Joyce Nuhu, a clinical officer at Nguvumali Health Center in Tanga, northeastern Tanzania, recalls an incident involving one of her clients, Aisha Juma, who had brought her child to the facility for treatment.
"Aisha came to the health center one day, worried about her child. She told me that earlier that day she had returned home from the market to find her child in a worrying state. The child, who had only a slight fever the previous day, was now extremely weak. Not only was the child breathing rapidly, but now [the child] was also refusing to feed. Shocked by the sudden change, Aisha immediately sought help and rushed to the health facility."
When Joyce examined the child, it turned out to be pneumonia—a serious condition that requires prompt medical attention, especially in children and the elderly.
Thanks to Aisha's quick action in bringing her child to the health center, the staff were able to provide timely medical care. After treatment, Aisha's child improved and got discharged.
Fatina Msangi, medical doctor at Duga Health Center in Tanga, attending to a sick child. Photo: PATH/Olgah Odek.
This is a common scenario in many primary health facilities in Tanzania and other low- and middle-income countries. What is critical is that, when sick children arrive at primary health care facilities—like Aisha's child—they are appropriately screened, diagnosed, managed, and if needed, referred to urgent care without delay.
Here is the problem: The lives of children with severe illness are needlessly at risk because critical screening and diagnostic tools are either unavailable, not functioning properly, or not suited for infants who need them most. Health care providers also lack the appropriate training.
Additionally, there is neither a clear global guidance to help countries in choosing the best devices, nor available information on their cost-effectiveness or suitability in primary care.
When children’s danger signs are overlooked or inadequately managed, their lives are put at risk. Additionally, they may receive antibiotics that they don’t need, which may result in drug-resistant superbugs. This is because clinical signs alone do not always detect severe illness in children.
Joyce Nuhu says that, "Before the Tools for Integrated Management of Childhood Illness (TIMCI) project’s interventions, it was very difficult to detect hypoxemia in very sick children on arrival at the center." Joyce adds that she faced difficulty detecting hypoxemia because she did not have the right tools to appropriately screen, diagnose, or manage severely sick children or know when to refer them.
To address these challenges, PATH led the TIMCI project in Tanzania and three other countries from 2019 to 2024. In collaboration with the governments of India, Kenya, Senegal, and Tanzania, along with global partners, TIMCI worked to improve access to affordable and appropriate tools that help health care workers identify critically ill children and refer them for timely treatment.
“By making primary health care service delivery more accessible, accountable, affordable, and reliable, TIMCI has helped make progress toward universal health coverage targets mandated by the UN Sustainable Development Goal 3.8.”— Michael Ruffo, TIMCI project director
TIMCI's primary focus has been the introduction of pulse oximeters at primary health care facilities in the four project countries. These devices reliably help health care providers detect hypoxemia—or dangerously low levels of oxygen in the blood—and identify the need for urgent treatment, including referral to higher-level facilities and access to oxygen, which can be lifesaving.
Pulse oximeters are crucial in diagnosing and managing various clinical conditions that can result in hypoxemia, such as acute respiratory illnesses like pneumonia and COVID-19, newborn conditions, obstetric emergencies, asthma, and heart failure. They are also essential for safe surgery and can help chronic disease patients manage their oxygen needs at home.
Joyce’s recollection of Aisha's experience serves as a compelling example of the broader issues the TIMCI project sought to address.
“"Before TIMCI, it was incredibly difficult to detect hypoxemia in very sick children upon arrival [at the center]."”— Joyce Nuhu, Nguvumali Health Center clinical officer
PATH's TIMCI introduced 302 pulse oximeters in 236 primary health care facilities across the four project countries, along with training and supportive supervision for health care providers. Additionally, 189 digital tools (tablets), known as clinical decision support algorithms (CDSAs), were implemented across 153 facilities.
These CDSAs provide health care workers with tailored recommendations on clinical assessment and management based on patient information and clinical protocols derived from World Health Organization and national guidelines.
TIMCI aims to improve access to affordable and appropriate tools to help health workers identify critically ill children and refer them for treatment without delay.
Joyce notes that adhering to the Integrated Management of Childhood Illness (IMCI) approach—which takes a systemic view of the whole child—was challenging and time-consuming without the necessary tools. She shares that since the introduction of CDSAs and handheld pulse oximeters, detecting hypoxemia in children—and subsequently managing them or referring them for urgent medical attention—has become much easier.
“I believe the TIMCI findings will catalyze positive change in our policies to improve the detection of severe illness among children and the general population at large.”— Amos Mugisha, PATH Tanzania country director
Integrating pulse oximetry and CDSA use into national and global guidelines, including the World Health Organization’s IMCI strategy, is an important step towards ensuring consistent and correct use, and improved care. Through TIMCI, 1,409 health care providers were trained in the use of these devices as part of IMCI.
Another TIMCI objective was to generate evidence on the clinical impact, feasibility, acceptability, cost, and cost-effectiveness of pulse oximetry and CDSAs, and the ways they impact quality-of-care outcomes.
As a result of this work, 209,269 young children (0 to 59 months old) were enrolled in research across the four project countries. In addition, 273,000 community and civil society members were engaged through workshops, meetings, social mobilization, distribution of materials, and awareness-raising sessions.
“Among key findings from the research, TIMCI demonstrated that pulse oximetry and CDSAs are broadly feasible in primary care settings (if certain preconditions are met).”— Grace Mahalu, research scientist, Ifakara Health Institute
TIMCI also collaborated with national and global stakeholders to use evidence generated from the study to inform guidelines and planning, as well as strengthen the market for multimodal devices, including evidence on the integration of pulse oximetry into IMCI treatment guidelines in study intervention areas.
As TIMCI’s five-year journey comes to an end, it leaves behind valuable lessons on how to integrate pulse oximetry and CDSAs into primary health care, including the following:
- Pulse oximetry and CDSA implementation must be embedded in wider efforts to strengthen quality of care, support antimicrobial stewardship, and address barriers to accessing higher levels of care, including provision of medical oxygen.
- Pulse oximetry and CDSA should be integrated with strategies to strengthen the quality of primary care provision (including IMCI) and the care/follow-up of children who are not completing referrals.
- Careful consideration is needed as to when and how pulse oximetry should be used (i.e., for which populations, by which health care providers, at which facility level, and at what point in the workflow).
TIMCI’s success can be attributed to the strength of its partner network, including close collaboration with national ministries of health in implementation and observer countries, international agencies, local research partners, local communities, and broader advocacy networks.
The project team hopes that it is through this government-led, dynamic, and highly participatory approach that effective scale-up efforts to ensure access to affordable, robust, and appropriate pulse oximetry, embedded within broader oxygen access, continue to be a national and global priority.
By equipping health care workers with these tools and appropriate training, TIMCI worked to ensure that children like Aisha's receive timely and accurate diagnoses, reducing the risk of overlooked danger signs and improving overall child health outcomes in Tanzania and beyond.
The project has transformed how health care workers like Joyce approach cases similar to that of Aisha's child’s, leading to better management of childhood illnesses. These efforts not only improved health care delivery but also increased community awareness and involvement in child health issues.
In June 2024, PATH brought together TIMCI observer countries, ministries of health, and national/global stakeholders to review the project outcomes in Dar es Salaam, Tanzania. Photo: PATH/Olgah Odek.
