The feasibility and ongoing use of electronic decision support to strengthen the implementation of IMCI in KwaZulu-Natal, South Africa

BACKGROUND: Continued efforts are required to reduce preventable child deaths. User-friendly Integrated Management of Childhood Illness (IMCI) implementation tools and supervision systems are needed to strengthen the quality of child health services in South Africa. A 2018 pilot implementation of electronic IMCI case management algorithms in KwaZulu-Natal demonstrated good uptake and acceptance at primary care clinics. We aimed to investigate whether ongoing electronic IMCI implementation is feasible within the existing Department of Health infrastructure and resources. METHODS: In a mixed methods descriptive study, the electronic IMCI (eIMCI) implementation was extended to 22 health facilities in uMgungundlovu district from November 2019 to February 2021. Training, mentoring, supervision and IT support were provided by a dedicated project team. Programme use was tracked, quarterly assessments of the service delivery platform were undertaken and in-depth interviews were conducted with facility managers. RESULTS: From December 2019 – January 2021, 9 684 eIMCI records were completed across 20 facilities, with a median uptake of 29 records per clinic per month and a mean (range) proportion of child consultations using eIMCI of 15% (1–46%). The local COVID-19-related movement restrictions and epidemic peaks coincided with declines in the monthly eIMCI uptake. Substantial inter- and intra-facility variations in use were observed, with the use being positively associated with the allocation of an eIMCI trained nurse (p < 0.001) and the clinician workload (p = 0.032). CONCLUSION: The ongoing eIMCI uptake was sporadic and the implementation undermined by barriers such as low post-training deployment of nurses; poor capacity in the DoH for IT support; and COVID-19-related disruptions in service delivery. Scaling eIMCI in South Africa would rely on resolving these challenges.