摘要：Objectives . To prepare for the implementation of Integrated Management of Childhood Illness (IMCI) in Benin, we studied the management of ill children younger than 5 years at outpatient health facilities. Methods . We observed a representative sample of consultations; after each consultation, we interviewed caregivers and reexamined children. Health workers' performance was evaluated against IMCI guidelines. To identify determinants of performance, statistical modeling was performed and 6 focus groups with health workers were conducted to solicit their opinions. Results . Altogether, 584 children were enrolled and 101 health workers were observed; 130 health workers participated in focus group discussions. Many serious deficiencies were found: incomplete assessment of children's signs and symptoms, incorrect diagnosis and treatment of potentially life-threatening illnesses, inappropriate prescription of dangerous sedatives, missed opportunities to vaccinate, and failure to refer severely ill children for hospitalization. Quantitative and qualitative analyses showed various health facility–, health worker–, caregiver-, and child-related factors as possible determinants of health worker performance. Conclusions . Action is urgently needed. Our results suggest that to improve health care delivery, interventions should target both the health system and the community level. Each year in developing countries, more than 12 million children younger than 5 years die. About 70% of these deaths are a result of 5 conditions: pneumonia, diarrhea, malaria, measles, and malnutrition. 1 To reduce child mortality from these conditions, the World Health Organization developed the Integrated Management of Childhood Illness (IMCI) strategy. 1 At the health facility level, IMCI defines a minimum standard of care for ill children aged 1 week to 59 months. These guidelines describe steps for assessing, classifying, treating, and referring ill children; counseling the child's caregiver; and vaccinating underimmunized children. Diagnoses (or “classifications”) are based on signs and symptoms (e.g., fever = malaria; cough with fast breathing = pneumonia), and the only equipment required is a scale and a watch. In March 1999, the Benin Ministry of Public Health formally adopted the IMCI strategy and selected Ouémé Département in southeastern Benin as a pilot site; the population is about 1 million and mostly rural, and the mortality rate for children younger than 5 years is 158 per 1000 live births. 2 To prepare for the implementation and evaluation of IMCI, we studied the management of ill children seen as outpatients at health facilities in Ouémé Département. The objectives were to identify areas needing emphasis during IMCI training and to identify institutional factors, such as supervision, drug supplies, and time management, that may have affected IMCI implementation. At first analysis of the results, we found serious deficiencies in the care children were receiving. In addition, the results suggested that public health facilities were underused and that caregivers may not be complying with health workers' recommendations to refer seriously ill children to a hospital. To understand the causes of these deficiencies, we used 2 complementary strategies: statistical modeling to identify predictors of health workers' performance, and focus group discussions with health workers to solicit their opinions on why the problems exist.
