Every year, about 12 million children die before reaching their fifth birthday. Over 70% of these deaths, the vast majority occurring in the developing world, are due to acute respiratory infections, diarrhoeal diseases, malaria, measles and malnutrition, often in combination.
In the past decade, major progress has been made to reduce and contain childhood mortality and morbidity through universal childhood immunization, control of diarrhoeal diseases and acute respiratory infections, nutrition programmes (including breast-feeding promotion) and through implementation of other primary health care activities. In spite of this progress, major challenges remain, as mortality rates are still unacceptably high, especially in the sub-Saharan Africa and South Asia.
In keeping with the Convention on the Rights of the Child, every child has the right to, inter alia, access to care for the most prevalent causes of illness and death, as well as to measures to prevent them.
What is IMCI?
Integrated Management of Childhood Illness (IMCI) is a strategy for reducing the mortality and morbidity associated with the major causes of childhood illness. Its development by WHO and UNICEF started in 1992. It was decided to initially focus on improving care at the first level health facilities where millions of children arrive sick each day, most of them with one or more of the major causes of illness and death. A set of generic guidelines for management of childhood illness at this level was completed in 1996 and is now starting to be used as the basis for introducing this component of IMCI in countries. These generic materials cannot be used without substantial adaptation at country level, based on the country-specific situation.
The current focus is on improving the quality of care of children at first-level health
facilities (health centres and outpatient services) in both rural and urban areas through the use of standardized procedures and on integrated approach to health care. The curative component of IMCI is adapted to address the most common life-threatening conditions for children in each country focusing on diarrhoea, pneumonia, measles and malaria (where applicable) as well as the management of severe malnutrition and nutrition counseling. IMCI incorporates simple life-saving technologies promoted by WHO and UNICEF, such as ORT, into a more comprehensive approach which addresses not only individual diseases but the sick child as a whole. IMCI also has health promoting and preventive elements including: reducing missed opportunities for immunization, breast-feeding and other nutritional counseling, vitamin A and iron supplementation, and treatment of helminth infestations. It should be noted that all children, not only sick children, should be targeted with these preventive and promotive interventions. IMCI pays particular attention to improving the communication and counseling skills of health workers.
The IMCI strategy, therefore, seeks to reduce childhood mortality and morbidity by adopting a broad and cross-cutting approach with the following components:
- improving family and community practices through education of mothers, fathers, other child care-takers and members of the community with focus on: health seeking behaviour, compliance, care at home and on overall health promotion.
IMCI is not a vertical programme. It is an integrated strategy that incorporates many of the elements of diarrhoeal disease and ARI control programmes and some of the child-oriented aspects of malaria control, nutrition and other related programmes. It also depends on the effective functioning of the EPI and essential drugs programmes. It demands and facilitates an active collaboration between all of these existing programmes. It is an important step toward improving the quality of care of sick children within the primary health care context.
IMCI implementation involves a combination of focused appropriate technical guidance and problem-solving at district and health facility levels around issues affecting service delivery. The latter must involve the district-level health staff, first-level health workers and members of the communities they serve. In this way, IMCI can contribute to capacity building at district and local levels while revitalizing the health services to improve primary health care services for children.
A number of principles underlie and should guide the implementation of the IMCI strategy:
The first step in the introduction of IMCI in a country is a thorough orientation of all relevant stakeholders as to what this strategy entails. This process seeks consensus on the priority problems to be addressed, based on the country specific situation, and on how to proceed with implementation of the integrated approach and a statement of national commitment to the strategy.
Following a decision to work towards integration of management of childhood illness, the first step is to define standard guidelines for care specifically tailored to the country. Sometimes aspects of this will need to be modified for different regions of a country. A convenient and cost-effective way of achieving this step is to start with the generic WHO/UNICEF guidelines and adapt them. This adaptation process must involve programme managers of all relevant sections of the ministry of health as well as relevant partners from other relevant sectors/institutions, paediatricians and their professional associations, NGOs and potential partners in funding and technical support.
It provides the opportunity to review policies and practices related to child health care and to revise them in a way that allows integration and avoids contradiction. An important component is the development of food and feeding guidelines that are practical and appropriate to families, taking into account local feeding practices and needs. The process of adaptation requires active consensus building and takes time but yields guidelines appropriate to the context and ensures a sense of ownership of those involved, an essential factor in their subsequent use. Once adapted guidelines are available, the process of modifying the materials of the generic WHO/UNICEF training course for first-level health workers can be undertaken relatively easily.
In parallel with the process
of adapting the case management guidelines, it is essential to start planning
for the introduction of the IMCI approach. Hence, an IMCI implementation
plan that addresses the various elements, including a training plan, should
be developed. Consideration must also be given to factors enabling trained
health workers to apply their skills, including the availability of the
necessary essential drugs and supplies.
Experience to date
Globally, more than 35 countries have expressed an interest in IMCI. In the countries that have taken an early lead in implementing IMCI, locally-adapted guidelines on management of childhood illness have already been developed in ten countries (Bolivia, Dominican Republic, Ecuador, Indonesia, Nepal, Peru, Philippines, Tanzania, Uganda, Zambia) and in six of these the first round of training at district level has been carried out. This early experience has demonstrated the feasibility of the approach, provided encouraging evidence of improved care and identified important issues that will need to be addressed in expanding beyond a few districts.
Early experience with IMCI implementation
has underlined the importance of involving all stakeholders in the process
of consensus building. It has also highlighted the importance of national
capacity building and the identification of local, national and external
resources and institutions to support the introduction, and expansion of
the coverage, of IMCI activities.
IMCI and CDD/ARI
As IMCI activities expand in countries, it is anticipated that single disease programmes focused on childhood diarrhoea (CDD) and ARI will be phased out. It is important, however, that support to these programmes continue in countries and districts where IMCI is not yet implemented so as not to lose the considerable gains already made.
In those countries where IMCI implementation has not yet started, efforts should be made toward greater integration in the planning and implementation (including training) of CDD and ARI programmes. Such integration will enable countries to be in a better position to implement IMCI. As part of this early preparatory phase, policy makers and programme managers should strengthen the foundation for IMCI introduction by addressing key issues such as improving the availability of essential drugs, organization of services and on-going support for preventive and promotive child health action including communication activities for CDD, ARI and other programmes.
IMCI and Quality assurance
The overall potential impact of IMCI
is the reduction of mortality, as well as morbidity and suffering, through
access to quality health care in health facilities and improved correct
case management at home, in addition to improved preventive and promotive
health action. IMCI has potential to contribute to quality assurance through:
- the improvement of the organization of work at the health facility level through participatory problem-solving techniques;
- the improvement of supervision and monitoring in order to improve standards of care through quality control techniques; and
- monitoring user satisfaction.
Considerable effort has been invested over the last decade by UNICEF and WHO to develop information, education and communication materials, approaches and activities related to the individual health conditions addressed by the IMCI approach. These remain valid and their continued use is important. Nevertheless, as countries mov
Considerable effort has been invested over the last decade by UNICEF and WHO to develop information, education and communication materials, approaches and activities related to the individual health conditions addressed by the IMCI approach. These remain valid and their continued use is important. Nevertheless, as countries move towards greater integration and review and, where necessary, revise their policies, it will be necessary to develop appropriate messages and materials compatible with the new integrated guidelines. These should include advice on health promoting behaviour, early home care for illness, appropriate care seeking and compliance with treatment advice. Communication strategies to address these concerns and to accelerate household/community based action will be further developed by WHO and UNICEF for adaptation at country level.
IMCI in relation to equity and child rights
No child should leave a health facility with a common but life-threatening condition undiagnosed and/or untreated. Fortunately, this does not happen frequently in developed countries. Yet it is a widespread daily occurrence in the less developed countries. This is a gross inequity that must be addressed; the fact that we know well how to address this problem increases the moral imperative to do so as a matter of priority. Hence, the training of health workers in order to improve their skills, including communication and counseling skills, and to enable them to improve the quality of care provided to children as well as effective communication with mothers, other child-care takers and community is essential. Further, every effort should be made to reach the difficult-to-reach children.
Partnerships for IMCI
From its outset, the IMCI approach has been a joint WHO/UNICEF initiative. It quickly attracted the attention of the World Bank. In a recent World Development Report, IMCI was recognized it as one of the most cost-effective components of a package of essential clinical and public health services, in fact, the one likely to have the greatest overall impact on the global burden of disease. The World Bank, as well as some development assistance agencies, are now working to include IMCI in selected country programmes focused in areas such as child health, early childhood development, improving the quality of health services and health system reform. IMCI is already receiving the financial support of a number of governments through their development assistance agencies, both for global activities and in individual countries.
At country level, as mentioned above, essential and productive partnerships have been established involving government departments, universities, NGOs, community-based organizations and development agencies, as well as WHO and UNICEF.
Indicators for monitoring progress in the implementation of IMCI are now under development by WHO and UNICEF, in consultation with countries that have started implementing IMCI.