INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS
of Child Health and Development (CHD)
World Health Organization
Adaptation of the
technical guidelines and training materials for the course on Integrated
Management of Childhood Illness (IMCI)
5 Aug 1997
Download in Word format
Guidelines and training materials for the
Integrated Management of Childhood Illness (IMCI) need to be adapted by
each country before implementing activities. Adaptation ensures, first,
the inclusion of the most serious childhood illnesses that first-level
health workers must be able to treat. Countries also adapt the materials
to make them consistent with national treatment guidelines and other policies,
and to make guidelines feasible to implement through the health system.
The adaptation process, as a result, is
a key element in national preparations for implementing IMCI. It provides
a mechanism for developing consensus on technical issues across disease
conditions, and helps to mobilize persons, in and out of ministries of
health, with a range of expertise to contribute to the common effort to
improve the quality of health care for children.
WHO/CHD provides an Adaptation Guide
for the use of national programme staff and their expert advisors, who
come together to complete the various adaptation tasks.
The need for national adaptation
WHO and UNICEF provide generic case management guidelines, charts, and
related course materials which were developed to be appropriate in the
majority of developing countries where infant mortality is higher than
40 per 1000 live births, including where there is transmission of P.
falciparum malaria. These generic materials concentrate on the conditions
that make the greatest contribution, together more than 70%, to the mortality
of children under the age of five years: ARI (acute respiratory infections,
mostly pneumonia), diarrhoea, malaria, measles, and malnutrition.
These five conditions also account for more than 70% of problems for
which caretakers bring their children to a health facility. Although
ear infection is not a substantial contributor to mortality, it is a substantial
source of disability and a common reason for children to be brought to
a health facility. For this reason ear infection is also covered in the
The extent of adaptation a country needs to do has, therefore, been
minimized by making the generic case management guidelines as widely applicable
as possible. However, adaptation of the guidelines is required to
cover the most serious illnesses that contribute to child mortality in
a specific country and, for this, consensus must be reached on which childhood
conditions to include in the course. In countries where there is
no transmission of P. falciparum malaria, for example, consideration
of malaria is removed from the guidelines and training materials. Other
countries where dengue haemorrhagic fever is an important problem have
modified the materials to include this condition.
Types of adaptations
All countries preparing to implement IMCI
activities must go through the adaptation process. Certain adaptations
are essential while others may only be necessary to allow consensus to
be reached on treatment guidelines.
The following are the essential adaptations,
illustrated by examples of the adaptation decisions made in Uganda:
In addition to these essential adaptations,
consensus must be reached on treatment guidelines for each of the conditions
covered in the course. These may or may not require adaptation of the generic
guidelines. For example:
The selection of effective first- and second-line
antibiotics for treating pneumonia, dysentery and cholera. These must be
antibiotics to which organisms in the country are sensitive and that can
be made available in first-level facilities.
Uganda selected cotrimoxazole and amoxycillin
for treatment of pneumonia; cotrimoxazole and nalidixic acid for dysentery;
cotrimoxazole and erythromycin for cholera.
The identification of appropriate complementary
foods for children of different age groups. These foods must be readily
available, affordable, and culturally acceptable for mothers to give to
After a study of locally appropriate and
available foods in the Central Region, Uganda made this recommendation
for complementary foods to be introduced to children aged 6 months up to
12 months: Thick porridge made out of either maize or cassava or millet
or soya flour. Add sugar and oil mixed with either milk or pounded groundnuts.
The identification of specific terms for signs
of illness that are used in the communities in which IMCI is being implemented.
These terms help health workers to assess the child's illness, and help
mothers to recognize when to take a child to the health worker for care.
In the Central Region, there was no commonly
understood term for fever. A study found that the best term that described
fever without other signs or conditions of illness, was ayokya omubiri
(hot skin). The study also revealed that caretakers may not spontaneously
volunteer the information that a child has had olukusense (the local
word for measles) for fear of spreading the illness to other children in
the house by naming it. Other words, such as mulangira (The Prince),
may be used to avoid the name.
Countries have different policies on which
children should be given vitamin A. These policies are based on the epidemiology
of vitamin A deficiency and the feasibility of implementing various supplementation
plans through the first-level health facility. The generic guidelines on
vitamin A, therefore, need to be reviewed and if necessary, adapted, to
fit national policies and conditions that affect their implementation through
the health system.
The recommendations on breastfeeding, including
the timing for introducing complementary foods, may need to be adapted
in order to make the interventions during the sick child visit compatible
with other efforts to improve nutrition.
Where HIV infection is highly prevalent, countries
may consider several adaptations to the generic training materials, including
how to manage the child with related infections that do not respond to
initial treatment and how to counsel mothers on breastfeeding. Recommendations
on how to counsel mothers on breastfeeding need to consider several factors,
for example: the availability of HIV testing facilities, the training of
persons to counsel mothers, the accessibility to adequate breastmilk substitutes
in sufficient supply for those mothers who choose not to breastfeed, and
the ability of the individual mother to give the substitute safely and
in adequate amounts.
Once consensus among key Ministry officials
and other national experts is reached on the guidelines, changes need to
be made to the generic IMCI charts and throughout the training materials.
Examples of common adaptations to IMCI guidelines
|Types of adaptation
|Modification of guidelines based on epidemiology of malaria
||Bolivia, Ecuador, Indonesia, Nepal, Peru, Philippines, Tanzania, Uganda,
|Use of laboratory for the diagnosis of malaria
||Ecuador, Indonesia, Nepal, Peru, Philippines, Viet Nam
|Addition of classification box for Dengue Haemmorrhagic Fever
||Indonesia, Philippines, Viet Nam
|Addition of Vitamin A supplementation
||Indonesia, Nepal, Philippines, Tanzania, Uganda
|Extension of the recommendation to breastfeed exclusively, up to 6
||Bolivia, Ecuador, Nepal, Peru, Philippines, Uganda
The Adaptation Guide
The Adaptation Guide describes the
process of making decisions on the adaptations, and the appropriate changes
in the related training materials. It includes:
a description of the steps in the adaptation
process, and the essential persons who contribute to it,
the technical basis for the generic guidelines,
including references to the research used in deciding on the generic recommendations,
technical considerations in reviewing possible
three simple-to-use protocols to gather and
organize information related to improving home care and communication with
mothers: to adapt the feeding recommendations, to identify and validate
locally-used terms for signs of illness, and to design and test an adapted
card for counselling mothers,
instructions on how to make the physical changes
in the charts and IMCI training modules, and
Accompanying the Adaptation Guide are
tools to help the adaptation process, including computer files containing
the generic charts and modules and an illustration book to use in producing
camera-ready copies for local production. Training is also provided for
key national staff and consultants involved in assisting countries with
the adaptation of their materials. To date, almost fifty persons have been
trained during adaptation workshops.
specific changes in materials required for
other adaptations likely to be considered by countries.