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 inover 100 countries, the IMCI strategy has three components: improving healthworker skills, improving community practices related to child health anddevelopment, and strengthening health system supports for child healthactivities. Evidence from the likes of Peru, Brazil and Tanzania suggests thatone or more of these components is not being implemented and that theeffectiveness of IMCI is limited by lack of investment and weaknesses in healthsystems.

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

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

Findings revealthat:

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

IMCI is associatedwith improvements in the quality of care for sick children, and with anincrease in the proportion of children brought to a facility for treatment. Neverthelessthe proportion of children attending health facilities is still relatively low,as is the rate of compliance with referrals to hospital for severeconditions.  Several policy lessons canbe drawn from these initial findings:

• If reductions in childhood mortalityrates are to be achieved, higher proportions of sick children in Bangladeshmust receive basic, effective treatments for common life-threateningillnesses.
• Improvements in the quality of careand health systems support can help to increase the use of healthfacilities.
• Qualitative research and monitoringare important to ensure that health care interventions and deliverystrategies can be continuously improved.

Full results ofthe study will not be available until 2007, when IMCI will have been inoperation for long enough to have a real impact. In the meantime, these interimfindings suggest significant benefits.