ALgorithms for the MANagement of Acute CHildhood illnesses, better known as ALMANACH

With an area of about 30’000 km2 and a population of 3.5 million, Adamawa is one of the Northern, poorer States of Nigeria, characterized by the scarcity of qualified health practitioners at primary level, mainly in rural areas. This initiative aims to improve the management of acute infectious diseases and malnutrition among children, aged from two months to five years. A baseline study conducted before the start of the pilot showed that [lt] 10% of children were checked systematically for their needs of preventive measures. Seventy percent were given an incorrect treatment. Among them, 70% received one or more antibiotics, even though for 80% it was not justified. Based on digital material on tablet, ALMANACH was designed to strengthen knowledge among healthcare staff and guide them, step by step, through history taking and physical examination, to the correct diagnosis and treatment prescription.

Available on smartphones and tablets, ALMANACH is derived from the IMCI concept but goes beyond the static paper version. It is meant to improve the quality of diagnosis and treatment prescription for children, between 2 months and 5 years at primary care level. ALMANACH leads healthcare providers step by step, through history taking and physical examination to the diagnosis and the right treatment, in accordance with the national management guidelines. It suggests when to refer a child, when to perform a laboratory test and what treatment to prescribe at what dosage (the dosage is automatically calculated on the base of weight and/or age of the patient). A small atlas of dermatology is also included to facilitate the recognition of skin diseases. At the end of the day, all the clinical information are synchronized in real time with a Health Management Information System (DHIS2) for epidemiological evaluation and decision making. ALMANACH has been easily integrated into health staff’s daily routine.

The set of algorithms in ALMANACH was derived from the Integrated Management of Childhood Illnesses (IMCI) developed by UNICEF and WHO, to deal with a series of diseases causing 70% of the mortality in children under five years. Despite the effectiveness of the approach, acceptance and uptake of IMCI were less than anticipated. Reasons included the visual complexity of paper-based algorithms and the lack of local contextualisation.
Compared with the original paper-based algorithms, ALMANACH has the following advantages:
– Algorithms were adapted to the local context and requirements, in terms of disease prevalence and medicine availability at primary level.
– Updated versions of ALMANACH were delivered over the Internet and automatically downloaded and installed on tablets.
– ALMANACH is user-friendly; each screen shows a limited amount of information, usually one or two questions and the possible answers to select. Contents of the following screen result from the selected answer. The user is never overwhelmed with information.
– The tablet can be used offline and be connected to the Internet whenever necessary. Healthcare providers are able to download additional material as they wish, in addition to the educational material available on the tablet from the start.
– The application calculates the dosage of medicines automatically, based on the child’s parameters (weight/age). Hence no calculation is needed from the prescriber or the pharmacist.
– Caregivers attending the consultation with their children like the tablet, as the healthcare provider is said to put more emphasis on history taking and physical examination than without the tablet.
– Each day, consultation data (except for patients’ names and contact details) of each health facility (12 in the pilot) are sent over the Internet to the project manager’s office. Data of each facility are analysed monthly. An monthly epidemiological bulletin is shared among healthcare providers, primary health care managers in Adamawa and others involved in the project. Data can also be visualised on screen with the DHIS2 application. Whenever necessary, data can be monitored in real time, enabling detection of outbreaks of local epidemics or abnormalities associated with the misunderstanding of algorithms.