soles NOT yellow

JAUNDICE

• Advise the mother to give home care for the young infant.  

• Advise mother to return immediately if eyes, palms and soles appear yellow 

• If young infant older than 14 days refer to hospital for assessment.

• Follow up in 1 day

  • No jaundice

JAUNDICE

Advise mother to give home care for the young infant

 

Diarrhoea

THEN ASSESS FOR DIARRHOEA

ASK

LOOK

DOES THE YOUNG INFANT HAVE DIARRHOEA OR SIGNS OF DEHYDRATION?  IF YES ASK: 

  • For how long? 
  • Does the child have diarrhoea? 
  • Is the child vomiting? 
  • Is the child able to feed?

* What is diarrhoea in a young infant?

A young infant has diarrhoea if the stools have changed from usual pattern and are many and watery (more water than faecal matter).

The normally frequent or semi-solid stools of a breastfed baby are not diarrhoea.

Infants Movements 

• Does the infant move on his/her own? 

• Does the infant move even when stimulated but then stops? 

• Does the infant not move at all? 

• Is the infant restless and irritable? • Look for sunken eyes. 

Pinch the skin of the abdomen. 

Does it go back: 

• Very slowly (longer than 2 seconds)? 

• Slowly? 

• Immediately? 

• Assess the young infant’s ability to feed

• Assess the young infant’s urine output

Classify for DEHYDRATION

SIGNS

CLASSIFY AS

IDENTIFY TREATMENT

Two of the following signs: 

  • Movement only when stimulated or no movement at all. 
  • Sunken eyes 
  • Skin pinch goes back very slowly 
  • Child not passing urine.
  • Child not able to feed.

SEVERE

DEHYDRATION

If infant has no other severe classification: 

• Give fluid for severe dehydration (Plan C) OR If infant also has another severe classification: 

• Admit/Refer URGENTLY to hospital with mother or caregiver giving frequent sips of ORS on the way

• Advise mother to continue breast feeding. 

• If child is not passing urine admit/refer urgently to hospital. 

• If child is not able to feed, admit/refer urgently to hospital.

Two of the following signs: 

  • Restless and irritable 
  • Sunken eyes 
  • Skin pinch goes back slowly.

SOME DEHYDRATION

• Give fluid and breast milk for some dehydration (Plan B) 

• Advise mother when to return immediately

• Follow-up in 2 days if not improving

• If infant also has VERY SEVERE CLASSIFICATION 

• Admit/Refer URGENTLY to hospital** with the mother giving frequent sips of ORS on the way if child has diarrhoea.

• Advise mother to continue breast feeding 

• Follow-up in 3 days if not improving

Not enough signs to classify as some or severe dehydration.

NO DEHYDRATION

• Give fluids to treat diarrhoea at home and continue breast feeding at home (Plan A)

• Give ORS and Zinc sulphate if child has diarrhoea

• Advise mother when to return immediately 

• Follow-up in 2 days if not improving.

 

CHECK FOR HIV EXPOSURE AND INFECTION

ASK

• Has the mother and/or young infant had an HIV test? IF YES: 

• What is the mother’s HIV status?: 

  •  Antibody test is POSITIVE 
  • Antibody test is NEGATIVE 

If mother is HIV positive and NO positive DNA PCR test in child ASK: 


Is the mother on ART and young infant on ARV prophylaxis? 


IF NO TEST:

Mother and young infant status unknown

Perform HIV test for the mother: 

If positive, perform DNA PCR test for the young infant 


IF the mother is NOT available, do an antibody test on the child. 

If positive, do a DNA PCR test.

CLASSIFY HIV STATUS

SIGNS

CLASSIFY AS

IDENTIFY TREATMENT

  • POSITIVE DNA PCR test in young infant

CONFIRMED

HIV

INFECTION



• Initiate ART, counsel and follow up existing infections 

• Initiate Cotrimoxazole prophylaxis

• Assess child’s feeding and provide appropriate counseling to the mother/ caregiver 

• Advise the mother on home care 

• Offer routine follow up for growth, nutrition and development 

• Educate caregivers on adherence and its importance

• Screen for possible TB disease at every visit. 

• For those who do not have TB disease, start Isoniazid prophylactic therapy (IPT). Screen for possible TB disease throughout IPT 

• Immunize as per schedule 

• Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive HIV care of the child.

  • Mother HIV positive and negative DNA PCR in young infant. 

OR 

  • Mother HIV positive, young infant not yet tested. 

OR 

  • Positive antibody test in young infant whose mother is not available

HIV EXPOSED

• Treat, counsel and follow up existing infections 

• Initiate Cotrimoxazole prophylaxis 

• Start or continue PMTCT* prophylaxis as per the national recommendations 

• Assess child’s feeding and provide appropriate counseling to the mother/caregiver

• Advise the mother on home care

• Offer routine follow up for growth, nutrition and development 

• Screen for possible TB disease at every visit 

• Immunize as per schedule

• Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive care of the child.

Mother’s antibody test is NEGATIVE

HIV NEGATIVE

• Manage presenting conditions according to IMNCI and other recommended national guidelines 

• Advise the mother about feeding and about her own health.

 

THEN CHECK FOR TB

ASK

LOOK AND FEEL

For symptoms suggestive of TB

• Has the young infant had contact with a

person with Pulmonary Tuberculosis or chronic cough?

• Has the young infant had persistent fevers for 14 days or more?

• Does the young infant have pneumonia which is not responding to standard therapy?

• Has the young infant been coughing for 14 days or more?

Look or feel for physical signs of TB

• Determine weight for age

– Weight less than 1.5kg?

– Weight for age less than -3 Z score?

SIGNS

CLASSIFY AS

IDENTIFY TREATMENT

Presence of ANY of the symptoms and signs suggestive of TB OR weight less than 1.5kg or 3Z score with any symptom.


PRESUMPTIVE

TB



• Refer to hospital for further

assessment and management

• Ask about the caregiver’s health and treat as necessary

A sick young infant with no TB symptoms or signs

NO

PRESUMPTIVE

TB

• Treat, counsel, and follow up

existing infections

• Ask about the caregiver’s health and treat as necessary

THEN CHECK FOR FEEDING PROBLEM OR LOW WEIGHT FOR AGE IN BREASTFED INFANTS

ASK

LOOK AND FEEL

Is the infant breastfed? If yes, how many times in 24 hours? 

 

Does the infant usually receive any other foods or drinks? 

 

If yes, how often? If yes, what do you use to feed the infant?

Determine weight for age. 

– Weight less than 1.5 kg?

– Weight for age less than

-3 Z score?

 

Look for ulcers or white patches in the mouth (thrush).

ASSESS BREASTFEEDING:

• Has the infant breast-fed in the previous hour?

• If the infant has not fed in the previous hour, ask the mother to put her infant to the breast. Observe the breastfeed for 4 minutes. 

• (If the infant was fed during the last hour, ask the mother if she can wait and tell you when the infant is willing to feed again.)

 

• Is the infant well attached?

-not well attached? -good attachment?

 

TO CHECK ATTACHMENT, LOOK FOR:

– More areola seen above infant’s top lip than below bottom lip

– Mouth wide open

– Lower lip turned outwards

– Chin touching breast

(All of these signs should be present if the attachment is good).

• Is the infant suckling effectively (that is, slow deep sucks, sometimes pausing)?

-not suckling effectively? -suckling effectively?

• Clear a blocked nose if it interferes with breastfeeding.

 Classify all FEEDING

 

SIGNS

CLASSIFY AS

IDENTIFY TREATMENT

• Weight

< 1.5 kg, or

• Weight

< -3 Z score

VERY LOW

WEIGHT

• Treat to prevent low blood sugar.

• Refer URGENTLY to hospital.

• Teach the mother to keep the young infant warm on the

way to hospital

• Check for HIV

• Not well attached

to breast or

• Not suckling

eectively, or

• Less than 8

breastfeeds in 24

hours, or

• Receives other

foods or drinks, or

• Low weight for

age, or

• Thrush (ulcers or

white patches in

mouth)

FEEDING

PROBLEM

and/or

LOW

WEIGHT

FOR AGE

• If not well attached or not suckling effectively, teach

correct positioning and attachment.

– If not able to attach well immediately, teach the mother

to express breastmilk and feed by a cup

• If breastfeeding less than 8 times in 24 hours, advise to

increase frequency of feeding. Advise the mother to breastfeed as often and for as long as the infant wants, day

and night.

• If receiving other foods or drinks, counsel mother about

breastfeeding more, reducing other foods or drinks, and

using a cup.

• If not breastfeeding at all:

– Refer for breastfeeding counselling and possible

relactation.

– Advise about correctly preparing breastmilk substitutes and using a cup.

• Check for TB

• Advise the mother how to feed and keep the low weight

infant warm at home

• If thrush, teach the mother how to treat thrush at home.

• Advise mother to give home care for the young infant.

• Follow up FEEDING PROBLEM or thrush on day 3.

• Follow up LOW WEIGHT FOR AGE on day 14.

• Not low weight for age and no other signs of inadequate feeding

NO FEEDING PROBLEM

• Advise mother to give home care for the young infant.

• Praise the mother for feeding the infant well.

THEN CHECK THE YOUNG INFANT‘S IMMUNIZATION STATUS

Age

Vaccine

Birth*

BCG

 

bOPV-0

6 Weeks

bOPV-1

 

DPT / HepB / Hib -1

PCV 10-1

ROTA 1

  • Give all missed doses on this visit. 
  • Immunize sick infant unless being reffered
  • Include sick babies and those without a mother child health booklet. 
  • If the child has no booklet, issue a new one today. 
  • Advise the mother when to return for the next dose.

Assess the child’s growth and development milestones

• Plot the child’s weight on his/her growth card (child health card or mother baby passport)

• Ask mother about what the child is now able to do in terms of physical movement,

communication and interaction.

Assess the Child for ECD / other problems including Congenital Malformations

Ask mother for any other problem or identified external malformations

• Check child for any external malformations and abnormal signs

• Refer infant to hospital, if they have any external malformations


ECD-Early Childhood Development

Assess the Mother’s Health Needs

• Check if had full course of tetanus toxoid, if not,

give an appointment.

• Ask if pregnant , if so give an antenatal appointment. If not, ask if interested to talk

about family planning.

• Ask if RCT has been done and the results.

• If mother is an adolescent, link to appropriate clinic or service provider for support.

TREAT THE YOUNG INFANT

1. Give First Doses of Intramuscular Gentamicin and Intramuscular Ampicillin

– Gentamicin: Give 5 mg/kg/day in once daily injection. 

In low birthweight (<2.5kg) infants, give 4 mg/kg/day in once daily injection. 

To prepare the injection: From a 2 ml vial containing 40 mg/ml, remove 1 ml gentamicin from the vial and add 1 ml distilled water to make the required strength of 20 mg/ml.

– Ampicillin: Give 50mg/kg IM

* If referral is not possible, continue treatment for seven days

2. Prevent Low Blood Sugar

– If the young infant is able to breastfeed: Ask the mother to breastfeed the young infant.

– If the young infant is not able to breastfeed but is able to swallow: Give 20–50 ml (10 ml/kg) expressed breastmilk before departure. 

If not possible to give expressed breastmilk, give 20–50 ml (10 ml/kg) sugar water. (To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean water.)

– If the young infant is not able to swallow: Give 20–50 ml (10 ml/kg) of expressed breastmilk or sugar water by nasogastric tube.

3. Keep the Young Infant Warm on the Way to the Hospital

– Provide skin-to-skin contact, OR

– Keep the young infant clothed or covered as much as possible all the time, especially in a cold environment. Dress the young infant with extra clothing, including a hat, gloves, and socks. Wrap the infant in a soft dry cloth and cover with a blanket.

4. Refer Urgently

– Write a referral note for the mother to take to the hospital.

– If the infant also has SOME DEHYDRATION OR SEVERE DEHYDRATION and is able to drink: Give the mother some prepared ORS and ask her to give frequent sips of ORS on the way. Advise the mother to continue breastfeeding.

– Use the appropriate plan, A, B or C.

5. How to Give Oral Medicines at Home

– Follow the instructions below to teach the mother about each oral medicine to be given at home. Also, follow the instructions listed with each medicine’s dosage table.

– Determine the appropriate medicines and dosage for the infant’s age or weight.

– Tell the mother the reason for giving the medicine to the infant.

– Demonstrate how to measure a dose.

– Watch the mother practice measuring a dose by herself.

– Ask the mother to give the dose to her infant.

– Explain carefully how to give the medicine, then label and package the medicine.

– If more than one medicine will be given, collect, count, and package each medicine separately.

– Explain that all the tablets or syrups must be used for the course of treatment, even if the infant gets better.

– Check the mother’s understanding before she leaves the clinic.

6. Give Oral Amoxicillin

* Local Infection: Give oral amoxicillin twice daily for 5 days

* Pneumonia (fast breathing alone) in infant 7–59 days old: Give oral amoxicillin twice daily for 7 days

AMOXICILLIN Desired range is 75 to 100 mg/kg/day divided into 2 daily oral doses. Give twice daily

WEIGHT(kg)

Dispersible Tablet 

(250 mg) Per Dose

Dispersible Tablet 

(125 mg) Per Dose

Syrup

(125 mg in 5 ml) Per dose

1.5 to 2.4

1/2 tablet

1 tablet

5 ml

2.5 to 3.9 

1/2 tablet

1 tablet

5 ml

4.0 to 5.9 

1 tablet

2 tablets

10 ml

 

COUNSEL THE MOTHER 

TEACH THE CAREGIVER TO TREAT LOCAL INFECTIONS AT HOME

Follow the instructions below for every oral drug to be given at home. Also, follow the instructions listed with each drug’s dosage table.

  • Explain how the treatment is given.
  • Observe as the first treatment is administered in the clinic.
  • In case of worsening infection, the caregiver should return to the clinic.
  • Confirm the mother’s understanding before leaving the clinic.

TO TREAT SKIN PUSTULES OR UMBILICAL INFECTION

Apply Gentian Violet twice daily for 5 days.

The mother should:

  • Wash hands.
  • Gently cleanse pus and crusts with soap and water.
  • Dry the area.
  • Apply Gentian Violet.
  • Wash hands.
  • Administer oral antibiotics: Flucloxacillin and Ampicillin.

TO TREAT THRUSH (WHITE PATCHES IN MOUTH) OR MOUTH ULCERS

The mother should:

  • Wash hands.
  • Cleanse the mouth with a clean, soft cloth soaked in saltwater.
  • Administer Nystatin.
  • Wash hands.

If breastfed, advise the mother to wash her breast after feeds and apply the same medicine on the areola.

TREAT EYE INFECTION WITH TETRACYCLINE EYE OINTMENT

  • Clean both eyes 3 times daily for 5 days.
  • Wash hands.
  • Gently wipe away pus with a clean cloth and water.
  • Apply tetracycline eye ointment in both eyes 3 times daily.
  • Open the eyes of the young infant.
  • Squirt a small amount of ointment on the inside of the lower lid.
  • Wash hands again.
  • Continue treatment until redness is gone.
  • Do not use other eye ointments or drops, or put anything else in the eye.

TEACH THE MOTHER/CAREGIVER TO GIVE ORAL DRUGS AT HOME

Follow the instructions below for every oral drug to be given at home. Also, follow the instructions listed with each drug’s dosage table.

  • Determine the appropriate drugs and dosage for the child’s age or weight.
  • Explain the reason for giving the drug to the child.
  • Demonstrate how to measure a dose.
  • Observe the mother/caregiver practicing measuring a dose.
  • Request the mother/caregiver to give the first dose to the child.
  • Explain carefully how to administer the drug, then label and package the drug.
  • If more than one drug will be given, collect, count, and package each drug separately.
  • Emphasize that all oral drug tablets or syrups must be used to finish the course of treatment, even if the child improves.
  • Confirm the mother’s/caregiver’s understanding before they leave the clinic.
baby-attaching-breast

TEACH CORRECT POSITIONING AND ATTACHMENT FOR BREASTFEEDING

Demonstrate how to hold the infant:

  • With the infant’s head and body straight.
  • Facing her breast, with the infant’s nose opposite her nipple.
  • With the infant’s body close to her body.
  • Supporting the infant’s whole body, not just the neck and shoulders.

Show how to help the infant attach:

  1. Touch the infant’s lips with her nipple.
  2. Wait until the infant’s mouth is wide open.
  3. Move the infant quickly onto her breast, aiming the infant’s lower lip well below the nipple.
  • Look for signs of good attachment and effective suckling. If not achieved, try again.
  • If still ineffective, ask the mother to express breast milk and feed with a cup and spoon in the clinic.
  • If able to feed with a cup and spoon, advise the mother to continue breastfeeding and express breast milk after each feed.
  • If not able to feed with a cup and spoon, refer to the hospital.

TEACH THE MOTHER TO TREAT BREAST OR NIPPLE PROBLEMS

  • If the nipple is flat or inverted, evert the nipple several times with fingers before each feed and put the baby on the breast.
  • If the nipple is sore, apply breast milk for a soothing effect and ensure correct positioning and attachment. If discomfort persists, feed expressed breast milk with a cup and spoon.
  • If breasts are engorged, let the baby continue to suck if possible. If the baby cannot suckle effectively, help the mother express milk and then put the young infant to the breast. Applying warm compresses on the breast may help.
  • If breasts develop an abscess, advise the mother to feed from the other breast and refer. If the young infant needs more milk, provide appropriate formula.
TEACH THE MOTHER HOW TO KEEP THE YOUNG INFANT WITH LOW WEIGHT OR LOW BODY TEMPERATURE WARM A

TEACH THE MOTHER HOW TO KEEP THE YOUNG INFANT WITH LOW WEIGHT OR LOW BODY TEMPERATURE WARM AT HOME:

  • Avoid bathing the young infant with low weight or low body temperature; instead, sponge with lukewarm water to clean (in a warm room).
  • Promote skin-to-skin contact (Kangaroo mother care) as much as possible, day and night.
  • When not in skin-to-skin contact or if this is not possible:
  1. Warm the room (>25°C) with a home heater.
  2. Clothe the young infant in 3-4 layers of warm clothes, cover the head with a cap (include gloves and socks), and wrap him/her in a soft dry cloth, and cover with a warm blanket or shawl.
  3. Let the baby and mother lie together on a soft, thick bedding.
  4. Change clothes (e.g., napkins) whenever they are wet.

  • Periodically feel the feet of the baby—baby’s feet should always be warm to touch.

1. Correct Positioning and Attachment for Breastfeeding

Show the mother how to hold her infant:

  • With the infant’s head and body in line.
  • With the infant approaching the breast with the nose opposite to the nipple.
  • With the infant held close to the mother’s body.
  • With the infant’s whole body supported, not just the neck and shoulders.

Show her how to help the infant attach:

  • Touch her infant’s lips with her nipple.
  • Wait until her infant’s mouth is opening wide.
  • Move her infant quickly onto her breast, aiming the infant’s lower lip well below the nipple.
  • Look for signs of good attachment and effective suckling. If attachment or suckling is not good, try again.

2. How to Feed by a Cup

  • Put a cloth on the infant’s front to protect his clothes as some milk can spill.
  • Hold the infant semi-upright on the lap.
  • Hold the cup so that it rests lightly on the infant’s lower lip.
  • Tip the cup so that the milk just reaches the infant’s lips.
  • Allow the infant to take the milk himself. DO NOT pour the milk into the infant’s mouth.

3. How to Express Breastmilk

Ask the mother to:

  • Wash her hands thoroughly.
  • Make herself comfortable.
  • Hold a wide-necked container under her nipple and areola.
  • Place her thumb on top of the breast and the other fingers on the underside of the breast so they are opposite each other (at least 4 cm from the tip of the nipple).
  • Compress and release the breast tissue between her thumb and fingers a few times.
  • If the milk does not appear, she should reposition her thumb and fingers closer to the nipple and compress and release the breast as before.
  • Compress and release all the way around the breast, keeping her thumb and fingers the same distance from the nipple.
  • Be careful not to squeeze the nipple or rub the skin or move her thumb or fingers on the skin.
  • Express one breast until the milk just drips, then express the other breast until the milk just drips.
  • Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes.
  • Stop expressing when the milk no longer drips from the start.

4. How to Keep the Low Weight Infant Warm at Home

  • Keep the young infant in the same bed with the mother.
  • Keep the room warm (at least 25°C) with a home heating device and ensure there is no draught of cold air.
  • Avoid bathing the low-weight infant. When washing or bathing, do it in a very warm room with warm water, dry immediately and thoroughly after bathing, and clothe the young infant immediately.
  • Change clothes (e.g., nappies) whenever they are wet.
  • Provide skin-to-skin contact as much as possible, day and night. For skin-to-skin contact(KANGAROO METHOD/KANGAROO MOTHER CARE):
  1. Dress the infant in a warm shirt open at the front, a nappy, hat, and socks.
  2. Place the infant in skin-to-skin contact on the mother’s chest between the mother’s breasts. Keep the infant’s head turned to one side.
  3. Cover the infant with the mother’s clothes (and an additional warm blanket in cold weather).

  • When not in skin-to-skin contact, keep the young infant clothed or covered as much as possible at all times. Dress the young infant with extra clothing, including a hat and socks, loosely wrap the young infant in a soft dry cloth, and cover with a blanket.

  • Check frequently if the hands and feet are warm. If cold, re-warm the baby using skin-to-skin contact.

  • Breastfeed the infant frequently (or give expressed breastmilk by cup).

5. How to Give Home Care for the Young Infant

EXCLUSIVELY BREASTFEED THE YOUNG INFANT (for breastfeeding mothers)

  • Give only breastfeeds to the young infant.
  • Breastfeed frequently, as often and for as long as the infant wants, day or night, during sickness and health.

MAKE SURE THAT THE YOUNG INFANT IS KEPT WARM AT ALL TIMES

  • In cool weather, cover the infant’s head and feet and dress the infant with extra clothing.

WHEN TO RETURN (Follow-up visit)

Infant’s Condition

Follow-up Day

JAUNDICE

Day 2

DIARRHOEA

Day 3

FEEDING PROBLEM

Day 3

THRUSH

Day 3

LOCAL INFECTION

Day 3

PNEUMONIA

Day 4

SEVERE PNEUMONIA (referral refused or not possible)

Day 4

LOW WEIGHT FOR AGE (in infant receiving no breast milk)

Day 7

LOW WEIGHT FOR AGE (in breastfed infant)

Day 14

CONFIRMED HIV INFECTION or HIV EXPOSED: POSSIBLE HIV INFECTION

Per national guidelines

WHEN TO RETURN IMMEDIATELY:

Advise the caretaker to return immediately if the young infant has any of these signs:

  • Breastfeeding poorly
  • Reduced activity
  • Becomes sicker
  • Develops a fever
  • Feels unusually cold
  • Develops fast breathing
  • Develops breathing problems
  • Palms or soles appear yellow.

Follow-up Care for the Sick Young Infant where Referral is Refused or Not Feasible

For Sick Young Infant with Possible Serious Bacterial Infection or Very Severe Disease

Clinical Severe Infection:

If using a 2-day gentamicin regimen:

  • Follow up on day 2 and day 4 of treatment.
  • Reassess the young infant at each contact.
  • If improving, complete the 2-day treatment with IM gentamicin.
  • Continue oral amoxicillin until all tablets are finished.

If using a 7-day gentamicin regimen:

  1. Follow up during every injection contact.
  2. Refer the infant if:
  • Worsening after treatment is started.
  • Any new sign of clinical severe infection appears.
  • Clinical severe infection is still present after day 8 of treatment.
  • No improvement on day 4 after 3 full days of treatment.

Local Bacterial Infection:

After 2 days:

  • Check umbilicus for redness or pus.
  • Check skin pustules for severity.
  • Check eyes for pus, swelling, or redness.

    Treatment:

  • If issues persist or worsen, refer to the hospital.
  • If improved, continue the 5-day antibiotic and home treatment.
  • If severe pustules persist or worsen, refer to the hospital.

Jaundice:

After 1 day:

  • Look for jaundice.
  • If palms and soles are yellow or age is 14 days or more, refer to the hospital.
  • If not yellow and age is less than 14 days, advise on home care and return instructions.

Eye Infection:

After 2 days:

  • Look for pus draining from the eyes.

Treatment:

  • If pus persists, check treatment correctness and refer to the hospital if needed.
  • If no pus, continue treatment for 5 days.

Diarrhoea (Some Dehydration):

After 2 days:

  • Ask if diarrhoea has stopped.

    Treatment:

  • If not stopped, assess and treat for diarrhoea.
  • If stopped, advise to continue exclusive breastfeeding and give zinc for 10 days.

When to Return Immediately:

Advise the caretaker to return immediately if the young infant has any of these signs:

  • Breastfeeding poorly.
  • Reduced activity.
  • Becomes sicker.
  • Develops a fever.
  • Feels unusually cold.
  • Develops fast breathing.
  • Develops breathing difficulty.
  • Palms or soles appear yellow.

Follow-up Care for Specific Conditions:

Feeding Problem:

After 2 days, reassess feeding.

  • Ask about any feeding problems identified during the initial visit.
  1. Counsel the mother about any new or continuing feeding problems.
  2. If significant changes in feeding are advised, ask her to return after 2 days.
  3. For low weight for age, instruct the mother to return after 14 days for weight measurement.

  • Exception:

  1. If feeding is not expected to improve or if the infant has lost weight, refer the child.

Low Weight or Low Birth Weight:

After 2 days, weigh the young infant and assess if still low weight for age.

  • Reassess feeding.
  1. If no longer low weight for age, praise the mother and encourage continuation until normal weight is attained.
  2. If still low weight for age but feeding well, praise the mother and advise weighing again within a month or at the next immunization visit.
  3. If still low weight for age with a feeding problem, counsel the mother. Ask to return in 14 days (or at the next immunization visit within 2 weeks). Continue every 2 weeks until feeding improves, and weight gain is regular or no longer low weight for age.

  • Exception:

    • If feeding is not expected to improve or if the infant has lost weight, refer to the hospital.

Thrush or Mouth Ulcers:

  • After 2 days, look for ulcers or white patches in the mouth (thrush).
  • Reassess feeding.
  1. If thrush or mouth ulcers worsen or if there are problems with attachment or sucking, refer to the hospital.
  2. If thrush or mouth ulcers are the same or better, and the baby is feeding well, continue with Gentian Violet or Nystatin for a total of 5 days.

ASSESS AND CLASSIFY A SICK YOUNG INFANT 0-2 MONTHS Read More »

Manage HIV/AIDS using IMCI approach

Manage HIV/AIDS using IMCI approach

CHECK FOR HIV EXPOSURE AND INFECTION

All children found to have pneumonia, persistent diarrhea, ear discharge or very low weight for age (any of these features) and have no urgent need or indication for referral, should be assessed for symptomatic HIV infection. 

  • Children may acquire HIV infection from an infected mother through vertical transmission in utero, during delivery or while breastfeeding.
  • Without any intervention, 30 – 40% babies born to infected mothers will themselves be infected.
  • Most children born with HIV die before they reach their fifth birthday, with most not surviving beyond two years.
  • Good treatment can make a big difference to children with HIV and their families.
  • The child’s status may also be the first indicator that their parents are infected too.

ASSESS FOR HIV EXPOSURE AND INFECTION 

ASK

LOOK, FEEL AND DIAGNOSE

• Ask for mother’s HIV status to establish child’s HIV exposure* 

Is it: 

Positive, Negative or Unknown (to establish child’s HIV exposure) 

 

• Ask if child has had any TB Contact

Child <18 months 

• If mother is HIV positive**, conduct DNA PCR for the baby at 6 weeks or at first contact with the child 

• If the mother’s HIV status is unknown, conduct an antibody test (rapid test) on the mother to determine HIV exposure. 

PRESUMPTIVE SYMPTOMATIC DIAGNOSIS OF HIV INFECTION IN CHILDREN <18 MONTHS 

• Pneumonia *** 

• Oral Candidiasis /thrush 

• Severe sepsis 

• Other AIDS defining conditions**

 

Child ≥18 months 

• If the mother’s antibody test is POSITIVE, the child is exposed. Conduct an antibody test on the child. 

 

Child whose mother is NOT available: 

• Child < 18 months 

Do an antibody test on the child. If positive, do a DNA PCR test. 

• Child ≥ 18 months 

Do an antibody test to determine the HIV status of the child

CLASSIFY HIV STATUS

SIGNS

CLASSIFY AS

TREATMENT

• Child < 18 months and DNA PCR test POSITIVE 

 

• Child ≥ 18 months and Antibody test POSITIVE 

CONFIRMED HIV INFECTION

• Initiate ART, counsel and follow up existing infections 

• Initiate or continue cotrimoxazole prophylaxis

• Assess child’s feeding and provide appropriate counseling to the mother/caregiver

• Offer routine follow up for growth, nutrition and development and HIV services 

• Educate caregivers on adherence and its importance 

• Screen for possible TB disease at every visit. 

• For those who do not have TB disease, start Isoniazid prophylactic therapy (IPT). Screen for possible TB throughout IPT 

• Immunize for measles at 6 months and 9 months and boost at 18 months 

• Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive HIV care of the child.

Child<18 months 

• If mother test is positive and child’s DNA PCR is negative OR 

• If mother is unavailable; child’s antibody test is positive and DNA PCR is negative

HIV EXPOSED

• Treat, counsel and follow up existing infections 

• Initiate or continue Cotrimoxazole prophylaxis 

• Give Zidovudine and Nevirapine prophylaxis as per the national PMTCT guidelines 

• Assess child’s feeding and provide appropriate counseling to the mother/caregiver  

• Offer routine follow up for growth, nutrition and development 

• Repeat DNA PCR test at 6 months. If negative, repeat DNA PCR test again at 12 months. If negative, repeat antibody test at 18 months

• Continue with routine care for under 5 clinics 

• Screen for possible TB at every visit 

• Immunize for measles at 6 months and 9 months and boost at 18 months

• Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive care of the child.

• No test results for child or mother 

• 2 or more of the following conditions: 

• Severe pneumonia 

• Oral candidiasis/thrush 

• Severe Sepsis

 OR

• An AIDS defining condition

SUSPECTED SYMPTOMATIC HIV INFECTION

• Treat, counsel and follow-up existing infections

• Give cotrimoxazole prophylaxis

• Give vitamin A supplements from 6 months of age every 6 months

• Assess the child’s feeding and provide appropriate counseling to the mother

• Test to confirm HIV infection

• Refer for further assessment including HIV care/ ART

• Follow-up in 14 days, then monthly for 3 months and then  every 3 months or as per immunization schedule 

Mother’s HIV status is NEGATIVE 

OR 

Mother’s HIV status is POSITIVE and child is ≥ 18 months with antibody test NEGATIVE 6 weeks after completion of breastfeeding

HIV NEGATIVE

• Manage presenting conditions according to IMNCI and other recommended national guidelines 

• Advise the mother about feeding and about her own health

THEN CHECK FOR TB

ASK

LOOK AND FEEL

For symptoms

suggestive of TB

  • Has the child been coughing for 14 days or more?

  • Has the child had persistent fever for 14 days or more?

  • Has the child had poor weight gain in the last one month?*

History of contact

  • Has the child had contact with a person with Pulmonary Tuberculosis or chronic cough?

Look or feel for physical signs of TB

  • Swellings in the neck or armpit

  • Swelling on the back

  • Stiff neck

  • Persistent wheeze not responding to

brochodilaters.

Collect sample for GeneXpert or smear microscopy

 

If available, send the child for laboratory tests (GeneXpert or smear microscopy) and/ or Chest X-Ray.

CLASSIFY

SIGNS

CLASSIFY AS

TREATMENT

Two or more of the following in HIV Negative child AND one or more of the following in HIV

Positive child:

  • At least two symptoms suggestive of TB

  • Positive history of contact with a TB case

  • Any physical signs suggestive of TB

OR

  • A positive GeneXpert or smear microscopy test

TB

• Initiate TB treatment

• Treat, counsel, and follow up any

co- infections

• Ask about the caregiver’s health and

treat as necessary

• Link the child to the nearest TB clinic

for further assessment and ongoing

follow-up

• If GeneXpert or smear microscopy

test is not available or negative,

refer for further assessment

Positive history of contact with a TB case and

NO other TB symptoms or signs listed above

TB

EXPOSURE

• Start Isoniazid at 10mg/kg for 6

months

• Treat, counsel, and follow up

existing infections

• Ask about the caregiver’s health and

treat as necessary

• Link child to the nearest TB clinic

NO TB symptoms or signs

NO TB

• Treat, counsel, and follow up

existing infections 

• Start Isoniazid in HIV positive child

above 1 year at 10mg/kg for 6

months

THEN CHECK THE CHILD‘S IMMUNIZATION AND VITAMIN A STATUS

Immunization Schedule

  • Follow National Guidelines as per the Child Health Card/Mother Baby Passport.

Age

Vaccine

Birth

BCG*

 

OPV-0

6 weeks

DPT+HepB+HIB

 

OPV-1

RTV1

PCV1

10 weeks

DPT+HepB+HIB

 

OPV-2

RTV2

PCV2

14 weeks

DPT+HepB+HIB

 

OPV-3

IPV

RTV3

PCV3

9 months

Measles

 

  • BCG: Bacillus Calmette-Guérin (given at birth)
  • OPV: Oral Polio Vaccine
  • DPT: Diphtheria, Pertussis, Tetanus
  • HepB: Hepatitis B
  • HIB: Haemophilus influenzae type b
  • RTV: Rotavirus Vaccine
  • PCV: Pneumococcal Conjugate Vaccine
  • IPV: Inactivated Polio Vaccine

VITAMIN A SUPPLEMENTATION

Give every child a dose of Vitamin A every six months from the age of 6 months.

Record the dose on the child’s chart.

ROUTINE DEWORMING TREATMENT

Give every child mebendazole every six months from the age of 1 year. Record the dose on the child’s chart.

 

Manage HIV/AIDS using IMCI approach

  • All children less than 5 years who are HIV infected should be initiated on ART irrespective of CD4 count or clinical stage. 
  • Remember that if a child has any general danger sign or a severe classification, he or she needs URGENT REFERRAL. ART initiation is not urgent, and the child should be stabilized first.

Steps when Initiating ART in Children 

STEP 1: DECIDE IF THE CHILD HAS CONFIRMED HIV INFECTION 

Child is under 18 months: 

  • HIV infection is confirmed if virological test (PCR) is positive.

Child is over 18 months: 

  • Two different serological tests are positive.
  • Send any further confirmatory tests required.

If results are discordant, refer 

If HIV infection is confirmed, and child is in stable condition, GO TO STEP 2

 

STEP 2: DECIDE IF CAREGIVER IS ABLE TO GIVE ART

Check that the caregiver is willing and able to give ART. The caregiver should ideally have  disclosed the child’s HIV Status to another adult who can assist with providing ART, or be part of a support group.

  • Caregiver able to give ART: GO TO STEP 3
  • Caregiver not able: classify as CONFIRMED HIV INFECTION

but NOT ON ART. Counsel and support the caregiver. Follow-up regularly. Move to STEP 3 once the caregiver is willing and able to give ART.

 

STEP 3: DECIDE IF ART CAN BE INITIATED IN YOUR FACILITY
  • If a child is less than 3 kg or has TB, Refer for ART initiation.
  • If child weighs 3 kg or more and does not have TB, GO TO STEP 4
STEP 4: RECORD BASELINE INFORMATION ON THE CHILD’S HIV TREATMENT CARD

Record the following information:

  • Weight and height
  • Pallor if present
  • Feeding problem if present
  • Laboratory results (if available): Hb, viral load, CD4 count and percentage. Send for any laboratory tests that are required. Do not wait for results. GO TO STEP 5
STEP 5: START ON ART, COTRIMOXAZOLE PROPHYLAXIS AND ROUTINE TREATMENTS
  • Initiate ART treatment:
  1. Child up to 3 years: ABC or AZT +3TC+ LPV/R or recommended first-line regimen
  2. Child 3 years or older: ABC + 3TC + EFV, or recommended first-line regimen.
  • Give co-trimoxazole prophylaxis
  • Give other routine treatments, including Vitamin A and immunizations
  • Follow-up regularly as per national guidelines.

Recommended First-Line ARV Regimens

Patient Category

Indication

ARV Regimen

Adults and Adolescents (aged 10 and above)

Initiating ART

TDF+3TC+EFV

 

Alternative Regimens

TDF+3TC+DTG (Contraindications for EFV)

ABC+3TC+DTG (Contraindications for TDF)

Pregnant or Breastfeeding Women

Initiating ART

TDF+3TC+EFV

 

Alternative Regimen

ABC+3TC+ATV/r (Contraindications for TDF or EFV)

Children (3 to <10 years)

Initiating ART

ABC+3TC+EFV

 

Alternative Regimen

ABC+3TC+NVP (Contraindications for EFV)

Children Under 3 Years

Initiating ART

ABC+3TC+LPV/r

 

Alternative Regimen

AZT+3TC+LPV/r (Hypersensitivity reaction to ABC)

Second- and Third-Line ART Regimens

Population

Patients Failing First-Line Regimens

Second-Line Regimens

Third-Line Regimens

Adults, Pregnant and Breastfeeding Women, Adolescents

TDF + 3TC + EFV

AZT+3TC+ATV/r (recommended) or AZT+3TC+LPV/r (alternative)

All 3rd line regimens guided by resistance testing

  

If not exposed to INSTIs: DRV/r + DTG ± 1-2 NRTIs

If exposed to INSTIs: DRV/r + ETV±1-2 NRTIs

TDF + 3TC + DTG

 

ABC+ 3TC+ DTG

ABC+ 3TC+ EFV

ABC/3TC/NVP

TDF/3TC/NVP

AZT/3TC/NVP

 

TDF+3TC+ATV/r (recommended) or TDF+3TC+LPV/r

AZT/3TC/EFV

Children (3–<10 years)

ABC + 3TC + EFV

AZT+3TC+LPV/r

For children above 6 years, and prior exposure to INSTIs, DRV/r±1-2 NRTIs

  

ABC+ 3TC + NVP

AZT+3TC+NVP

ABC+3TC+LPV/r

For children below 6 years, AZT/3TC/EFV

 
 

DRV/r+ RAL+ 2 NRTIs

AZT+3TC+LPV/r

Children Under 3 Years

ABC+3TC+LPV/r pellets

AZT+3TC+RAL

Optimize regimen using genotype profile

  

AZT+3TC+LPV/r pellets

ABC+3TC+RAL

 

AZT+3TC+NVP

ABC+3TC+LPV/r

 
Principles for Selecting ARV Regimens:
  • Lower toxicity
  • Better palatability and lower pill burden
  • Increased durability and efficacy
  • Sequencing to spare other formulations for the 2nd line regimen
  • Harmonization across age and population
  • Lower cost
  • Facilitate achieving a recommended regimen for the majority of PLHIV
Rationale for Alternative Regimens:
  • TDF+3TC+DTG: EFV contraindications
  • ABC+3TC+DTG: TDF contraindications
  • ABC+3TC+ATV/r: Contraindications for TDF or EFV
  • ABC+3TC+NVP: EFV contraindications in children (3 to <10 years)
  • AZT+3TC+LPV/r: Hypersensitivity reaction to ABC (rare)
Considerations:
  • Dolutegravir (DTG) benefits: low potential for drug interactions, shorter time to viral suppression, higher resistance barrier, long half-life, and low cost.
  • ABC+3TC+EFV once-a-day dose for improved adherence.
  • LPV/r-based regimen for children under 3 years due to reduced risks and high resistance barrier.

ABC: Abacavir

AZT: Zidovudine

3TC: Lamivudine

LPV/r: Lopinavir/Ritonavir

RTV: Ritonavir

NVP: Nevirapine

EFV: Efavirenz

DTG: Dolutegravir

TDF: Tenofovir Disoproxil Fumarate

RAL: Raltegravir

ATV/r: Atazanavir/Ritonavir

 

TB/HIV Co-Infection Treatment Based on Age/Weight

AGE/WEIGHT

FIRST LINE TB/HIV CO-INFECTION

< 2 Weeks

Start TB treatment immediately, start ART (Usually after 2 weeks of age) once tolerating TB drugs

> 2 Weeks and <35 kgs

ABC/3TC/LPVr/RTV If not able to tolerate super boosted LPVr/RTV then use ABC/3TC + RAL for duration of TB treatment. After completion of TB treatment revert back to the recommended 1st line regimen ABC/3TC +LPVr.

If on ABC/3TC/EFV regimen – continue If on NVP based regimen, change to EFV.

>35 kgs body weight and < 15 years age

ABC/3TC/DTG continue with the regimen AND double the dose for DTG If on PI based regimen switch the patients to DTG, hence doubling the dose

DOSAGE OF COTRIMOXAZOLE PROPHYLAXIS

WEIGHT (KG)

SUSPENSION 240MG PER 5ML

SINGLE STRENGTH TABLET 480MG (SS)

DOUBLE STRENGTH TABLET 960MG (DS)

1-4

2.5ml

1/4 SS tab

–

5-8

5ml

1/2 SS tab

1/4 DS tab

9-16

10ml

1 SS tab

1/2 DS tab

17-30

15ml

2 SS tab

1 DS

>30(Adults and adolescents)

–

2 SS

1 DS

Dose by body weight is 24-30 mg/kg once daily of the trimethoprim-sulphamethaxazole – combination drug.

• Oral thrush management– use miconazole gel 

• Cotrimoxazole use is still recommended 

• Most infants and children initiated on treatment take time before immune recovery occurs 

• Children on LPV/r – continue with boosted ritonavir 

• RAL – for those unable to tolerate super boosted LPV/r

 

Paediatric ARVs Dosages

WEIGHT RANGE (KG)

ABACAVIR + LAMIVUDINE

120 mg ABC + 60 mg 3TC

ZIDOVUDINE + LAMIVUDINE

60 mg ZDV + 30 mg 3TC

EFAVIRENCE (EFV) 

Once Daily 200mg tabs

LAMIVUDINE + ZIDOVUDINE

Twice Daily 200mg tabs

3 – 5.9

0.5 tab

1 tab

–

 

6 – 9.9

1 tab

1.5 tabs

–

 

10 – 13.9

1 tab

2 tabs

1 tab 

1.5 tabs

14 – 19.9

1.5 tabs

2.5 tabs

1.5 tabs 

+ 1 tab in AM & 0.5 tab in PM

20 – 24.9

2 tabs

3 tabs

1.5 tabs 

1 tab in AM & 0.5 tab in PM

25 – 34.9

300 mg ABC + 150 mg 3TC

300 mg ZDV + 150 mg 3TC

2 tabs 

1 tab in AM & 0.5 tab in PM

 

Manage Side Effects of ARV Drugs

SIGNS or SYMPTOMS

APPROPRIATE CARE RESPONSE

Yellow eyes (jaundice) or abdominal pain

Stop drugs and REFER URGENTLY

Rash

If on abacavir, assess carefully. Call for advice. If severe, generalized, or associated with fever or vomiting: stop drugs and REFER URGENTLY

Nausea

Advise drug administration with food. If it persists for more than 2 weeks or worsens, call for advice or refer.

Vomiting

If medication is seen in vomitus, repeat the dose. If vomiting persists, bring the child to the clinic. REFER URGENTLY if vomiting everything or associated with severe symptoms.

Diarrhoea

Assess, classify, and treat using diarrhoea charts. Reassure that it may improve in a few weeks. Follow up as per chart booklet. Call for advice or refer if not improved after two weeks.

Fever

Assess, classify, and treat using fever chart.

Headache

Give paracetamol. If on efavirenz, reassure that it is common and usually self-limiting. Call for advice or refer if it persists for more than 2 weeks or worsens.

Sleep disturbances, nightmares, anxiety

Due to efavirenz. Administer at night on an empty stomach with low-fat foods. Call for advice or refer if it persists for more than 2 weeks or worsens.

Tingling, numb, or painful feet or legs

If new or worse on treatment, call for advice or refer.

Changes in fat distribution

Consider switching from stavudine to abacavir, consider viral load. Refer if needed.

GIVE FOLLOW – UP CARE FOR ACUTE CONDITIONS 

  • Care for the child who returns for follow-up using all the boxes that match the child’s previous classifications.

  • If the child has any new problem, assess, classify fully and treat as on the ASSESS AND CLASSIFY chart.

PNEUMONIA

After 2 days

Check the child for general danger signs.

Assess the child for cough or difficult breathing.

Ask:

  • Is the child breathing slower?
  • Is there less fever?
  • Is the child eating better?

Treatment:

  • If any general danger sign, administer a dose of second-line antibiotic, then admit or refer URGENTLY to the hospital.
  • If chest indrawing, breathing rate, fever, and eating have not improved, switch to the second-line antibiotic and ADMIT or REFER (If this child had measles within the last 3 months or is known or confirmed HIV infection, refer).
  • If breathing slower, less fever, or eating better, complete the 5 days of antibiotic.
WHEEZING

After 2 days

Check the child for general danger signs or chest indrawing.

Assess the child for cough or difficult breathing.

Ask:

  • Is the child breathing slower?
  • Is the child still wheezing?
  • Is the child eating better?

For Children under 1 year:

  • If wheezing and any of the following;

General danger sign or stridor in a calm child or chest indrawing, fast breathing, poor feeding;

  • Give intravascular/intramuscular antibiotic. Then admit or refer URGENTLY to the hospital.
  • If no wheezing, breathing slower, and eating better; continue the treatment for 5 days.

For Children over 1 year:

  • If wheezing and any of the following;

General danger sign or stridor in a calm child or chest indrawing, fast breathing, poor feeding;

  • Give intravascular/intramuscular antibiotic. Then admit or refer URGENTLY to the hospital.
  • If breathing rate and eating have not improved; change to second-line antibiotic and ADMIT OR REFER urgently to the hospital.
  • If still wheezing; continue oral bronchodilator.
  • If breathing slower, no wheezing, and eating better, continue the treatment for 5 days.
  • If the child has unilateral wheeze and is not responding to bronchodilators, TB disease is likely and should be evaluated.
PERSISTENT DIARRHOEA

After 5 days

Ask:

  • Has the diarrhea stopped?
  • How many loose stools is the child having per day?

Treatment:

  • If the diarrhea has not stopped (child is still having 3 or more loose stools per day), do a full reassessment of the child. Give any treatment needed. Then refer to the hospital.
  • If the diarrhea has stopped (child having fewer than 3 loose stools per day), tell the mother to follow the usual feeding recommendations for the child’s age, but give one extra meal every day for 1 month. Ask her to continue giving Zinc sulfate for a total of 10 days.
  • NB: Attention to diet is an essential part of the management of a child with persistent diarrhea
DYSENTERY

After 2 days

Assess the child for diarrhea. > See ASSESS & CLASSIFY chart

Ask:

  • Are there fewer stools?
  • Is there less blood in the stool?
  • Is there less fever?
  • Is there less abdominal pain?
  • Is the child eating better?

Treatment:

  • If the child is dehydrated, treat dehydration according to classification.
  • If the number of stools, the amount of blood in stools, fever, abdominal pain, or eating is worse: Admit or Refer to the hospital.

If the condition is the same: add Metronidazole to the treatment. Give it for 5 days. Advise the mother to continue ciprofloxacin and zinc and to return in 2 days.

  • Exceptions – if the child:

    • is less than 12 months old, or 

    • was dehydrated on the first visit or to the hospital.

    • had measles within the last 3 months , then Admit or Refer URGENTLY

  • If fewer stools, less blood in the stools, less fever, less abdominal pain, and eating better, continue giving Ciprofloxacin and zinc sulfate until finished.
UNCOMPLICATED MALARIA

If fever persists after 3 days, or recurs within 14 days:

Do a full reassessment of the child. >See ASSESS & CLASSIFY chart. Assess for other causes of fever. 

Treatment:

  • If the child has any general danger sign or stiff neck, treat it as VERY SEVERE FEBRILE DISEASE.
  • If the child has any cause of fever other than malaria, provide treatment.
  • If malaria is the only apparent cause of fever and confirmed by microscopy: Give oral DIHYDROARTEMISININ-PIPERAQUINE (DHA-PPQ). Give paracetamol. If the child is under 5 kg and was given DHA-PPQ assess further.
  • Advice mother to return again in 3 days if the fever persists – If fever has been present every day for 7 days, refer for assessment.
FEVER – NO MALARIA

If fever persists after 3 days:

Do a full reassessment of the child. > See ASSESS & CLASSIFY chart (see pg 6) Assess for other causes of fever.

Treatment:

  • If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.
  • If the child has any cause of fever other than malaria, provide appropriate treatment.
  • If malaria is the only apparent cause of fever:

    • Treat with the first-line oral antimalarial. Give paracetamol. Advise the mother to return again in 3 days if the fever persists.

    • If fever has been present every day for 7 days, refer for assessment.

  • If the child has persistent fever, cough, and reduced playfulness despite other treatment, evaluate for TB.

EYE OR MOUTH COMPLICATIONS OF MEASLES

After 2 days:

Look for red eyes and pus draining from the eyes. Look at mouth ulcers. Smell the mouth.

Treatment for Eye Infection:

  • If pus is draining from the eye, ask the mother/caregiver to describe how she has treated the eye infection.
  • If treatment has been correct, refer to the hospital. If treatment has not been correct, teach mother/caregiver correct treatment.
  • If the pus is gone but redness remains, continue the treatment.
  • If there is no pus or redness, stop the treatment.

Treatment for Mouth Ulcers:

  • If mouth ulcers are worse, or there is a very foul smell from the mouth, refer to the hospital.
  • If mouth ulcers are the same or better, continue using half-strength gentian violet or Nystatin for a total of 5 days.

Treatment for thrush:

  • If thrush is worse, check that treatment is being given correctly.
  • If the child has problems with swallowing, refer to the hospital.
  • If thrush is the same or better, and the child is feeding well, continue Nystatin for a total of 7 days.
  • If thrush is no better or is worse consider symptomatic HIV infection.
EAR INFECTION

After 5 days:

Reassess for ear problem. > See ASSESS & CLASSIFY chart Measure the child’s temperature.

Treatment:

  • If there is tender swelling behind the ear or high fever (38.5°C or above), admit or refer URGENTLY to the hospital.
  • Acute ear infection: if ear pain continues or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking to dry the ear. Follow-up in 5 days.
  • Chronic ear infection: Check that the mother is wicking the ear correctly. Encourage her to continue. Review in 2 weeks.
  • If ear discharge continues for more than 2 months: Admit or refer to the hospital.
  • If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet finished the 5 days of antibiotic, tell her to use till treatment is completed.
FEEDING PROBLEM

After 5 days:

Reassess feeding. See questions at the top of the COUNSEL THE MOTHER. Ask about any feeding problems found on the initial visit.

  • Counsel the mother/caregiver about any new or continuing feeding problems. If you counsel the mother/caregiver to make significant changes in feeding, ask her to bring the child back again after 5 days.
  • If the child is very low weight for age, ask the mother to return 14 days after the initial visit to measure the child’s weight gain.
PALLOR 

After 14 days:

  • Give iron and folate. Advise mother to return in 14 days for more iron and folate.
  • Continue giving iron and folate every day for 2 months.
  • If the child has palmar pallor after 2 months, refer for assessment.
MALNUTRITION 

After 14 days:

If the child is gaining weight, encourage the mother to continue with feeding. Counsel the mother about any feeding problem.

SEVERE MALNUTRITION WITHOUT COMPLICATIONS 

After 7 days or during regular follow-up:

  • Do a full assessment of the child >See ASSESS AND CLASSIFY chart.
  • Assess child with the same measurements (WFH/L, MUAC) as on the initial visit.
  • Check for edema of both feet.
  • Check the child’s appetite by offering ready-to-use therapeutic food if the child is 6 months and older.

Treatment:

  • If the child has SEVERE MALNUTRITION WITH COMPLICATIONS (WFH/L less than -3 z-scores or MUAC is less than 11.5mm or edema of both feet AND has developed a medical complication or edema, or fails the appetite test), refer URGENTLY to the hospital.
  • If the child has SEVERE MALNUTRITION WITHOUT COMPLICATIONS (WFH/L less than -3 z-scores or MUAC is less than 11.5 mm or edema of both feet but NO medical complication and passes the appetite test) counsel the mother and encourage her to continue with appropriate RUTF feeding. Ask the mother to return in 7 days.
  • If the child has MODERATE ACUTE MALNUTRITION (WFH/L between -3 and -2 z-scores or MUAC between 11.5 and 12.5 mm), advise the mother to continue RUTF. Counsel the mother.

MODERATE ACUTE MALNUTRITION

 After 14 days:

  • Assess the child using the same measurement (WFH/L or MUAC) used on the initial visit.
  • If WFH/L, weigh the child, measure height or length and determine if WFH/L.
  • If MUAC, measure using MUAC tape.
  • Check the child for edema of both feet.
  • Reassess feeding. See questions in the COUNSEL THE MOTHER chart.

Treatment:

  • If the child is no longer classified as MODERATE ACUTE MALNUTRITION, praise the mother and encourage her to continue.
  • If the child is still classified as MODERATE ACUTE MALNUTRITION, counsel the mother about any feeding problem found. Ask the mother to return again in 14 days. Continue to see the child every 2 weeks until the child is feeding well and gaining weight regularly or his or her WFH/L is -2 z-scores or more or MUAC is 12.5 or more.
  • Assess all children with failure to thrive or growth faltering for possible TB disease. Exception: If you do not think that feeding will improve, or if the child has lost weight or his or her MUAC has diminished, refer the child.
HIV EXPOSED & INFECTED CHILDREN

HIV INFECTED CHILD

After 1 month:

  • Assess the child’s general condition. Do a full assessment
  • Treat the child for any condition found.
  • Ask for any feeding problems, counsel the mother about any new or continuing feeding problems.
  • Advise the mother/caregiver to bring the child back if any new illness develops or she is worried.
  • Counsel the mother/caregiver on any other problems and ensure community support is being given. Refer for further psychosocial/counseling if necessary.
  • Continue with routine follow-up for growth and development, nutrition, immunization, vitamin A, deworming.
  • Assess adherence to ART and Cotrimoxazole and advise accordingly.
  • Offer or refer child for comprehensive HIV management and care (including ART) as per the national ART guidelines.
  • Plan for defaulter tracking system; identification and tracking of children.
  • Follow up monthly.

HIV EXPOSED CHILD (<18 months): For children tested DNA PCR Negative

After 1 month:

  • Assess the child’s general condition. Do a full reassessment.
  • Ask for any feeding problems or poor appetite, counsel the mother about any new or continuing feeding problems.
  • Treat the child for any condition found.
  • Give Cotrimoxazole prophylaxis from 6 weeks and emphasize the importance of compliance.
  • Start or continue with ARV prophylaxis for a total of 12 weeks.
  • Screen for possible TB Disease.
  • Continue with routine follow-up for growth and development, nutrition, immunization, vitamin A, deworming.
  • Follow-up schedule of HIV Exposed infant monthly up to 24 months.
  • Refer to Early Infant Diagnosis (EID) algorithm for confirmation of HIV status.
  • Refer to the HIV exposed infant follow-up card and register for further follow-up instructions.

Feeding Counseling

For Mothers and caregivers of infants under 18 months.

Goals:

  • Discuss ongoing HIV risk from breastfeeding and the implications on test results.
  • Support the mother as she makes choices about feeding for the infant.
  • Ensure that the mother understands the testing procedure for infants under 18 months.
  • If positive, discuss the need to start ART immediately.

Just after giving birth, the mother should be counseled on:

  • HIV testing for herself: if she did not test in antenatal, she should be tested soon after delivery.
  • Infant feeding practices.
  • HIV testing for the infant: at 6 weeks, the infant can be tested.

Overview of Infant Feeding Guidelines for Exposed Infants

  • HIV+ mothers should exclusively breastfeed infants for the first 6 months.
  • Complementary feeds should be introduced from 6 months.
  • Continue to breastfeed for 12 months.
  • During breastfeeding, the infant should receive daily NVP until 1 week after stopping breastfeeding.
  • Breastfeeding should only stop once a nutritionally adequate and safe diet without breast milk can be provided.
  • When an infected mother decides to stop breastfeeding at any time, they should do so over the course of 1 month.

Manage HIV/AIDS using IMCI approach Read More »

TREAT THE CHILD in IMCI

TREAT THE CHILD in IMCI

TREAT THE CHILD

  • CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART.
  • TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME

Follow the instructions below for every oral drug to be given at home

Also, follow the instructions listed with each drug’s dose

  1. Determine the appropriate drugs & dosage for the child’s age or weight.
  2. Tell the mother the reason for giving the drug to the child.
  3. Demonstrate how to measure the dose.
  4. Watch the mother practice measuring a dose by herself.
  5. Ask the mother to give the first dose to her child.
  6. Explain carefully how to give the drug, then label & package the drug.
  7. If more than one drug will be given, collect, count & package each drug separately.
  8. Explain that all the oral drugs – tablets or syrup must be used to finish the course of treatment, even if the child gets better.
  9. Check the mother’s understanding before she leaves the clinic.

Give an appropriate oral antibiotic**

pneumonia

FOR PNEUMONIA, ACUTE EAR INFECTION:

FIRST-LINE ANTIBIOTIC: Oral Amoxicillin

Age or Weight

Amoxicillin(Give two times daily for 5 days)

2 months up to 12 months (4 – <10 kg)

1 tablet (250 mg) or 5 ml syrup

12 months up to 3 years (10 – <14 kg)

2 tablets (250 mg) or 10 ml syrup

3 years up to 5 years (14-19 kg)

3 tablets (250 mg) or 15 ml syrup

FOR PROPHYLAXIS IN HIV CONFIRMED OR EXPOSED CHILD:

ANTIBIOTIC FOR PROPHYLAXIS: Oral Cotrimoxazole

Age

Cotrimoxazole(Give once a day starting at 4-6 weeks of age)

Less than 6 months

2.5 ml syrup

6 months up to 5 years

5 ml syrup or 2 tablets (20/100 mg)

FOR DYSENTERY:

FIRST-LINE ANTIBIOTIC: Oral Ciprofloxacin

Age

Ciprofloxacin(Give 15 mg/kg two times daily for 3 days)

Less than 6 months

1/2 tablet (250 mg)

6 months up to 5 years

1 tablet (250 mg) or 1/2 tablet (500 mg)

FOR CHOLERA:

FIRST-LINE ANTIBIOTIC FOR CHOLERA: Erythromycin

SECOND-LINE ANTIBIOTIC FOR CHOLERA: Tetracycline

Age or Weight

Erythromycin

Tetracycline

2 years up to 5 years (10 – 19 kg)

1 tablet (250 mg)

1 tablet (250 mg)

Give four times daily for 3 days

malaria

FOR UNCOMPLICATED MALARIA

FIRST-LINE ANTIMALARIAL: ARTEMETHER + LUMEFANTRINE (AL)

SECOND-LINE ANTIMALARIAL: DIHYDROARTEMISININ-PIPERAQUINE (DHA-PPQ)

Artemether + Lumefantrine Tablets Dosage

Weight (kg)

Age (Years)

AL Dosage

Below 15

Below 3

20mg Artemether and 120mg Lumefantrine

15 – 24

3 – 7

40mg Artemether and 240mg Lumefantrine

Counsel the Mother or Caregiver on Malaria Management for a Sick Child:

  • Show caregivers how to prepare the dispersible tablet.
  • If vomiting within 30 minutes, repeat the dose; if persistent, return for review.
  • Explain the dosing schedule and confirm understanding.
  • Emphasize completing all 6 doses over 3 days, even if the child feels better.
  • Follow up after 3 days of treatment.
  • Advise immediate return if the condition worsens or symptoms persist after 3 days.

SECOND LINE: DIHYDROARTEMISININ 20MG + PIPERAQUINE 160MG

Dihydroartemisinin + Piperaquine Dosage

Body Weight (kg)

Dose (mg)

5 to < 8

20 + 160

8 to <11

30 + 240

11 to < 17

40 + 320

FOR SEVERE MALARIA

FIRST-LINE TREATMENT FOR SEVERE MALARIA: ARTESUNATE

Artesunate is provided as a powder accompanied by a 1ml vial of 5% bicarbonate. The preparation involves further dilution with either normal saline or 5% dextrose, with the specific amounts varying for intravenous (IV) or intramuscular (IM) administration (refer to the table below).

Preparing IV/IM Artesunate

Component

IV

IM

Artesunate Powder (mg)

60mg

60mg

Sodium Bicarbonate (mls, 5%)

1ml

1ml

Normal Saline or 5% Dextrose (mls)

5mls

2mls

Artesunate Concentration (mg/ml)

10mg/ml

20mg/ml

Note:

  • Artesunate is administered IV/IM for a minimum of 24 hours.
  • Do not use water for injection in the preparation.
  • Do not administer if the solution appears cloudy.
  • Administer artesunate within 1 hour after preparation.

After 24 hours of artesunate administration, if the child can eat and drink, transition to a full course of artemisinin combination therapy (ACT), typically the first-line oral anti-malarial, Artemether Lumefantrine.

Quinine for Severe Malaria

For Intravenous (IV) Infusion:

  • Typically, use 5% or 10% dextrose.
  • Administer at least 1ml of fluid for each 1mg of quinine.
  • Do not exceed an infusion rate of 5mg/kg/hour.
  • Utilize 5% dextrose or normal saline for infusion, maintaining a ratio of 1ml of fluid for each 1mg of quinine.
  • The 20mg/kg loading dose should take 4 hours or longer.
  • The 10mg/kg maintenance dose should take 2 hours or longer.

For Intramuscular (IM) Quinine:

  • Take 1ml of the 2mls in a 600mg Quinine sulfate IV vial and add 5mls water for injection, creating a 50mg/ml solution.
  • For a loading dose, administer 0.4mls/kg.
  • For maintenance dosing, administer 0.2mls/kg.
  • If more than 3mls is needed (for a child over 8kg for a loading dose or over 15kg for maintenance doses), divide the dose into two IM sites, ensuring not to exceed 3mls per injection site.

Artemether for Severe Malaria

  • Administer a loading dose of 3.2mg/kg IM stat, followed by 1.6mg/kg IM daily until the patient can tolerate oral medications.
  • Subsequently, provide a complete course of Artemether Lumefantrine (AL).

Admit or refer patients with:

  • Severe anemia (Hemoglobin level <5g/dl or hematocrit <15%)
  • Two or more convulsions within a 24-hour period.
  • Hyperparasitemia and stability. These patients can be treated with AL, DHA-PPQ, or oral quinine if ACT is unavailable, but close monitoring is essential.

Treatment for Severe Malaria in Children with Very Severe Febrile Disease:

For Pre-referral Treatment:

Check available pre-referral treatment options (rectal artesunate suppositories, artesunate injection, or quinine).

If rectal artesunate suppository is available: Insert the first dose and urgently refer the child.

If intramuscular artesunate or quinine is available: Administer the first dose and urgently refer the child to the hospital.

If Referral is Not Possible:

For Artesunate Injection:

  • Administer the first dose intramuscularly.
  • Repeat the dose every 12 hours until the child can take oral medication.
  • Provide the full dose of oral antimalarial as soon as the child can take it orally.

For Artesunate Suppository:

  • Administer the first dose of the suppository.
  • Repeat the same dose every 24 hours until the child can take oral antimalarial.
  • Provide the full dose of oral antimalarial as soon as the child can take it orally.

For Quinine:

  • Administer the first dose of intramuscular quinine.
  • Ensure the child remains lying down for one hour.
  • Repeat quinine injection at 4 and 8 hours later, then every 12 hours until the child can take an oral antimalarial.
  • Do not continue quinine injections for more than 1 week.
  • If the risk of malaria is low, refrain from giving quinine to a child less than 4 months of age.

Age or Weight

Rectal Artesunate Suppository (50 mg suppositories, Dosage 10 mg/kg)

Rectal Artesunate Suppository(200 mg suppositories, Dosage 10 mg/kg)

Intramuscular Artesunate(60 mg vial, 20mg/ml, 2.4 mg/kg)

Intramuscular Quinine (150 mg/ml, in 2 ml ampoules)*

Intramuscular Quinine (300 mg/ml, in 2 ml ampoules)*

2 – 4 months (4 – <6 kg)

1 

 

1/2 ml

0.4 ml

0.2 ml

4 – 12 months (6 – <10 kg)

2

 

1 ml

0.6 ml

0.3 ml

12 months – 2 years (10 – <12 kg)

2 

 

1.5  ml

0.8 ml

0.4 ml

2 – 3 years (12 – <14 kg)

3

1

1.5 ml

1.0 ml

0.5 ml

3 – 5 years (14 – 19 kg)

3

1

2 ml

1.2 ml

0.6 ml

*Note: Dosages are given in milliliters (ml) and milligrams per kilogram (mg/kg) based on the child’s weight or age.

GIVE PARACETAMOL FOR HIGH FEVER >38.5°c OR EAR PAIN

Paracetamol for Fever or Ear Pain:

AGE or WEIGHT

Paracetamol Tablet (100 mg)

Paracetamol Tablet (500 mg)

2 months up to 3 years (4 – <14 kg)

1/4 tablet every 6 hours

Not applicable

3 years up to 5 years (14 – <19 kg)

1/2 tablet every 6 hours

1/2 tablet every 6 hours

FOR CONVULSIONS

FOR CONVULSIONS

Give Diazepam to Stop Convulsions

  • Turn the child to his/her side and clear the airway. Avoid putting things in the mouth.
  • Give 0.5mg/kg diazepam injection solution per rectum using a small syringe without a needle (like a tuberculin syringe) or using a catheter.
  • Check for low blood sugar, then treat or prevent.
  • Give oxygen and REFER.

If convulsions have not stopped after 10 minutes, repeat diazepam dose.

Diazepam Dosage

Age or Weight

Diazepam 10mg/2mls Dosage

2 months – 6 months (5 – 7 kg)

0.5 ml

6 months – 12 months (7 – <10 kg)

1.0 ml

12 months – 3 years (10 – <14 kg)

1.5 ml

3 years – 5 years (14-19 kg)

2.0 ml

Note: Dosages are given in milliliters (ml) based on the child’s weight or age.

**For measles, persistent diarrhea, severe malnutrition ****

  1. Give vit A- 3 doses:
  • Give two doses for treatment of Measles. Give the first dose in the clinic and give mother another dose to give at home the next day.
  • Give one dose for other disease conditions if the child has not had a dose in the previous one month.
  • Give one dose as per Vitamin A schedule for prevention.
  • To give Vitamin A, cut open the capsule and give drops
  • Ask mother to bring the child back for 3rd dose 2-4 wks

Age Range

200,000 IU Capsule

100,000 IU Capsule

50,000 IU Capsule

Up to 6 months

Not applicable

1/2 capsule

1 capsule

6 months up to 12 months

1/2 capsule

1 capsule

2 capsules

12 months up to 5 years

1 capsule

2 capsules

4 capsules

For anemia***

Iron and Folate Administration Guidelines

  • Dosage: Give one dose at 6 mg/kg of iron daily for 14 days.
  • Caution: Avoid iron in a child known to suffer from Sickle Cell Anemia.
  • Note: Avoid folate until 2 weeks after the child has completed the dose of sulfa-based drugs.

Iron/Folate Tablet Dosage Based on Age or Weight

Age or Weight

Ferrous Sulfate 200 mg + 250 mcg Folate

Iron Tablet (200 mg)

Folic Acid Tablet (5 mg)

2 up to 4 months (4 – 6 kg)

–

1/4

1/2

4 up to 12 months (6 – 10 kg)

–

1/4

1

12 months up to 3 years(10 – 14 kg)

1/2 tablet

1/2

1

3 years up to 5 years(14 – 19 kg)

1/2 tablet

1/2

1

**Zinc Sulphate Administration for Diarrhea:

  • Dosage: Give once daily for 10 days.

Age

Zinc Sulphate Dispersible Tablet (20 mg)

0 months up to 6 months

1/2*

6 months up to 5 years

1

*Dispose the other half tablet of Zinc Sulphate 20mg

Deworm**

Give mebendazole if:

  • Give 500 mg mebendazole as a single dose in clinic if:
  • hookworm/whipworm are a problem in children in your area, and
  • the child is 1 years of age or older, and
  • the child has not had a dose in the previous 6 months
  • If a child is below 2yrs- give 250mg

Treat the Child to Prevent Low Blood Sugar

If the child is able to breastfeed:

  • Ask the mother to breastfeed the child.

If the child is not able to breastfeed but is able to swallow:

  • Give expressed breast milk or a breast-milk substitute.

If neither of these is available, give sugar water*.

  • Give 30 – 50 ml of milk or sugar water* before departure.

If the child is not able to swallow:

  • Give 50 ml of milk or sugar water* by nasogastric tube.

If no nasogastric tube is available, give 1 teaspoon of sugar moistened with 1-2 drops of water sublingually and repeat doses every 20 minutes to prevent relapse.

* To make sugar water: Dissolve 4 level teaspoons of sugar (20 grams) in a 200-ml cup of clean water.

TEACH THE MOTHER TO TREAT LOCAL INFECTIONS AT HOME

  • Explain to the mother what the treatment is and why it should be given.
  • Describe the treatment steps listed.
  • Watch the mother as she does the first treatment  in the clinic.
  • Tell her how often to do the treatment at home.
  • Check the mother’s understanding before she leaves the clinic.

Treat eye infection with tetracycline eye ointment

Clean both eyes 3 times daily:

Wash hands.

  • Ask the child to close eyes.
  • Use a clean cloth & water to gently wipe away the pus.

Apply tetracycline eye ointment in both eyes 4 times daily:

  • Ask the child to look up.
  • Squirt a small amount of the ointment on the inside of the lower eyelid.
  • Wash hands again.
  • Treat until there is no pus discharge.
  • Do not use other eye ointments or drops or put anything else in the eye.

Dry the ear by wicking

  • Clear the Ear by Dry Wicking and Give Ear Drops*
  • Dry the ear at least 3 times daily.
  • Roll clean absorbent cloth or soft, strong tissue paper into a wick.
  • Place the wick in the child’s ear.
  • Remove the wick when wet.
  • Replace the wick with a clean one and repeat these steps until the ear is dry.
  • Instill quinolone ear drops after dry wicking three times daily for two weeks.

* Quinolone ear drops may include ciprofloxacin, norfloxacin, or ofloxacin.

Treat mouth ulcers with gentian violet

  • Treat for mouth ulcers twice daily.
  • Wash hands.
  • Wash the child’s mouth with clean soft cloth wrapped around the finger and wet with salt water.
  • Paint the mouth with half-strength gentian violet (0.25% dilution).
  • Wash hands again.
  • Continue using GV for 48 hours after the ulcers have been cured.
  • Give paracetamol for pain relief.

Soothe the throat, relieve the cough with a safe remedy.

Safe remedies to recommend:

  • Breast milk for exclusively breastfed infants.
  • Simple linctus.
  • Tea with honey.
  • Lemon tea.

Give these treatments only in the clinic.

  • Intramuscular antibiotic e.g., PPF, CAF for acute ear infection, very severe disease, & pneumonia.
  • Quinine for severe malaria.
  • Diazepam rectally for convulsing children.
  • Sugar water or milk by NGT in treatment/prevention of low blood sugar for a child who cannot swallow.

Treat Thrush with Nystatin

  • Treat thrush four times daily for 7 days
  • Wash hands
  • Wet a clean soft cloth with salt water and use it to wash the child’s mouth.
  • Instill nystatin 1 ml four times a day.
  • Avoid feeding for 20 minutes after medication.
  • If breastfed, check the mother’s breasts for thrush. If present, treat with nystatin.
  • Advise mother to wash breasts after feeds. If bottle fed advise change to cup and spoon.
  • Give paracetamol if needed for pain
TREATMENT OF DEHYDRATION

TREATMENT OF DEHYDRATION

GIVE EXTRA FLUID FOR DIARRHOEA AND CONTINUE FEEDING 

Plan A: Treat diarrhoea with no dehydration(Treat Diarrhoea at Home)

Counsel the mother on the 4 Rules of Home Treatment:

  1. Give Extra Fluid
  2. Give Zinc Supplements (age 2 months up to 5 years)
  3. Continue Feeding
  4. When to Return.

1. Give Extra Fluid  (Give ORS and other Fluids- as much as the child will take)

ADVISE THE MOTHER

  • Breastfeed frequently and for longer at each feed.
  • If the child is exclusively breast-fed, give ORS in addition to breast milk.
  • If the child is not exclusively breast-fed, give one or more of the following: ORS solution, food-based fluids (such as soup, enriched bujii, and yoghurt drinks, rice water), or safe clean water.
  • Give fresh fruit juice or mashed bananas to provide potassium.
  • Advise mothers/caregivers to continue giving ORS as instructed
  • Give ORS at home when: The child has been treated with Plan B or Plan C during this visit, OR if the child cannot return to a clinic if the diarrhoea gets worse.
  • Teach the mother how to mix and give ORS. Give the mother 2 packets of ORS to use at home.
  • Show the mother how much fluid to give in addition to the usual fluid intake:

Age Group

Fluid Amount after Each Loose Stool

Up to 2 years

50 to 100 ml

2 years or more

100 to 200 ml

Advise the mother/caregiver to: 

  • Give frequent small sips from a cup. 
  • If the child vomits, wait 10 minutes. Then continue, but more slowly.
  • Continue giving extra fluids until the diarrhoea stops.

2. Give Zinc (age 2 months up to 5 years)

Tell the mother how much zinc to give (20 mg tab):

Age Group

Zinc Dosage

2 months up to 6 months

1/2 tablet daily for 14 days

6 months or more

1 tablet daily for 14 days

Show the mother how to give zinc supplements:

  • Infants: Dissolve the tablet in a small amount of expressed breast milk, ORS or safe water, in a small cup or spoon.
  • Older children: Tablets can be chewed or dissolved in a small amount of water.

3. Continue Feeding

  • Exclusive breastfeeding if age is less than 6 months.

4. When to Return

  • Provide guidance on when the mother should return for further evaluation or if the condition worsens.

Plan B: Treat Diarrhoea at Facility with ORS (Some Dehydration)

Give in the clinic recommended amount of ORS over 4-hr period:

1. DETERMINE THE AMOUNT OF ORS TO GIVE DURING THE FIRST 4 HRS:

WEIGHT

AGE (Use when weight is unknown)

Amount of ORS (in ml)

< 6 kg

Up to 4 months

200 – 450

6 – <10 kg

4 months up to 12 months

450 – 800

10 – <12 kg

12 months up to 2 years

800 – 960

12 – 19 kg

2 years up to 5 years

960 – 1600

Use the child’s age only when you do not know the weight. The approximate amount of ORS required (in ml) can also be calculated by multiplying the child’s weight (in kg) times 75. 

  • If the child wants more ORS than shown, give more.
  • For infants under 6 months who are not breastfed, also give 100 – 200 ml clean water during this period if you use standard ORS. This is not needed if you use new low osmolarity ORS.

2. SHOW THE MOTHER HOW TO GIVE ORS SOLUTION.

  • Give frequent small sips from a cup.
  • If the child vomits, wait 10 minutes. Then continue, but more slowly.
  • Continue breastfeeding whenever the child wants.

3. AFTER 4 HOURS:

  • Reassess the child and classify the child for dehydration.
  • Select the appropriate plan to continue treatment.
  • Begin feeding the child in the clinic.

4. IF THE MOTHER MUST LEAVE BEFORE COMPLETING TREATMENT:

  • Show her how to prepare ORS solution at home.
  • Show her how much ORS to give to finish the 4-hour treatment at home.
  • Give her enough ORS packets to complete rehydration. Also, give her 2 packets as recommended in Plan A.
  • Explain the 4 Rules of Home Treatment:
  1. Give Extra Fluid
  2. Give Zinc (age 2 months up to 5 years)
  3. Continue Feeding (exclusive breastfeeding if age less than 6 months)
  4. When to Return

Plan C: Treat severe dehydration quickly

plan c treatment deydration

Can you give IV fluids?

  • If YES:

Start IV fluid immediately. If the child can drink, give ORS by mouth while the drip is set up. Give 100 ml/kg Ringer’s Lactate Solution or, if not available, use normal saline as follows: 

AGE

STEP 1 (First give 30 ml/kg in:)

STEP 2 (Then give 70 ml/kg in:)

Infants (under 12 months)

1 hour*

5 hours

Children (12 months up to 5 years)

30 minutes*

2 hours 30 minutes

*Repeat once if the radial pulse is still very weak or not detectable.

  • Reassess the child every 1-2 hours. If the hydration status is not improving, give the IV drip more rapidly.
  • Also, give ORS (about 5 ml/kg/hour) as soon as the child can drink: usually after 3-4 hours (infants) or 1-2 hours (children).
  • Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment.

  • If NO

Is IV treatment available nearby (within 30 minutes)?

  • If YES

Admit or Refer URGENTLY to hospital for IV treatment. If the child can drink, provide the mother with ORS solution and show her how to give frequent sips during the trip.

  • If NO

Are you trained to use a naso-gastric (NG) tube?

  • If YES:

Start rehydration by NG tube (or mouth) with ORS solution: give 20 ml/kg/hour for 6 hours (total of 120 ml/kg). Reassess the child every 1-2 hours:

  • If there is repeated vomiting or increasing abdominal distension, give the fluid more slowly.
  • If hydration status is not improving after 3 hours, send the child for IV therapy.
  • After 6 hours, reassess the child. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment.

 

  • If NO

Can the child drink?

  •  If YES,

Start rehydration by NG tube (or mouth) with ORS solution:

  • If NO

Then refer URGENTLY to the hospital for IV or NGT rehydration.

Treating Shock

  1. Give 20 ml/kg bolus of Ringer’s Lactate (<15 minutes).
  2. Reassess the child
  3. Signs persist? Repeat bolus of Ringer’s Lactate (<15 minutes) and proceed to Plan C.
  4. Signs do not present? Treat child for severe dehydration – Plan C,STEP 2.

GIVE FOLLOW-UP CARE

  • Care for the child who returns for follow-up.
  • If the child has any new problems, assess, classify & treat the new problem.

If PNEUMONIA

Follow up after 2 days.

  • Check the child for general danger signs.
  • Assess the child for a cough or difficulty in breathing.
  • Ask!
  1. Is the child breathing slower?
  2. Is there less fever?
  3. Is the child eating better?

  • In case of any problem, classify & treat or refer URGENTLY.

If PERSISTENT DIARRHEA

Follow up after 5 days.

  • Ask!
  1. Has the diarrhea stopped?
  2. How many loose stools is the child having per day?

  • In case of any problem, classify, treat & or refer URGENTLY.

If DYSENTERY

Follow up after 2 days.

  • Assess the child for diarrhea.
  • Ask!
  1. Are there fewer stools?
  2. Is there less blood in the stool?
  3. Is there less fever?
  4. Is there less abdominal pain?
  5. Is the child eating better?

  • Assess for persistence of the problem, establish any new problem, classify, treat or refer URGENTLY.

If MALARIA

If fever persists after 2 days or returns after 14 days, then follow up is necessary.

  • Do a full assessment of the child, classify, treat or refer URGENTLY.

If MEASLES

Follow up after 2 days.

  • Look for red eyes & pus draining from the eyes.
  • Look at mouth ulcers.
  • Smell the mouth.
  • Reassess, classify, treat or refer URGENTLY.

If EAR INFECTION

Follow up after 5 days.

  • Reassess the ear problem.
  • Measure the child’s temp.
  • Classify – acute or chronic ear infection, treat or refer URGENTLY.

If FEEDING PROBLEM

Follow up after 5 days.

  • Reassess feeding.
  • Ask about any feeding problems found on the initial visit.
  • Counsel the mother about any new or continuing feeding problems.
  • If the child is very low weight for age, ask the mother to return 30 days after the initial visit to measure the child’s weight.

If PALLOR

Follow up after 14 days.

  • If the child is not sickler, give iron.
  • If the child is sickler, give F/A.
  • Advise the mother to return after 14 days for more Fe or F/A.
  • Continue giving iron or folic acid every 14 days for 2 months.
  • If the child has palmar pallor after 2 months, refer URGENTLY.

If VERY LOW WEIGHT

Follow up after 30 days.

  • Weigh the child & determine if the child is still very low weight for age.
  • Reassess feeding.
  • If the child is still low weight for age, counsel about any feeding problem.
  • Ask the mother to return in 1 month.
  • Continue reassess & counseling until the child is no longer low weight for age.
  • If the child increasingly loses weight refer URGENTLY.

IF ANY MORE FOLLOW VISITS ARE NEEDED BASED ON THE INITIAL VISIT OR CURRENT VISIT, ADVISE THE MOTHER OF THE NEXT FOLLOW UP VISIT. ALSO, ADVISE THE MOTHER WHEN TO RETURN IMMEDIATELY.

COUNSEL THE MOTHER

FOOD

  1. Assess the child’s feeding.
  2. Ask questions about the child’s usual feeding.
  3. Compare the mother’s answers to the feeding recommendations.

Ask!

  • Do you breastfeed your child?
  1. How many times during the day?
  2. Do you breastfeed during the night?

  • Does the child take any other foods or fluids?

  1. What food or fluids?
  2. How many times per day?
  3. What do you use to feed the child?
  4. If very low weight for age: how large are the servings? does the child receive his/her own serving? who feeds the child & how?

  • During the illness has the child’s feeding changed? If yes. How?

FEEDING RECOMMENDATIONS DURING SICKNESS AND HEALTH FOR CHILDREN UP TO 6 MONTHS OF AGE

  • Breastfeed often as the child wants day and night, at least 8 times in 24 hrs.
  • Do not give other foods or fluids.
  1. Only if the child between 4-6 months appears hungry after BF or is not gaining weight adequately, you can add complementary food as listed under 6-12 months of age.
  2. Give these foods 1-2 times per day after BF.

6-12 MONTHS OF AGE

  • Breastfeed as often as the child wants.
  • Give an adequate serving of:
  1. A) Thick porridge made of either maize or cassava or millet or soya floor. Add sugar and oil, mix either milk or pounded ground nuts.
  2. B) Mixtures of mashed foods made out of posho (maize or millet) or rice or Matooke, potatoes or cassava. Mix with fish or beans or pounded ground. Add green vegetables, give a snack like an egg or banana or bread. 3 times/day if breastfed, 5 times/day if not breastfed.

12 MONTHS – 2 YEARS OF AGE

  • Breastfeed as often as the child wants.
  • Give an adequate serving of:
  1. Mixtures of mashed foods made out of either Matooke or potatoes or cassava or posho (maize or millet) or rice.
  2. Mix with either fish or beans or meat or pounded ground nuts.
  3. Add green vegetables.
  4. Thick porridge made of either maize or cassava or millet or soya, add sugar and oil, mix with either milk of pounded ground nuts.
  5. Snacks like an egg or banana or bread or family food 5 times a day.

2 YEARS OF AGE AND OLDER

  • Give family foods at 3 meals each day, also twice daily give nutritious snacks between meals such as banana or eggs or bread.
  1. A good daily diet should be adequate in quantity and include an energy-rich food (e.g., thick cereal with added oil), meat, fish, eggs, fruits, and vegetables.

COUNSEL THE MOTHER ABOUT FEEDING PROBLEMS

  • If the child is not being fed as described in the above recommendations, counsel the mother accordingly.
  • If the mother reports difficulty with BF, assess BF as needed.
  1. Important is to show the mother correct positioning and attachment for Breastfeeding, and ensure general breast hygiene before BF.

  • If the child is less than 6 months of age and is taking other milk or foods:

  1. Build the mother’s confidence that she can produce all the breast milk that the child needs.
  2. Suggest giving more frequent, longer BF day and night and gradually reducing other milk or foods.
  3. If the mother is away from the child due to work, suggest that the mother expresses breast milk to leave for the baby.
  4. But if other milk needs to be continued, counsel the mother to BF as much as possible, including night.
  5. Make sure that other milk is a locally appropriate breast milk substitute such as cow’s milk.
  6. Make sure other milk is correctly and hygienically prepared and given in adequate amounts.
  7. Finish prepared milk within an hour.
  8. If the child is being given diluted milk or thin porridge:
  • Remind mothers that thick foods which are dense in energy and nutrients are needed by infants and young children.
  • Do not dilute the milk.
  • Increase the thickness of porridge.
  1. If the mother is using a bottle to feed the child:
  • Recommend substituting a cup for a bottle.
  • Show the mother how to feed the child with a cup.
  1. If the child is not being fed actively, counsel the mother to:
  • Sit with the child and encourage eating.
  • Give the child an adequate serving on a separate plate or bowl.
  1. If the mother is not giving green leafy vegetables or other foods rich in vit A:
  • Encourage her to provide vit A-rich foods frequently e.g. green leafy vegetables, carrots, liver.
  1. If the child is 6 months of age and above and appropriate complementary foods have not been introduced:
  • Gradually introduce thick porridge mixed with available protein e.g. milk, add sugar and fat.
  • Gradually introduce a mixture of mashed food mixed with relish, add green leafy vegetables and fat.
  • Give a nutritious snack.
  1. Child eats solid food but without enough nutrient density or variety:
  • Give a variety of mixtures of mashed food made out of local staples mixed with relish made out of animal or plant protein.
  • Add green leafy vegetables and fat.
  • Follow up any feeding problem in 5 days.
  1. Advise the mother to increase fluid during illness.
  2. For any sick child, BF more frequently & for longer at each feed.
  3. Increase fluid e.g. rice water, yoghurt, clean water, if not exclusive BF.
  4. For a child with diarrhea, giving extra fluid can be life-saving.
  5. Give fluid according to Plan A, B, C.
  6. Advise the mother on when to return to the health worker.

Follow up : If the child has

Condition

Follow-up

Pneumonia, dysentery, malaria, measles

2 days

Persistent diarrhea, acute/chronic ear infection, feeding problem, any other not improving

5 days

Pallor

14 days

Very low weight for age

30 days

Advise on when to return immediately

Any sick child

-not able to drink or breastfeed

-becomes sicker 

-develops a fever

If child has no pneumonia: cough or cold, return if

-fast breathing 

-difficult breathing

If child has diarrhea: return if

-blood in stool Drinks or breastfeeds poorly

Counsel the mother about her own health

  • If the mother is sick, provide care for her or refer.
  • If she has a breast problem e.g. engorgement, sore nipples, breast infection provide care or refer.
  • Advise to eat well.
  • Check her immunization, give TT if needed.
  • Make sure she has access to FP, STD?AIDS counseling/prevention, antenatal if pregnant.

TREAT THE CHILD in IMCI Read More »

Assessing and Classification of a Sick Child and General Danger Signs.

Assessing and Classification of a Sick Child and General Danger Signs.

Assessing and Classification of a Sick Child

Determine whether this is an initial visit or a return (follow up) visit. 

If it is an initial visit, Ask, “what is the child’s problem”?

After knowing the problem;

  • Check for general danger signs.

A general danger sign is an indicator that a child has a severe problem and therefore needs urgent referral.

General danger signs include:

  • The child is unable to drink/feed.
  • Vomiting everything.
  • The child has convulsions.
  • The child is lethargic or unconscious.
  • Child is convulsing now.

Then ask about other main symptoms

GENERAL DANGER SIGNS

General danger signs in children are indicators of serious illness that require immediate action to save the child’s life. 

These signs are seen in children aged two months up to five years and should not be ignored. The 4 general Danger signs according to World Health Organisation are;

  • Unable to breastfeed or drink: If a child is unable to suck or swallow when offered a drink or breastmilk, it is considered a danger sign.
  • Vomiting everything: If a child is not able to hold down any food, fluids, or oral medications and vomits everything, it is a cause for concern.
  • Convulsions: Convulsions are characterized by the child’s arms and legs stiffening due to muscle contractions or repeated abnormal movements. The child may also lose consciousness or be unresponsive to spoken directions.
  • Lethargic or unconscious: A lethargic child is drowsy, not alert, and shows no interest in their surroundings. They may not look at their mother or respond to stimuli. An unconscious child cannot be awakened and does not respond to touch, shaking, or spoken words.

Child with any General Danger sign needs URGENT attention: complete assessment, give any pre-referral treatment immediately and refer.

  1. Not able to drink or breastfeed:

“Not able to drink or breast-feed” means that the child is not able to suck or swallow when offered a drink or breast milk.

NB: if not sure of the mother’s answer, offer the child clean water/breastmilk

  1. Vomiting everything:

“Vomiting everything” means;

  • Child is not able to hold anything down at all.

What goes down comes back up.

  • NB: if not sure of the mother’s answer, offer the child clean water/breastmilk. Observe if the child vomits
  1. Convulsions:

A convulsion is any involuntary movement in any part of the body.

  • A child can have this danger sign if there is a history of convulsions or convulsing during the visit.
  • A history of convulsions only counts as a danger sign if the convulsions happened during the present illness.
  • Use words for convulsions that caregivers understand. eg fits or spasms.
  1. Lethargic or unconscious:

“Lethargic or unconscious” means that:

  • The child is not awake and alert when he should be.
  • He is drowsy and does not show interest in what is happening around him.
  • The child may stare blankly and appears not to notice what is going on around him.; or
  • Unconscious child cannot be awakened. He does not respond when touched, shaken, or spoken to

CHECK FOR GENERAL DANGER SIGNS 

ASK

LOOK

–Is the child able to drink or breastfeed?

-See if the child is lethargic or unconscious.

-Does the child vomit everything?

-Is the child convulsing now? If yes, treat immediately.

-Has the child had convulsions in this illness?

  

A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.

SIGNS

CLASSIFY AS

TREATMENT

Any general danger sign

VERY

SEVERE

DISEASE


• Give diazepam if convulsing now.

• Quickly complete the assessment.

• Give any pre-referral treatment immediately.

• Treat to prevent low blood sugar.

• Keep the child warm.

• Refer URGENTLY.

• Screen for possible TB disease and check for HIV.

*ANYTHING IN BOLD IS URGENT PRE-REFERRAL TREATMENT

THEN ASK ABOUT MAIN SYMPTOMS:

Four main symptoms

The health worker attending to a sick child MUST ask about all the four main symptoms below.

  • Cough or difficult breathing
  • Diarrhoea
  • Fever
  • Ear problem

When a symptom is present, assess further on that symptom.

Cough or Difficult breathing
  • Pneumonia is among the leading causes of death in children under five years.
  • Most children with cough or difficulty breathing have only a cough or a cold.
  • A few children with cough or difficulty breathing may also have pneumonia.

ASSESSING FOR COUGH OR DIFFICULT BREATHING – THE CHILD MUST BE CALM

Does the child have cough or difficult breathing?

ASK

LOOK, LISTEN, FEEL

IF YES, ASK

For how long?

Count the breaths in one minute.

Use respiratory rate timers where available

• Look for chest in-drawing*

• Look and listen for stridor**

• Look and listen for wheeze***

• Check for central cyanosis

• Check for oxygen saturation using pulse oximetry where available.

• Check AVPU****

• If wheezing with either chest indrawing or fast breathing: Assess

for possible Asthma.

• If wheezing assesses for possible TB disease.

 

-Is the child convulsing now? If yes, treat immediately.

 

If the child is: 

2 months up to 12 months 

12 months up to 5 years 

Fast breathing is:

50 breaths per minute or more

40 breaths per minute or more

SIGNS

CLASSIFY AS

TREATMENT

Any general danger sign 

OR 

• Oxygen saturation less than 90% 

• Chest indrawing or

Stridor in calm child. 

• Central Cyanosis

• AVPU = V, P or U

VERY

SEVERE

DISEASE

• Give diazepam if convulsing now.

• Quickly complete the assessment.

• Give any pre-referral treatment immediately.

• Treat to prevent low blood sugar.

• Keep the child warm.

• Give fist oral dose of oral cotrimoxazole

• Give Vit A

• Refer URGENTLY.

• Screen for possible TB disease and check for HIV.

Note: *ANYTHING IN BOLD IS URGENT PRE-

REFERRAL TREATMENT

 

*Chest in-drawing is present if the lower

chest wall moves in during inspiration.

 

**Stridor – a harsh sound heard during

inspiration.

 

***Wheeze – a musical sound heard

during expiration.

 

****AVPU – Alert, responsive to Voice,

responsive to Pain, Unresponsive

 

Chest indrawing in

calm child

OR

• Fast breathing

AND

• No signs of severe

pneumonia

PNEUMONIA

• Give Amoxicillin Dispersible Tablet. 

• Give Vitamin A. 

• Treat wheeze if present.

• If wheezing, follow-up in 2 days.

• Soothe the throat and relieve the cough with a safe remedy.

• Screen for possible TB disease and check for HIV.

• If wheezing (or disappeared after rapidly acting bronchodilator) give an inhaled bronchodilator for 5 days

• If coughing for more than 14 days or recurrent wheeze, refer for possible TB or asthma assessment.

• Review in 2 days, if not possible, admit OR refer children with chest

indrawing.

• Advise mother when to return immediately.

No signs of pneumonia or very severe disease.

NO PNEUMONIA: COUGH OR COLD

• Treat wheeze if present.

• If wheezing, follow-up in 2 days.

• Soothe the throat and relieve the cough with a safe remedy.

• Follow-up in 5 days if not improving.

• Screen for possible TB disease and check for HIV.

• Advise mother when to return immediately.

Diarrhoea
Diarrhoea
  • Diarrhoea is the passage of three or more watery stools in 24 hours. It is common in children, especially those between 6 months and 2 years of age.
  • It is the 2nd leading cause of mortality in under-fives.
  • Most of these deaths are usually due to dehydration.
  • If an episode of diarrhoea lasts less than 14 days, it is an acute diarrhoea and if 14 days or more, it is persistent diarrhoea. 
  • Diarrhoea with blood in the stool, with or without mucus, is called dysentery.
  • Frequent passage of normal stool is not diarrhoea.

Does the child have diarrhoea?

ASK

LOOK, LISTEN, FEEL

IF YES, ASK

For how long?

• Is there blood in the stool?

– Look at the child’s general conditions.

Check:

  • Weak/ absent pulse
  • Not alert; AVPU*<A
  • Cold hands +Temp gradient
  • Capillary refill >3 sec

Is the child:

  • Lethargic or unconscious?
  • Restless and irritable?

– Look for sunken eyes

– Offer the child fluid, is the child:

  •  Not able to drink or drinking poorly?
  •  Drinking eagerly, thirsty?

– Pinch the skin of the abdomen.

Does it go back:

  • Very slowly (longer than 2 seconds)?
  • Slowly?
  • Immediately?
 

Remember to classify all children with diarrhoea for dehydration.

for DEHYDRATION 

SIGNS

CLASSIFY AS

TREATMENT

All four of:

• Weak/absent pulse

• AVPU* < A

• Cold hands + Temp

gradient

• Capillary refill > 3 sec

PLUS

• sunken eyes and very

slow/slow skin pinch.

HYPOVOLAEMIC

SHOCK

FROM

DIARRHOEA/

DEHYDRATION

• TREAT FOR SHOCK. Give Ringer’s Lactate 20mls/kg.

 – A second bolus may be given if required before proceeding to step 2 of PLAN C.

• Treat for and to prevent low blood sugar.

• Assess for severe acute malnutrition.

• Assess for severe anaemia.

• NB: If HB<5g/dl transfuse urgently

• Admit or refer urgently to hospital

• Screen for possible TB disease and check for HIV

• If a child is 2yrs or older & there’s cholera in your area, give oral cotrimoxazole for cholera.

Two or more of the following

signs:

• Restless, irritable

• Sunken eyes

• Drinks eagerly, thirstily

• Skin pinch goes back slowly

SOME DEHYDRATION

If child also has a severe classification:

– Admit or refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.

Advise the mother to continue breastfeeding.

 OR

If the child has no severe classification:

– Give fluid and food for some dehydration (Plan B).

– Give vitamin A.

– Give ORS and Zinc Sulphate.

• Follow-up in 2 days if not improving.

• Screen for possible TB disease and check for HIV

• Advise mother when to return immediately.

Not enough signs to classify as

some or severe dehydration.

NO DEHYDRATION

If child also has a severe classification:

– Admit or refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.

Advise the mother to continue breastfeeding.

 OR

• If the child has no severe classification:

– Give fluid and food to treat diarrhoea at home (Plan A).

– Give vitamin A.

– Give ORS and Zinc Sulphate.

• Follow-up in 5 days if not improving.

• Screen for possible TB disease and check for HIV.

• Advise mother when to return immediately.

and if diarrhoea 14 days or more

Dehydration present:

(hypovolaemic shock,

severe dehydration, some dehydration).

SEVERE PERSISTENT DIARRHOEA

• Treat hypovolaemic shock and any other form of dehydration before referral unless the child has another severe classification.

• Give Vitamin A. 

• Give ORS and Zinc Sulphate.

• Give Multivitamin / Mineral supplements.

• Admit or refer URGENTLY to hospital with mother giving frequent sips of ORS on the way.

• Screen for possible TB disease and check for HIV.

No dehydration

PERSISTENT DIARRHOEA

• Advise the mother on feeding a child who has PERSISTENT DIARRHOEA. 

• Give vitamin A.

• Give ORS and Zinc Sulphate.

• Give Multivitamin / Mineral supplements.

• Check for HIV infection.

• Follow-up in 5 days.

• Screen for possible TB disease and check for HIV

and if blood in stool

Blood in the stool.

DYSENTERY

• Treat with Ciproflaxacin.

• Give Vitamin A. 

• Give ORS and Zinc Sulphate.

• Follow-up in 2 days.

• Screen for possible TB disease and check for HIV.

Fever

Fever is present if :-

  • There is history from parent/caregiver or
  • Child feels hot or
  • Child has temperature 37.5° c and above

A child with fever may have malaria, measles or another severe disease. Malaria currently causes 11% of under five deaths. Fever may also be due to a simple cough, cold or other viral infection.

To classify and treat fever, you must know malaria risk in your area.

  • High Malaria risk; > 5% of fever cases in children are due to malaria.
  • Low Malaria risk; 5% or less of fever cases in children are due to malaria.

Does the child have fever? (by history or feels hot or temperature 37.5°C* or above)

IF YES:

  • Has the child travelled to a high risk (Malaria endemic, seasonal transmission or epidemic prone) area in the last 1 month?

Decide Malaria Risk: high or low risk.

ASK

LOOK &  FEEL

THEN ASK:

• For how long?

• If more than 7 days, has fever been present every day?

• Has the child had signs of measles within the last 3 months?

LOOK AND FEEL:

• Look or feel for stiff neck.

• Look for runny nose.

Look for signs of MEASLES:

• Generalized rash and one of

these: cough, runny nose, or red eyes.

• Look for any other cause of fever•••

 

High Malaria risk:

Do a malaria test

 ○ Endemic Zone

 ○ Seasonal Transmission Zone

 ○ Epidemic prone areas

Low malaria risk:

 ○ Do a malaria test if there is no obvious cause of fever.

TEST POSITIVE

• P.falciparum PRESENT

• P.vivax PRESENT

 

TEST NEGATIVE

• P.falciparum or P.vivax

absent

NOTE: If you can’t test, don’t withhold treatment.

SIGNS

CLASSIFY AS

TREATMENT

• Any general danger sign or

 • Stiff neck.

 AND 

• Confirm malaria with a test.

 

VERY SEVERE FEBRILE DISEASE OR SEVERE MALARIA

• Give first dose of artesunate or quinine for severe malaria.

• Give first dose of an appropriate antibiotic (Give first dose of Ceftriaxone)

• Treat the child to prevent low blood sugar.

• Give one dose of paracetamol in the clinic for high fever (≥38.5 °C).

• Admit or Refer URGENTLY to hospital.

• Screen for possible TB disease and check for HIV.

• Malaria test POSITIVE**

UNCOMPLICATED MALARIA

• Give recommended first line oral antimalarial   

• Give Artemether + Lumefantrine (AL).

• Give one dose of paracetamol in clinic for high fever (≥38.5 °C).

• Give appropriate antibiotic treatment for an identified bacterial cause of fever.

• Give Vitamin A.

• Follow up in 3 days if fever persists.

• If fever is present every day > 7 days assess further or refer 

• Screen for possible TB disease and check for HIV

• Advise when to return immediately.

• Malaria test NEGATIVE

FEVER: NO MALARIA

• Give one dose of paracetamol in clinic for high fever (≥38.5 °C) 

• Assess for other possible causes of fever 

• Follow up in 3 days if fever persists.

• If fever is present every day for more than 7 days assess further or refer.

• Screen for possible TB disease and check for HIV 

• Advise mother when to return immediately.

 

CHECK FOR COMPLICATIONS OF  MEASLES

Check for Complications of MEASLES.

If the child has signs of measles now or within the last 3 months 

• Look for mouth ulcers, are they deep or extensive?

• Look for pus draining from the eye 

• Look for clouding of the cornea

SIGNS

CLASSIFY AS

TREATMENT

Generalized rash of measles and 

• One of: cough, runny nose or red eyes

SUSPECTED MEASLES

• Give Vitamin A (See page 14) 

• Notify, take blood sample for confirmation. 

• Screen for possible TB disease and check for HIV.

• Advise mother when to return immediately.

Any general danger sign or 

• Clouding of cornea or 

• Deep or extensive mouth ulcers.

SEVERE COMPLICATIONS OF MEASLES

• Give Vitamin A.

• Give first dose of Ceftriaxone Antibiotic.

• If clouding of the cornea or pus draining from the eye, apply tetracycline eye ointment.

• Notify, take blood sample for confirmation OR refer 

• Admit or refer URGENTLY to hospital 

• Screen for possible TB disease and check for HIV.

• Pus draining from the eye or 

• Mouth ulcers.

EYE OR MOUTH COMPLICATIONS OF MEASLES

• Give Vitamin A

• If pus draining from the eye, treat eye infection with tetracycline eye ointment.

• If mouth ulcers, treat with nystatin

• Follow-up in 2 days.

• If child has no indication for referral, notify and draw blood sample for confirmation of measles 

• Screen for possible TB disease and check for HIV

• No pus draining from the eye or mouth ulcers.

NO EYE OR MOUTH COMPLICATIONS OF MEASLES

• Give Vitamin A if not received in the last 1 month.

• If child has no indication for referral, draw blood and send for confirmation.

• Screen for possible TB disease immediately after the measles infection and check for HIV.

EAR PROBLEM
  • A child with an ear problem may have an ear infection.
  • Ear infection may cause pus to collect behind the eardrum causing pain and often fever.
  • If not treated, the eardrum may burst, discharge pus and the child feels less pain.
  • However, the child may suffer poor hearing or worse deafness.
  • Ear infection may lead to Mastoiditis or Meningitis.

Does the child have an ear problem?

ASK

LOOK AND FEEL

IF YES, ASK

• Is there ear pain? 

• Is there ear discharge? If yes, for how long?

  • Look for pus draining from the ear. 
  • Feel for tender swelling behind the ear.
  •  Drinking eagerly, thirsty?

Pinch the skin of the abdomen.

Does it go back:

  • Very slowly (longer than 2 seconds)?
  • Slowly?
  • Immediately?

Classify EAR PROBLEM

SIGNS

CLASSIFY AS

TREATMENT

• Tender swelling behind the ear.

MASTOIDITIS

• Give first dose of Ceftriaxone Antibiotic.

• Give first dose of paracetamol for pain

• Refer URGENTLY to hospital or admit 

• Check for HIV.

• Pus is seen draining from the ear or 

• Discharge is reported for less than 14 days,or

 • Ear pain.

ACUTE EAR INFECTION

• Give Amoxicillin dispersible tablets for 5 days. 

• Give paracetamol for pain

• Dry the ear by wicking

• Check for HIV infection 

• Follow-up in 5 days

• Pus is seen draining from the ear or discharge is reported for 14 days or more.

CHRONIC EAR INFECTION

• Dry the ear by wicking

• Check for HIV infection 

• Follow-up in 5 days

• No ear pain and No pus seen or reported draining from the ear.

NO EAR INFECTION 

  • No treatment.

THEN CHECK FOR ACUTE MALNUTRITION

Good nutrition results from the adequate intake of macronutrients, micronutrients and water to supply the metabolic (anabolic and catabolic) processes in the body.

There are two components of nutrition;

  1. Macronutrients
  2. Micronutrients

What is Malnutrition?

  • Malnutrition is defined as a state when the body does not have enough of the required nutrients (under-nutrition) or has excess of required nutrients (overnutrition).
  • Inadequacies of macro or micro nutrients may result in failure to thrive, poor growth or wasting.
  • These processes are often measured by their anthropometric consequences (weight for age, height for age or weight for height).
  • Undernutrition is the most common form of malnutrition in developing countries.

ASSESS FOR MALNUTRITION 

ASK

LOOK AND FEEL

Is there a history of TB contact? 

• Look for oedema of both feet.

• Determine the child’s weight for Height/length (WFHL*) and plot on the IMNCI Chart booklet to determine the z-score. 

• Determine the growth pattern; Is the growth faltering? (Weight curve flattening or dropping for at least 2 consecutive months?) 

• Measure MUAC**mm in a child 6 months or older 

• IF WFH/L less than -3 z-score or MUAC less than 115mm then:

 

Check for any medical complication present: 

• Any general danger signs. 

• Any severe classification. 

• Pneumonia with chest in-drawing. 

If no medical complication present: 

• Conduct an appetite test. 

• Child is 6 months or older, offer RUTF to eat

 Is the child 

> Not able to finish RUTF portion 

> Able to finish RUTF portion 

• Child is less than 6 months, assess breastfeeding 

> Does the child have breastfeeding problems? If child has acute Malnutrition and is receiving RUTF, DO NOT give iron because there is already adequate amount of IRON in RUTF

Classify Malnutrition

SIGNS

CLASSIFY AS

TREATMENT

• Oedema of both feet, OR 

• WFH/L less than -3 z scores 

OR 

• MUAC Less than 11.5 cm and ANY one of the following: 

– medical complication present or 

– not able to finish RUTF***

or 

– Breast feeding problem (<6 months)

SEVERE ACUTE MALNUTRITION WITH COMPLICATIONS FOR CHILDREN

• Treat the child to prevent low blood sugar.

• Keep the child warm 

• Give first dose of Benzylpenicillin + Gentamicin

• Give Vitamin A 

• Refer URGENTLY to hospital 

• Admit or refer urgently to hospital if child has any other complications (Danger signs: Diarrhoea, Pneumonia, Fever, No appetite, etc) 

• Immunize as per schedule. 

• Screen for possible TB disease and check for HIV.

For all children: 

• With visible severe wasting 

• Oedema of both feet, 

• <-3 Z Score ( weight for age or weight for height/Length) For children 6 months up to 59 months: MUAC <11.5 cm

SEVERE ACUTE MALNUTRITION 

As above

• WFH/L less than -3 z scores 

OR 

• MUAC Less than 11.5 cm 

AND 

• Able to finish RUTF

SEVERE MALNUTRITION WITHOUT COMPLICATIONS

• Give oral Amoxicillin DT for 5 days 

• Give ready to use therapeutic food for child aged six months and above 

• Screen for possible TB disease and check for HIV • Follow up in 7 days.

• Assess the child’s feeding and counsel the mother on the feeding recommendations.

• Immunize as per schedule.

• Advise mother when to return immediately

For all age groups: 

• Static weight or losing weight 

• 3 to <-2 Z- Score 

If age 6 months up to 59 months MUAC 11.5 to 12.5 cm

MODERATE ACUTE MALNUTRITION

• If growth is faltering for 2 consecutive months, give Vitamin A, assess further or refer to a hospital.

• Assess the child’s feeding and counsel the mother on the feeding recommendations.

• Give Albendazole if the child is 1 year or older and has not had a dose in the previous 6 months. 

• If feeding problems, follow up in 14 days.

• Screen for possible TB disease and check for HIV 

• Immunize as per schedule.

• Advise mother when to return immediately

For all age groups: 

• Static weight or losing weight 

• -2 to <-1 Z- Score 

If age 6 months up to 59 months MUAC 12.5 to 13.5cms

AT RISK OF ACUTE MALNUTRITION

• If child is less than 2 years old, and has growth faltering, assess the child’s feeding and counsel the mother on feeding according to the feeding recommendations 

• Give Albendazole if the child is 1 year or older and has not had a dose in the previous 6 months.

• Follow up in 14 days 

• If feeding problem, follow-up in 5 days

• Screen for possible TB disease and check for HIV 

• Immunize as per schedule

• Advise mother when to return immediately

WFH/L > -1 to +2 Z scores 

OR 

MUAC > 13.5 cm

NO ACUTE MALNUTRITION

• If the child is less than 2 years old, assess the child’s feeding and counsel the mother on feeding according to the feeding recommendations.

• If feeding problem, follow-up in 5 days

• Give Albendazole if child is 12 months and has not had a dose in the previous 6 months

• Immunize as per schedule 

 • Screen for possible TB disease and check for HIV

 CHECK FOR ANAEMIA 

Anaemia

The condition of having a lower-than-normal number of red blood cells or quantity of hemoglobin. Anemia diminishes the capacity of the blood to carry oxygen.

Common Causes

  • Iron deficiency; may result from a diet deficient in iron.
  • Intestinal parasites.
  • Repeated nosebleeds.
  • Haemolysis, due to: Malaria and other Inherited blood disorders like sickle cell disease)
  • Chronic illness, such as tuberculosis and AIDS.
  • Severe malnutrition (due to lack of protein to produce haemoglobin)

ASSESS FOR ANAEMIA

LOOK AND FEEL

Look for palmar pallor.

 Is it: 

• Severe palmar pallor? 

• Some palmar pallor? 

• No palmar pallor? 

• Do haemoglobin level (HB) test.

 

SIGNS

CLASSIFY AS

TREATMENT

• Severe palmar pallor 

• If HB<5g/dL

SEVERE ANAEMIA

• Treat to prevent low blood sugar

• Keep the child warm 

• Admit or refer URGENTLY to hospital 

• Screen for possible TB disease and check for HIV

• Some palmar pallor

ANAEMIA

• Assess the child’s feeding and counsel the mother on feeding.

• If growth is faltering for 2 consecutive months, assess further or refer to hospital 

• Give Iron and Folate.

• Give vitamin A 

• Give Albendazole if child is 1 year or older and has not had a dose in the last 6 months 

• Screen for TB disease and check for HIV 

• Follow up in 14 days 

• Immunize as per schedule

• Advise mother when to return immediately.

•  No Palmar pallor 

NO ANAEMIA

• If child is less than 2 years old, assess the child’s feeding and counsel the mother according to the feeding recommendations

• If feeding problems, follow up in 5 days

• Give Albendazole if child is 1 year or older and has not had a dose in the last 6 months

• Immunize as per schedule

• Screen for possible TB disease and check for HIV

 

CHECK FOR HIV EXPOSURE AND INFECTION

All children found to have pneumonia, persistent diarrhea, ear discharge or very low weight for age (any of these features) and have no urgent need or indication for referral, should be assessed for symptomatic HIV infection. 

  • Children may acquire HIV infection from an infected mother through vertical transmission in utero, during delivery or while breastfeeding.
  • Without any intervention, 30 – 40% babies born to infected mothers will themselves be infected.
  • Most children born with HIV die before they reach their fifth birthday, with most not surviving beyond two years.
  • Good treatment can make a big difference to children with HIV and their families.
  • The child’s status may also be the first indicator that their parents are infected too.

ASSESS FOR HIV EXPOSURE AND INFECTION 

ASK

LOOK, FEEL AND DIAGNOSE

• Ask for mother’s HIV status to establish child’s HIV exposure* 

Is it: 

Positive, Negative or Unknown (to establish child’s HIV exposure) 


• Ask if child has had any TB Contact

Child <18 months 

• If mother is HIV positive**, conduct DNA PCR for the baby at 6 weeks or at first contact with the child 

• If mother’s HIV status is unknown, conduct an antibody test (rapid test) on mother to determine HIV exposure. 

PRESUMPTIVE SYMPTOMATIC DIAGNOSIS OF HIV INFECTION IN CHILDREN <18 MONTHS 

• Pneumonia *** 

• Oral Candidiasis /thrush 

• Severe sepsis 

• Other AIDS defining conditions**


Child ≥18 months 

• If the mother’s antibody test is POSITIVE, the child is exposed. Conduct an antibody test on the child. 


Child whose mother is NOT available: 

• Child < 18 months 

Do an antibody test on the child. If positive, do a DNA PCR test. 

• Child ≥ 18 months 

Do an antibody test to determine the HIV status of the child

CLASSIFY HIV STATUS

SIGNS

CLASSIFY AS

TREATMENT

• Child < 18 months and DNA PCR test POSITIVE 


• Child ≥ 18 months and Antibody test POSITIVE 

CONFIRMED HIV INFECTION

• Initiate ART, counsel and follow up existing infections 

• Initiate or continue cotrimoxazole prophylaxis

• Assess child’s feeding and provide appropriate counseling to the mother/caregiver

• Offer routine follow up for growth, nutrition and development and HIV services 

• Educate caregivers on adherence and its importance 

• Screen for possible TB disease at every visit. 

• For those who do not have TB disease, start Isoniazid prophylactic therapy (IPT). Screen for possible TB throughout IPT 

• Immunize for measles at 6 months and 9 months and boost at 18 months 

• Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive HIV care of the child.

Child<18 months 

• If mother test is positive and child’s DNA PCR is negative OR 

• If mother is unavailable; child’s antibody test is positive and DNA PCR is negative

HIV EXPOSED

• Treat, counsel and follow up existing infections 

• Initiate or continue Cotrimoxazole prophylaxis 

• Give Zidovudine and Nevirapine prophylaxis as per the national PMTCT guidelines 

• Assess child’s feeding and provide appropriate counseling to the mother/caregiver  

• Offer routine follow up for growth, nutrition and development 

• Repeat DNA PCR test at 6 months. If negative, repeat DNA PCR test again at 12 months. If negative, repeat antibody test at 18 months

• Continue with routine care for under 5 clinics 

• Screen for possible TB at every visit 

• Immunize for measles at 6 months and 9 months and boost at 18 months

• Follow up monthly as per the national ART guidelines and offer comprehensive management of HIV. Refer to appropriate national ART guidelines for comprehensive care of the child.

• No test results for child or mother 

• 2 or more of the following conditions: 

• Severe pneumonia 

• Oral candidiasis/thrush 

• Severe Sepsis

 OR

• An AIDS defining condition

SUSPECTED SYMPTOMATIC HIV INFECTION

• Treat, counsel and follow-up existing infections

• Give cotrimoxazole prophylaxis

• Give vitamin A supplements from 6 months of age every 6 months

• Assess the child’s feeding and provide appropriate counseling to the mother

• Test to confirm HIV infection

• Refer for further assessment including HIV care/ ART

• Follow-up in 14 days, then monthly for 3 months and then  every 3 months or as per immunization schedule 

Mother’s HIV status is NEGATIVE 

OR 

Mother’s HIV status is POSITIVE and child is ≥ 18 months with antibody test NEGATIVE 6 weeks after completion of breastfeeding

HIV NEGATIVE

• Manage presenting conditions according to IMNCI and other recommended national guidelines 

• Advise the mother about feeding and about her own health

CHECK THE CHILD’S IMMUNIZATION, VITAMIN A & DEWORMING STATUS

  1. Immunization is one of the most cost effective health interventions for disease control.
  2. It targets children under the age of 5 years.
  3. It needs tremendous input and effort to make it happen.
  4. Immunization coverage can be enhanced through;
  • Routine Immunization
  • Supplemental Immunizations
  • Surveillance of the target diseases
  • Mopping up in high risk areas

A child’s body requires Vitamin A for; Growth and development, Protection against infections & reinforces the body’s immunity. Vit A deficiency may result from; Inadequate intake of vitamin A rich foods, Poor absorption of the vitamin A & rapid utilization of vitamin A stores due to illnesses

Vit A deficiency may lead to;

  • Increased incidence of illness
  • Delays recovery from infections
  • Leads to eye damage and may even lead to blindness
  • Increases the risk of death in sick children

Remember, Vit A supplementation can; 

  •  Reduces measles mortality by 50% 
  • Reduces diarrhea mortality by 33% 
  • Reduces all causes of mortality by 23%

CHECK CHILD’S IMMUNIZATION

 

  • *If BCG is not given at birth, it should not be given to children with symptomatic HIV /AIDS.
  • **Measles vaccine at 6 months is for HIV exposed/ infected children
  • ***Yellow fever vaccine should not be given to children with symptomatic HIV/AIDS.
  • ****RotaVirus vaccine should not be given to children over 15 months
  • Pentavalent not given if child had convulsion following previous dose or a child with recurrent convulsions or another active neurological disease
  • PCV10 & Pentavalent not given to Infants with a moderate or severe illness (temperature ≥39°C) until their condition improves.
  • PCV10 and Pentavalent contraindicated if severe allergic reactions or shock to a prior dose or any component of the vaccine.
  • Do not delay referrals of children with severe classifications to administer immunizations.

ASSESS OTHER PROBLEMS THE CHILD MIGHT HAVE

It is important to remember that the already discussed IMCI case management process ;

  • Does not cover all symptoms
  • Is not reviewing all pediatric medicine
  • Remember to address some complaints the caregiver may have raised, eg she may have said the child has an itchy skin, You may have observed another problem the mother didn’t say eg jiggers.
  • Treat any other problems according to your training, experience and clinic policy.
  • Refer the child for any other problem you cannot manage in the clinic.

Assessing and Classification of a Sick Child and General Danger Signs. Read More »

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