BY ELIJAH GOLDBERG.
Photography by Walimu.
A couple of years ago I was fortunate enough to meet a talented group of doctors from Uganda and the United States who have dedicated their lives to the study of severe illness. Together, these doctors and I formed Walimu, a non-profit organization that works to improve the quality of medical care for severely ill hospitalized patients in resource-limited settings.
Walimu aims to address a major gap in global health. As the global health community developed over the past half century, efforts centered on massive disease prevention or broader health system reform. Large-scale initiatives sought to increase funding for health-systems, prevent the spread of specific, high-burden diseases, or spur development of new cures. Smaller initiatives provided an alternative to the government-run health system, setting up mission-style centers of excellence for the poor, though never enough of them. There were few systematic efforts to improve the actual quality of health care delivered.
Why? The reasoning was that in settings with severely limited resources, and a severely sick population, access and prevention, not the standard of care, should be the priorities. Broader quality of care would come after there were enough doctors, drugs, resources, and money. This is an understandable mindset, particularly given the impression that good care requires a lot of money. Hospitals like Memorial Sloan-Kettering or the Cleveland Clinic conjure up images of quality, but certainly not affordability. For societies where access to any healthcare at all is a struggle for many, quality is a second priority, and a distant one at that.
The access and prevention first mindset has been changing. This change is due in part to a growing body of evidence on what constitutes appropriate assessment and management in resource-limited settings. The global health community has developed guidelines and algorithms, based on decades of randomized controlled trials and other studies, for health workers with access to few resources. But perhaps more importantly, the evidence shows that not only can good care be delivered with few resources, better care can also end up costing a lot less.
One particularly successful approach to high quality care with few resources is referred to as “syndromic management.” In the typical developing setting, patients are routinely assessed and treated improperly for a variety of reasons. Diagnostic support is minimal, drugs are scarce, and clinical knowledge is often limited. Many patients come in with syndromes of multiple, overlapping conditions challenging even by developed standards. Syndromic management provides clinicians with guidance on how to act decisively, particularly in life-threatening situations, even without a full picture of the disease state of the patient. Clinicians treat based on the signs, symptoms, patient history and local epidemiology and follow broadly standardized, evidence based algorithms that are often adapted to the setting.
Perhaps the most well known set of syndromic management guidelines is the Integrated Management of Childhood Illness (IMCI). Developed by the World Health Organization in the 1990s, IMCI has gathered all of the relevant data on how to best care for children in resource-limited settings and compiled it in one simple, accessible set of standards. IMCI assumes a minimum amount of diagnostic support and drug availability, providing a standard of care achievable in almost any setting.
IMCI is important because it works. Implemented in 75 countries, IMCI has decreased mortality for children under five, improved health worker performance and increased quality of care. IMCI is also typically cheaper, sometimes costing up to six times less. In just one example, a randomized study of IMCI implementation in Tanzania found a 13% drop in mortality over two years compared to standard care, and costs were similar or lower. IMCI demonstrates that there are more ways to improve health outcomes than simply boosting resources. Following the development of the IMCI, several of our doctors participated in the development of the Integrated Management of Adolescent and Adult Illness (IMAI) District Clinician Manual, which provides guidance in a similar format as the IMCI to health providers at district hospitals.
The unfortunate truth is that despite the potential to improve care cheaply, the IMAI and IMCI standards are not met everywhere. The doctors I work with know this all too well. They work on the wards of Uganda, enrolling patients into their studies and adding to the evidence base for appropriate care. But what they see all too frequently is care that is not tied to strong medical evidence. Patients go undiagnosed, or improperly managed. And while the lack of resources plays a role, it is only part of the explanation.
Walimu was founded to bridge the gap between what we know works and what actually happens everyday on the wards. We work primarily as a strategic and implementation partner for the IMAI-IMCI Alliance, an organization dedicated to disseminating the guidelines. We are an in-country partner for the Alliance and support their efforts to scale training. In addition, we developed the Severe Illness Management Support (SIMS) program, which supports the training through a series of behavioral change interventions that enable uptake and reinforce adoption of the IMAI guidelines. The program includes essential diagnostic equipment to enable health worker uptake of recommended practices, point-of-care access to the guidelines via mobile phones or tablet computers, and regular performance feedback to reinforce adherence to IMAI management guidelines.
A doctor at Mulago Hospital assessing a patient with a Walimu diagnostic kit.
Even as we support the training efforts of the Alliance, we are exploring new ways to change health provider behavior. At Mulago National Referral Hospital, we have begun a continuous quality improvement program. The program collects data on essential tasks for severe illness management, feeds that data back to ward staff, and then works with ward staff to design quality improvement projects. We hope to gradually transform management on the ward to adhere to international standards of excellence.
A focus on quality of care can yield great improvements in health, even while decreasing the cost of care. As the evidence base for resource-limited settings grows, the global health community should add quality alongside access and prevention as a central goal of international efforts.
 Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania. Dr Joanna RM Armstrong Schellenberg PhD, et. al. The Lancet – 30 October 2004 ( Vol. 364, Issue 9445, Pages 1583-1594 ) DOI: 10.1016/S0140-6736(04)17311-X