of Child Health and Development (CHD)
INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS
The management of childhood illness in developing countries: Rationale for an integrated strategy
Every year some 11 million children in developing countries die before they reach their fifth birthday, many during the first year of life. Seven in ten of these deaths are due to acute respiratory infections (mostly pneumonia), diarrhoea, measles, malaria or malnutrition - and often to a combination of these conditions (see figure 1). In addition, at least three out of four episodes of childhood illness are caused by one of these five conditions, and every day millions of parents seek health care for sick children, taking them to hospitals, health centres, pharmacists, community health care providers and traditional healers. Projections based on the global burden of disease analysis completed in 1996 indicate that these conditions will continue to be major contributors to child deaths in the year 2020, unless significantly greater efforts are made to control them.
The evidence that a large proportion of childhood morbidity and mortality
in the developing world is caused by just five conditions does not in itself
argue for an integrated approach to the management of childhood illness.
However, most sick children present with signs and symptoms related to
more than one of these conditions and this overlap means that a single
diagnosis may be neither possible nor appropriate (see figure
2).Treatment of childhood illness may also be complicated by the need
to combine therapy for several conditions. An integrated approach
to managing sick children is, therefore, indicated as is the need for child
health programmes to go beyond single diseases and address the overall
health of a child.
The IMCI strategy
The strategy combines improved management of childhood illness with
aspects of nutrition, immunization, and several other important influences
on child health, including maternal health (see figure
3). Using a set of interventions for the integrated treatment and prevention
of major childhood illnesses, the IMCI strategy aims to reduce death and
the frequency and severity of illness and disability, and to contribute
to improved growth and development. This set of interventions aims to improve
practices in both health facilities and in the home (see figure
The core intervention is integrated case management of the five most important causes of childhood deaths - acute respiratory infections (ARI), diarrhoea, measles, malaria and malnutrition - and of common associated conditions.
In individual countries, the combination of interventions that makes up IMCI may be modified to include other important conditions for which effective treatment and/or preventive practices have been identified. The main interventions of the global IMCI strategy may evolve, as new findings from analysis of the global burden of childhood disease and from child health research become available.
Implementation of the IMCI strategy in countries involves the following three components:
Benefits of the IMCI strategy
In health facilities, the IMCI strategy promotes the accurate identification
of childhood illnesses in outpatient settings, ensures appropriate combined
treatment of all major illnesses, strengthens the counselling of caretakers
and the provision of preventive services, and speeds up the referral of
severely ill children. The strategy also aims to improve the quality of
care of sick children at the referral level. In the home setting, it promotes
appropriate careseeking behaviours, improved nutrition and preventive care,
and the correct implementation of prescribed care. The benefits of
the IMCI strategy are summarised in Box 1.
The relationship of IMCI with other technical programmes
The IMCI strategy promotes a number of interventions and areas of activity, such as immunization, vitamin A supplementation and drug supply management, that are managed by other technical programmes (see figure 5).
IMCI management in countries will not involve taking on responsibility
for these other programmes, but will seek to ensure that activities are
well coordinated and effectively implemented in order to contribute to
IMCI. Examples of what IMCI can offer to other programmes and what it requires
from them are given in table 1. In all countries, the collaboration of
all relevant programmes is essential for the development and endorsement
of the IMCI clinical guidelines and for their promotion and use.
IMCI and health system reform
In many developing countries some type of reform of the health system is underway, often involving decentralization of management, including responsibilities for training and drug supplies. The emphasis in IMCI implementation on capacity building at district level is compatible with, and can contribute to, this aspect of health system reform. Another aspect of health system reform being promoted in some countries is essential services or a minimum package of activities and there is a strong rationale for including IMCI in such an approach. IMCI can also strengthen other aspects of reform such as improving the quality of care and improving cost-effectiveness.
Regardless of the approach taken by a country to health system reform, it is important that IMCI be explicitly discussed early in the process and included in plans, especially plans for capacity building at district level.
The IMCI strategy clearly focuses on the diseases of childhood that cause the greatest burden, globally, while allowing for the content to be adapted to individual country needs. An integrated approach is needed because of overlap in the signs and symptoms of the major diseases and because it is important to treat the child as a whole, not simply the most apparent disease. The strategy involves not only curative care interventions but also those to promote healthy growth and prevent diseases. Often, these too are aimed at more than one disease.
Effective IMCI requires action at different levels of the health service
and in the home and the community. Through improving the coordination and
quality of services provided by existing child health programmes, the IMCI
strategy will increase the effectiveness of care and at the same time reduce
costs. It offers a model for improving one aspect of service delivery that
could be applied to other aspects of health care. Finally, IMCI has
the potential to make a major contribution to health system reform and,
because it is one of the essential components of health services, should
be taken into account early in the reform process.