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The Integrated Management of Childhood Illness (IMCI) strategy encompasses a range of interventions for the prevention and management of major childhood illnesses, both in health facilities and in the home. It incorporates many elements of diarrhoeal disease and ARI control programmes, and child-related aspects of malaria control, nutrition, EPI, and essential drugs programmes. Implementing the strategy requires and facilitates active collaboration between these programmes, and requires efforts at different levels of the health system.
Implementing the IMCI strategy in countries involves three components:
The process involves three phases: introduction, early implementation
in a limited area, and expansion of activities and geographic coverage.
Introduction of IMCI in a country
Initial activities focus on the orientation of decision-makers and the adaptation of guidelines for the improvement of care at first-level health facilities. This phase includes the creation of a national IMCI working group. Box 2 summarises the steps to be carried out during the introduction phase.
Decision-makers in the health sector are informed about the IMCI strategy and the efforts required for its implementation. A series of individual and group meetings are held involving programme managers and technical staff, academic and training faculties, professional associations, and actual and potential partners such as donors, international agencies, NGOs and health related institutions. A formal orientation meeting is recommended as part of this process to provide an opportunity for a larger group to reach a common understanding of the concepts and practical principles of the IMCI strategy and its advantages and implications for the health system.
It is also recommended that the introductory phase include training of selected key national staff in an IMCI course for first-level health workers. This helps national staff to better facilitate discussions about IMCI and plan for the early implementation phase.
The orientation and training experience during this phase of activities
should enable the Ministry of Health (MOH) to make an informed choice about
whether or not to adopt the IMCI strategy. If the MOH chooses to
implement IMCI, this commitment should be formalized by an official endorsement
and the creation of a management and coordination group.
|The steps of IMCI introduction to countries
Once commitment has been made to the strategy, a country is encouraged
to gain experience with IMCI planning and implementation through a well-defined
set of activities within a limited geographical area. Experience during
this early implementation phase is used to guide future planning and implementation.
The initial focus of this phase is on developing case management
guidelines and improving care at first-level facilities. Steps include
planning, adaptation of guidelines and preparation of materials for in-service
training, initial implementation, and review and replanning. This
phase also includes activities to improve health systems and family and
community practices. Box 3 provides a list of steps to be completed during
the early implementation phase.
|Early implementation task
Careful planning, which takes into account the availability of resources, should guide the implementation of activities during this phase. WHO recommends that an IMCI planning workshop be organized at central level to prepare a national strategy and plan for early implementation. At this workshop the IMCI working group should decide how to:
Once a limited number of districts has been selected, the next step is to develop detailed implementation plans in collaboration with district health teams. At the same time, the IMCI generic guidelines are adapted to the country. Other tasks, such as assessments of drug availability, referral capacity, and of the health management information system are also completed and these should assist in implementing measures to make improvements in related aspects of the health care system.
During the early implementation phase, activities are carefully monitored by the IMCI working group, and the experience is thoroughly reviewed and analyzed at a formal review meeting which takes place after at least two or three IMCI training courses have been held in the selected districts.
Expansion of IMCI activities and geographic coverage
At the end of the early implementation phase, countries plan how to expand IMCI activities in districts already covered and initiate IMCI in additional districts. The range of IMCI activities is also broadened within the three components of improving case management skills, improving health systems, and improving family and community practices. The selection and the pace of implementation will be affected by the time required to build capacity for IMCI management at the district level, as well as the availability of IMCI tools and guidelines. During the transition to national IMCI coverage, which may require five years or more, countries should continue disease-specific control activities in those districts not yet covered by the IMCI strategy. In these districts, activities should be combined across relevant programmes as far as possible in preparation for integration.
Factors influencing the success of IMCI in a country
The success of IMCI in a country depends on the acceptance and the commitment of the MOH and other relevant bodies. It is essential that the process of early implementation be officially endorsed by the MOH and that this endorsement be accompanied by practical steps to facilitate the introduction of IMCI and related activities. These include the establishment of a management structure and issuing directives to assist inter-programme collaboration.
It is important throughout the process, but particularly during the initial phases, that time is taken to build consensus and to create a broad base of support for IMCI. This involves establishing or strengthening partnerships between existing programmes. The duration of the introduction and early implementation phases may vary from country to country depending on the rate at which consensus is reached and partnerships are formed.
Early experience also suggests that countries should consider identifying a focal person for IMCI. This person should serve as the coordinator for the IMCI working group or IMCI Task Force which is responsible for providing technical support for IMCI, for facilitating the coordination of concerned programmes and bodies, and for providing the core technical input needed for the adaptation of the IMCI guidelines and the planning of IMCI activities, including training.
In addition to the working group, WHO recommends that the MOH establish a high-level steering committee which includes senior MOH officials and advisors from other sectors, and senior faculty of universities and other teaching institutions. The function of this national steering committee is to review and validate the decisions of the working group and to facilitate higher-level policy decisions as needed.
WHO/CHD is developing generic guidelines to assist countries in planning the introduction and implementation of the IMCI strategy. Based on lessons learned from IMCI implementation to date, the guidelines will be updated as global experience accumulates. They will also be modified to support implementation of a broader range of IMCI activities, as tools and specific guidelines become available.