Using IMCI to improve child survival

The World Health Organization’s Integrated Management of Childhood Illness (IMCI) strategy has been introduced in a number of developing countries. Its aim is to improve child health and survival, but has this been achieved? What are the implications for other child survival policies and programmes?

WHO, UNICEF andtheir partners developed IMCI to reduce deaths among children under five yearsold by addressing the limitations of child health programmes that targetspecific diseases. IMCI focuses on improving healthworker skills by providing guidelines and training for the case management ofsick children. It supports and strengthens not only the health system withinwhich health workers function, but also family and community practices toprevent diseases, improve the use of health facilities and improve home care forill children.

The IMCI strategy wasintroduced in Tanzania and Uganda in 1996 and has since been implemented inmore than 100 countries. Implementation is usually in three phases: afterinitial orientation and planning, the second phase involves adapting theguidelines to each country’s context and implementation in limited areas,followed by monitoring and reviewing. The third phase is the expansion of therange of interventions and coverage in each country, while maintainingquality.  

This study formspart of the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact(MCE-IMCI), coordinated by the WHO’s Department of Child and Adolescent Healthand Development. It looks at the expectations of the WHO staff regarding howthe introduction of IMCI would lead to improvements in child health andnutrition, and compares these with the results of the MCE-IMCI. It considersthe implications of these findings for other public health initiatives. 

The study made anumber of findings, including the following:

• TheIMCI strategy was successfully implemented in most countries yet some of theWHO’s basic expectations regarding development failed to be met.
• Fourof the five countries studied (Bangladesh, Brazil, Peru, Tanzania and Uganda) in-depthhad difficulties in expanding the strategy to the national level whilemaintaining quality.
• Countrieswere slow to develop technical guidelines on how to deliver interventions at thefamily and community levels.
• Withoutthese technical guidelines, plans to increase coverage of the population ofvital interventions were delayed.
• Addressingkey health system limitations are essential to reducing child mortality.

The lessons learntfrom this study can be extended to other major health programmes that arebattling with some of the same obstacles hampering the implementation of IMCI.

The study makesthe following policy recommendations:

• Effortsto improve child survival must start with local epidemiology and must targetthe main causes of death by region, country and district.
• The two main elements of IMCI – integrated guidelines for the casemanagement of sick children at health facilities, plus good quality trainingand supervision – must continue to be implemented widely.
• More effective methods for reaching children with proveninterventions must move from the level of health facility to the community andmust tackle prevention and undernutrition.
• High coverage must be achieved at the district, national, regionaland global levels.
• Countries must be assisted with prioritising interventions on thebasis of effectiveness, cost and impact and their incorporation into long termimplementation plans for child survival.