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Integrated Management of Childhood Illness (IMCI) is a broad strategy, encompassing interventions at home and in the health facility, which aims to reduce childhood death, illness and disability and to contribute to improved growth and development.
Implementation is carried out in a phased manner, beginning with the introduction of IMCI, moving on to preparation for and implementation of initial activities in selected districts and, finally, to expansion of activities and geographic coverage. By May 1997, a total of 41 countries had begun discussions to implement IMCI or were in the various phases of implementation (see map):
The early implementation phase
During the second phase experience is gained with IMCI planning in selected districts. The tasks in this phase include selection of initial districts, adaptation of case management guidelines for major diseases of children and materials, training national and district level facilitators, preparation and planning at district level, and training health workers, including follow-up of trainees.
Experience in the countries that have completed this phase shows that achieving consensus on the adapted guidelines takes time, and that this consensus is critical. It has also demonstrated that follow-up visits to trained health workers are important and useful for reinforcing new skills. In Uganda and Tanzania, where these follow-up visits have been carried out, health workers have been found to be applying IMCI skills. A further lesson is that the training of course facilitators, where both clinical skills and facilitation skills must be learned, is very demanding.
The expansion phase
Only one country, Uganda, has begun expansion of coverage and activities. Activities in this phase include further strengthening of district-level capacity, expansion of training coverage and follow-up, improved drug availability and management, monitoring, and measurement of outcome indicators. Also included will be interventions at the referral and family and community levels, as guidelines for these become available.
Progress in early use countries
Since 1995, CHD has focused on direct assistance to a small number of "early use" countries, at least one from each WHO Region, in preparation and implementation of IMCI. Full technical assistance is provided with planning, adaptation of the guidelines and training materials for the IMCI course, implementing the first training courses and follow-up of training. The experience gained is being carefully documented, to learn more about the process through which individual countries adapt and implement the course, and about the national organizational and resource implications.
The principle adopted in all the early use countries has been to introduce IMCI into a small number of districts initially. CDD/ARI training is continued in areas not yet covered by IMCI plans. Experience during the first eighteen months is monitored closely and the information used to guide plans for expansion.
The following briefly summarizes progress in these early use countries:
Nepal established a "Working Group for IMCI" chaired by the Director of the Child Health Division. The guidelines and training materials have been adapted for two districts, and experience in implementing IMCI in these two districts in 1997 will provide the basis for development of a medium-term plan of action later in the year. Responsibility for implementing and monitoring IMCI at district level will rest with District Health Officers. Initial training at national level for these personnel will take place in August 1997.
Peru, the first country to have adapted and used the Spanish
translation of the IMCI training materials, conducted an adaptation workshop
in July 1996. This provided an opportunity to introduce health authorities
from other countries in the Region to the adaptation process. In
October 1996, two courses were held to train national trainers, with the
participation of senior paediatricians from neighbouring countries that
are planning to introduce IMCI. Although generally satisfied with the courses,
participants expressed a desire for more opportunities to practise particular
skills. As a result, the Regional Office for the Americas has strengthened
the training of IMCI course facilitators and developed an additional agenda
for facilitator training.
In the Philippines, a national orientation and planning workshop was held in 1995. In February 1996 a national IMCI Task Force was established which took charge of the adaptation process, with two adaptation groups, consisting of Department of Health staff, paediatricians and technical experts, undertaking the technical review and adaptation. IMCI has also been included as a component of the Early Child Development Project funded by the Asian Development Bank.
In mid-1995, Uganda established a broadly-based Task Force to steer IMCI implementation. Adaptation was completed in July 1996 and the first course, for national-level trainers, was conducted successfully in Mulago Hospital in Kampala during August. This was followed immediately by a course to train district trainers. These trainers subsequently carried out training courses in each of two districts, under the supervision of national-level trainers. Follow-up of trainees is an essential feature of the IMCI learning process. WHO has provided support for the development and introduction of tools for effective follow-up, which aims both to reinforce training and to monitor progress of the trainees, and supervisors were trained specifically for this purpose. After reviewing experience so far, Uganda has begun to expand the training to further districts in the same region and adaptation of the materials for use in other regions is now underway.
The United Republic of Tanzania has also made good progress. The IMCI course had already been partially adapted for the field test of the generic course in Arusha in early 1995, and the national programme completed the adaptation by August 1996. The first course for national trainers took place in Morogoro in September 1996 and this was followed by a workshop to develop the follow-up procedures. With financial support from UNICEF, GTZ , ODA and IDRC, the first round of training for district level trainers started in October, and for first level health workers in November. This course was, and most of the subsequent training will be, in Kiswahili, a translation having been completed in late 1996. Health workers were followed up 4 to 6 weeks after their training. Further training and implementation will be carried out in selected districts, with World Bank support, after which, towards the end of 1997, the experience will be evaluated to provide a base for decisions on future development. Tanzania recognizes the importance of including IMCI skills and knowledge in the basic training of paramedical staff, and is beginning to use the course materials for basic training of medical assistants in schools.
IMCI activities have been initiated in several other countries, for example:
In the Americas, a regional proposal for early implementation has been developed outlining objectives, strategies and implementation phases. Regional staff discussed the proposal with national programme staff at a meeting in Santa Cruz de la Sierra, Bolivia, and agreed to start the implementation of IMCI in four countries in the Region during 1996-1997. One of the first steps was the training in Peru described above. In addition, the Regional Office of the Americas, in collaboration with USAID and the BASICS project, has designed a five year Regional Plan that includes the implementation of IMCI in eight Latin American countries between 1997 and 2001.