EVALUATION OF THE ARI PROGRAM - A HEALTH FACILITY SURVEY IN SIMBU, PAPUA-NEW-GUINEA

The purpose of this health facility survey was to evaluate how the ARI (Acute Respiratory Infection) Program actually works in an everyday, non-research setting. We surveyed 33 clinics and aid posts, including 223 children with ARI and 104 health workers. In this primary health c are setting, health workers diagnosed 37 % of ARI cases as pneumonia, compared to 69 % in the same children assessed independently by traine d ARI surveyors using Papua New Guinea case management, which defines fast breathing as greater-than-or-equal-to 40 per minute for children 1 month to 5 years of age. Agreement between health workers and survey ors was reasonably good (kappa greater-than-or-equal-to 0.6) for the h istory of symptoms, but was poor (kappa <0.3) for diagnoses, treatment s and signs such as respiratory rate (RR) and chest indrawing. Health workers counted the RR in only 14 % of cases in the survey. In essence , we found that health workers in Simbu are not practising ARI case ma nagement. We conclude that case management guidelines which define fas t breathing as a rate of greater-than-or-equal-to 40 per minute classi fy too many obviously well children as pneumonia. Furthermore, we enco untered difficulties in measuring RR accurately, and documented marked inter-observer variation in this setting. Consequently, we are concer ned about the ARI Program's excessive reliance on RR and rigid protoco ls at the expense of clinical sense. Case management guidelines develo ped for aid post orderlies or village health workers may need to be mo dified, or used differently by experienced nurses at health centres, w ho recognize sick children better than by following a standardized pro tocol. Despite better overall ARI knowledge and practice by nurses, we could demonstrate an impact of the ARI Training Program only on commu nity health workers (CHWs). In order to improve ARI clinical practice, we recommend that the ARI Program in PNG initiates regular on-site cl inical supervision of nurses and CHWs at health centres.