Better health care for children in Bangladesh: the story so far

In Bangladesh, many children die before they reach the age of five. Over half die from pneumonia, diarrhoea, malnutrition or measles.  In 1998, the government introduced the Integrated Management of Childhood Illness (IMCI) strategy to improve child health. How effective has it been? 

Already adopted in over 100 countries, the IMCI strategy has three components: improving health worker skills, improving community practices related to child health and development, and strengthening health system supports for child health activities. Evidence from the likes of Peru, Brazil and Tanzania suggests that one or more of these components is not being implemented and that the effectiveness of IMCI is limited by lack of investment and weaknesses in health systems.

An interim evaluation of IMCI by the International Centre for Diarrhoeal Disease Research, Bangladesh and the World Health Organisation was undertaken in the Matlab sub-district of Bangladesh. 20 outpatient facilities were assessed: half using IMCI and half continuing with their standard care. Household surveys were conducted at the start of the study, and repeated once every six months over a two year period. Health facility surveys were conducted in 2000 and 2003.

From March 2002 all of the planned health systems support was available, and by April 2004, 94 percent of the health workers in the IMCI facilities had received training. To improve community practices, training of 127 nutrition workers and 102 health and family planning workers was complete by the end of 2003.

Findings reveal that:

• In the initial surveys, the quality of patient assessment and the subsequent provision of the correct treatment at all facilities were poor.
• 18 months after the introduction of IMCI, sick children visiting IMCI facilities were receiving better care than those visiting non-IMCI facilities with improvements in the rates of correct treatment at the IMCI facilities.
• Attendance at IMCI increased greatly after the introduction of IMCI, whilst attendance at the non-IMCI facilities fell.
• Use of IMCI facilities rose from 0.6 visits to 1.9 visits per child per year, but remains far lower than rates reported in Tanzania.
• In IMCI areas, there was a marked increase in the proportion of sick children taken to a health facility or health worker for care.
• Referrals of very sick children to hospital rose, but a large proportion of those referred to hospital for further treatment did not follow-up the referral.

IMCI is associated with improvements in the quality of care for sick children, and with an increase in the proportion of children brought to a facility for treatment. Nevertheless the proportion of children attending health facilities is still relatively low, as is the rate of compliance with referrals to hospital for severe conditions.  Several policy lessons can be drawn from these initial findings:

• If reductions in childhood mortality rates are to be achieved, higher proportions of sick children in Bangladesh must receive basic, effective treatments for common life-threatening illnesses.
• Improvements in the quality of care and health systems support can help to increase the use of health facilities.
• Qualitative research and monitoring are important to ensure that health care interventions and delivery strategies can be continuously improved.

Full results of the study will not be available until 2007, when IMCI will have been in operation for long enough to have a real impact. In the meantime, these interim findings suggest significant benefits.

Source(s):
‘Integrated Management of Childhood Illness (IMCI) in Bangladesh: early findings from a cluster-randomised study’, Lancet 364: 1595-1602, by S.E. Arifeen et al, 2004

Funded by: Bill and Melinda Gates Foundation; WHO Department of Child and Adolescent Health and Development; USAID

id21 Research Highlight: 12 July 2005

Further Information:
Shams El Arifeen
International Centre for Diarrhoeal Disease Research, Bangladesh
Dhaka
Bangladesh

Fax: +880 2 882 6050
Contact the contributor: shams@icddrb.org

International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh

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'Class act – IMCI training boosts health workers’ performance'

'Be quick – seeking care for life threatening malaria in southern Tanzania'

'Coverage story: how to deliver better child survival'

'Managing childhood illness: how effective is IMCI in Tanzania?'

'Young, poor and sick: socioeconomic inequities and child health in rural Tanzania'

'Danger in disguise – spotting the warning signs of severe childhood illnesses'