Niger's approach in applying quality assurance measures at district level succeeded in better preparing the target districts before the implementation of IMCI clinical guidelines at the health facility level. Improvements in supervision and availability of drug supply were documented. Exposing district supervisors to two types of training, quality assurance and clinical IMCI, was important in qualifying supervisors to support IMCI implementation. However, longer term follow up is necessary to confirm the long term impact of applying quality assurance measures to better prepare of IMCI implementation. In addition, the intervention included external financial support to revive district-level supervision. To sustain the achieved improvement, this cost needs to be transferred gradually to the district's health budget.
Since the project has provided financial support to revive district level supervision, to sustain the achieved success, it is important that the cost of conducting supervision be transferred gradually to the district's health budget.
Community involvement in cost recovery through participation in determining cost for service and in managing drug stock was key in assuring community's acceptance and trust in the system. Cost recovery was more effective when combined with stock management training. In Konni district, where cost recovery was combined with stock management training, results for improving availability of essential drugs were better than in Boboye, where such training was not conducted.
The observed drop in the number of outpatient visits induced by cost recovery is of particular importance, since the impact of IMCI is related to its ability to minimize missed opportunities of preventive and curative care at the outpatient level. Experience with cost recovery in other countries suggest that such a drop could be temporary . The strong recovery of outpatient visits in Badaguichiri health facility during the third quarter of 1998 could be a sign for the beginning of the reverse in the outpatient trend. Other factors, such as the rainy season in June to October and the harvest around the third quarter, could have contributed to the fluctuation in the number of outpatient visits. Longer monitoring of the level of health facility utilization is needed to fully understand the effect of cost recovery on health service utilization.
The observed difficulty in complying with IMCI standards for referral and follow-up visits presents a challenge not only to health authorities in Niger but also to the IMCI standards themselves. The current IMCI referral and follow up standards may not be suitable for a country like Niger with such a widely dispersed population and only 30% of the population living within five kilometers of a health facility. Health facility staff mentioned that referral was not feasible because of the lack of transportation and the long distance between health facilities and the district level hospital. The distance between health facilities and the district hospital ranged from 25 - 85 km. In addition, district level hospitals in both Konni and Boboye were not well equipped to deal with very sick children which further discouraged both health workers at the health facility level and mothers to use them as a referral site. Referral sites need to be included in future IMCI programs.