Article Text

Mentoring and quality improvement strengthen integrated management of childhood illness implementation in rural Rwanda
  1. Hema Magge1–5,
  2. Manzi Anatole4–6,
  3. Felix Rwabukwisi Cyamatare4,5,
  4. Catherine Mezzacappa1,4,5,
  5. Fulgence Nkikabahizi7,
  6. Saleh Niyonzima7,
  7. Peter C Drobac1,3,4,5,
  8. Fidele Ngabo7,
  9. Lisa R Hirschhorn1,3,5
  1. 1Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
  2. 2Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
  3. 3Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
  4. 4Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
  5. 5Partners In Health, Boston, Massachusetts, USA
  6. 6University of Rwanda, College of Medicine and Health Sciences, School of Public Health, Kigali, Rwanda
  7. 7Rwanda Ministry of Health, Kigali, Rwanda
  1. Correspondence to Dr Hema Magge, Brigham and Women's Hospital, Division of Global Health Equity, 75 Francis Street, Boston, MA 02115, USA; hmagge{at}


Objective Integrated Management of Childhood Illness (IMCI) is the leading clinical protocol designed to decrease under-five mortality globally. However, impact is threatened by gaps in IMCI quality of care (QOC). In 2010, Partners In Health and the Rwanda Ministry of Health implemented a nurse mentorship intervention Mentoring and Enhanced Supervision at Health Centres (MESH) in two rural districts. This study measures change in QOC following the addition of MESH to didactic training.

Design Prepost intervention study of change in QOC after 12 months of MESH support measured by case observation using a standardised checklist. Study sample was children age 2 months to 5 years presenting on the days of data collection (292 baseline, 413 endpoint).

Setting 21 rural health centres in Rwanda.

Outcomes Primary outcome was a validated index of key IMCI assessments. Secondary outcomes included assessment, classification and treatment indicators, and QOC variability across providers. A mixed-effects regression model of the index was created.

Results In multivariate analyses, the index significantly improved in southern Kayonza (β-coefficient 0.17, 95% CI 0.12 to 0.22) and Kirehe (β-coefficient 0.29, 95% CI 0.23 to 0.34) districts. Children seen by IMCI-trained nurses increased from 83.2% to 100% (p<0.001) and use of IMCI case recording forms improved from 65.9% to 97.1% (p<0.001). Correct classification improved (56.0% to 91.5%, p<0.001), as did correct treatment (78.3% to 98.2%, p<0.001). Variability in QOC decreased (intracluster correlation coefficient 0.613–0.346).

Conclusions MESH was associated with significant improvements in all domains of IMCI quality. MESH could be an innovative strategy to improve IMCI implementation in resource-limited settings working to decrease under-five mortality.

  • General Paediatrics
  • Health services research
  • Nursing Care

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