Work was initiated in 1995 on the development of training for the integrated management of childhood illness in referral-level facilities. Clinical guidelines for referral-level services are being developed, and the Division is exploring innovative methods of teaching and introducing these guidelines into appropriate health facilities.
In collaboration with the USAID/BASICS project, the monitoring tool Health Facility Quality Review has been developed and tested, and is now being used in Indonesia.
A consultative meeting of experts, held in Geneva in January 1996, strongly supported the need to introduce IMCI into the curricula of medical schools around the world. At this meeting, objectives and methods for doing this were recommended. Developmental work in this area will depend on the completion of the referral-level guidelines.
An informal consultation on the Behaviour Change Intervention Project was held in Geneva in September 1995. The small group of social scientists and programme implementers discussed and reviewed a project to develop interventions to improve household response to childhood illness. This consultation strongly endorsed the project, and emphasized the need to identify desired behaviours and systematize development of messages related to IMCI. The initial steps of the "planning guide" have been developed and will be field tested in the first half of 1997.
Since June 1995, four CHD-supported research projects have been completed and an additional eleven projects have been initiated. Although these projects are mostly related to management of diarrhoea and nutrition they are of direct relevance to IMCI and their fundings will, in due course, be incorporated into IMCI guidelines.
A double blind clinical trial evaluating the efficacy of cotrimoxazole in the treatment of persistent diarrhoea showed that there is no benefit in its routine use.
Two projects tested interventions to promote appropriate complementary feeding practices.
Two multicentre studies to evaluate the efficacy and safety of reduced osmolarity ORS solution in children with acute non-cholera diarrhoea (Bangladesh, Brazil, India, Peru, and Viet Nam) and in adults with cholera (Bangladesh and Indonesia).
An evaluation of the effects of training health workers on lactation counselling on their ability to assist mothers to resolve breastfeeding problems. The training is provided using the Lactation Counselling: A Training Course, developed by the Division in collaboration with UNICEF. Breastfeeding counselling is an integral part of the IMCI approach.
An evaluation of the impact of the national diarrhoeal disease control programme of the Philippines on diarrhoea morbidity and mortality among under fives.
A case control study in Peru will examine whether bulging fontanelle observed in association with vitamin A supplementation is associated with impairment in child development.
A study in Bangladesh will assess the validity of maternal responses to a questionnaire on the home management of diarrhoea by comparing responses related to changes in fluid intake by the child during the episode with observed changes in intake.
Three projects have been supported to examine the effect of vitamin A supplementation on the response to vaccines delivered in early infancy:
The following briefly summarizes progress to date in these countries:
· Indonesia commenced in 1995 with an orientation of high level decision-makers, programme managers, professional associations and representatives from major donor agencies. Plans for the adaptation process and preparation for training were prepared. A national Task Force, which draws on all the technical programmes involved, has now almost completed the adaptation of the guidelines and modules and the first training course should take place early in 1997. The Asian Development Bank and the World Bank are strongly interested in including IMCI in their supported programmes for the future.
· Nepal established a "Sick Child Working Group" which is undertaking the adaptation process. An adaptation workshop, designed to achieve consensus on the technical issues among all concerned parties, will round off the adaptation in November 1996 and the first course is planned for early 1997
The African region of WHO has prepared a strategy which aims to support countries in the systematic introduction of IMCI. The strategy includes strengthening the capacity of the Regional Office to provide consultant and technical support, as well as encouraging the countries themselves to take greater financial responsibility for the initiative. The strategy was formulated in conjunction with UNICEF, the World Bank and other major donors committed to health development in Africa.
In the Region of 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 from countries in the Region in a meeting in Santa Cruz de la Sierra, Bolivia, and agreed to initiate the implementation of IMCI in four countries of the Region during 1996/1997. The training in Peru described above was the first step in this. Training will start in Bolivia and Brazil before the end of 1996.
Because there is considerable overlap in the signs and symptoms of several of the major childhood diseases, a single diagnosis for a sick child is often inappropriate as shown in the following table. Focusing on the most apparent problem may lead to an associated, and potentially life-threatening, condition being overlooked. Treating the child may be complicated too by the need to combine therapy for several conditions.
This situation argues for child health programmes that address not single diseases but the sick child as a whole. A lot has been learned from disease-specific control programmes in the past 15 years. The challenge is to combine these lessons into a single more efficient and effective approach to managing childhood illness. A number of programmes in WHO and UNICEF have responded to this challenge by developing an approach now referred to as integrated management of the sick child. Already a number of other agencies, institutions and individuals are contributing to this initiative.
Evidence from surveys of health worker performance and of management of illness in the home suggest that, in both these areas, improvements can be made that are likely to reduce mortality significantly. As potentially fatal illnesses in children are often brought to the attention of health workers at first-level health facilities, the initiative for integrated management of the sick child is focusing first on improving their performance through training and support. At the same time work has started on approaches to changing family behaviour in relation to sick children including when and where families seek care outside the home.
The IMCI approach gives attention to prevention of childhood disease as well as to treatment. It emphasizes the importance of immunization, vitamin A supplementation if necessary, and improved infant feeding, including exclusive breastfeeding.
Providing care for sick children, along with interventions to keep them healthy, is an integral and essential component of the development of health systems to deliver Primary Health Care.
Approaching improvement to the management of childhood illness in an integrated manner means efficiency in training, and in the supervision and management of outpatient health facilities. Wastage of resources is reduced because children are treated with the most cost-effective intervention for their condition. The approach avoids the duplication of effort that may occur in a series of separate disease control programmes.
According to the World Bank's World Development Report 1993, integrated management of the sick child is the intervention likely to have the greatest impact in reducing the global burden of disease. This approach alone is calculated to be able to prevent 14% of that burden in low-income countries. According to the same report, management of the sick child ranks among the most cost-effective health interventions in both low-income and middle-income countries.
The importance and advantages of IMCI are summarized in Annex 1.
Management of childhood illness: a training course for first-level health facility workers
Integrated outpatient management of childhood illness at the first-level health facility has been described on four wallcharts which are also available in booklet form. The content of these is based on experience to date and on the findings of specially conducted research studies. The case management guidelines focus on detecting and managing the most common potentially fatal illnesses and associated conditions; they do not attempt to cover all childhood illnesses.
The case management guidelines constitute the technical core of a training course that has been developed for first-level health facility workers. The materials used for the course are listed in Box 1. Using these materials, the course facilitators teach the health workers a systematic case management process (see Box 2). The course emphasizes hands-on practice of the skills taught. Communication skills are emphasized in the course and are taught from the first day, in each module and throughout the clinical practice as well as in role plays in the classroom. A full description of the course is available from CHD.
The generic guidelines and training course prepared by WHO and UNICEF require adaptation to each country's local situation.
A draft guide to local adaptation has been prepared and is currently being revised and improved. This includes guidance on modification of such things as advice concerning foods and fluids to be included when counselling the mother, antimicrobials of choice in a particular epidemiological context, and other policy decisions (see Box 3).
Guidelines for conducting a training workshop on management of drug supplies followed by supervised practice in the place of work have been developed in collaboration with the USAID-funded BASICS Project to help health workers better manage the drugs essential for management of sick children. They will be field-tested soon and are expected to be ready for use by the end of 1996.
Numerous bilateral agencies and international organizations are also supporting these efforts through their funding of CHD (CDR) and other WHO programmes. Financial assistance to CHD is offered by Australia, Austria, Canada, China, Denmark, Germany, Italy, Japan, Luxembourg, Netherlands, Nigeria, Norway, Spain, Sweden, Switzerland, United Kingdom, and the USA. The World Bank, UNDP, and UNICEF also give financial and/or technical support. Funds specifically designated for the Integrated Management of Childhood Illness have been provided to WHO by the Governments of Australia, Japan, Luxembourg, Netherlands, Norway and Switzerland and by the US Agency for International Development. In addition, UNICEF and some bilateral agencies have allocated funds in their health projects in countries.
|Management of Childhood illness
Assess and Classify the Sick Child Age 2 Months up to 5 Years*
Treat the Child*
Counsel the Mother*
Management of the Sick Young Infant Age 1 Week up to 2 Months*
Other training materials/job aides4 wall charts (titles marked with * above)
Mother's counselling card
Recording forms (for assess and classify)
GuidesCourse Director's Guide
Facilitator Guide for Teaching Modules
Facilitator Guide for Clinical Practice in the Inpatient Ward
Facilitator Guide for Outpatient Clinical Practice
Management of Childhood Illness
Case Management Process
|Management of Childhood Illness
Steps in country-specific adaptation
Why Integrated Management of the Sick Child
is a PriorityThe health system and the services it delivers should:
· Addressing a major health problem: Pneumonia, diarrhoea, measles, malaria and malnutrition together account for 7 out of 10 of the 33 000 deaths that occur daily among the children of the developing world.
· Responding to a demand: Every day millions of parents take their children for care to hospitals and health centres, pharmacists and community health care providers. At least 3 out of 4 of these sick children are suffering one of these five conditions.
· Impact on health status: The World Bank's World Development Report 1993 Investing in Health identified management of the sick child as the intervention likely to have the greatest impact on the global burden of disease, potentially averting 14% of that burden in low-income countries or more than twice the amount averted by the next most effective intervention, childhood immunization.
· Prevention as well as cure: While integrated management of the sick child focuses on treatment, it also provides the opportunity for, and emphasizes, the two most important preventive interventions for child health: immunization and improved nutrition, especially breastfeeding.
· Cost-effectiveness: The same World Bank report ranked management of the sick child among the 10 most cost-effective interventions in both low- and middle-income countries.
· Cost saving: Inappropriate management of childhood disease is wasteful of scarce resources such as intravenous fluids and antibiotics. Control programmes specific to a single disease have been effective but can be inefficient because of duplication of effort. Integrated management of the sick child addresses both of these concerns and should result eventually in cost saving although an initial increased investment will be needed for training and reorganization.
· Improving equity: Virtually all children of the developed world and most well-off children in the developing world have ready access to the simple affordable treatments needed to protect them from death due to these five diseases. However, most children of the developing world do not have access to this life saving care. Given that this is one aspect of inequity which can be addressed immediately, with proven, inexpensive interventions, it should be addressed as a matter of urgency.
Collaborating InstitutionsThis initiative has been coordinated by the WHO Division of Diarrhoeal and Acute Respiratory Disease Control (CDR). This Division, now known as Child Health and Development (CHD), will continue this role. Other WHO Divisions that have collaborated are:
World Health Organization (Divisions/Programmes)Office of HIV/AIDS and Sexually Transmitted Diseases (ASD)
Division of Control of Tropical Diseases (CTD)
Action Programme on Essential Drugs (DAP)
Division of Emerging, and other Communicable Diseases Surveillance and Control (EMC)
Global Programme for Vaccines and Immunization (GPV)
Maternal Health and Safe Motherhood (MSM)
Oral Health (ORH)
Programme for the Prevention of Blindness (PBL)
Special Programme for Research and Training in Tropical Diseases (TDR)
World BankDepartment of Population, Health and Nutrition
UNICEFChild Survival Unit
Bamako Initiative Unit
In addition to the Ministries of Health in countries where activities related to integrated management of the sick child have been carried out, other research and academic institutions in the following countries have been involved in the development and early implementation activities:
Canada South Africa
The Gambia UK
Italy Viet Nam
A complete list of collaborating institutions may be made available on request.