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Child and Adolescent Health and Development |
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Integrated Management of Child Health |
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“IMCI” originally stood for “Integrated Management of Childhood Illness”. It refers to a broad WHO/UNICEF initiative that was launched globally in 1995 with the objective of reducing under-5 mortality, morbidity and disability, and improving child growth and development. Its “provocative” challenge was to move from the vertical disease-specific approach of traditional programmes to a more integrated and horizontal child approach, in line with the philosophy of primary health care. Top Integrated clinical guidelines Initially, developmental work focussed on the development of integrated clinical guidelines for the outpatient management of priority conditions in sick children below 5 years of age and a training package to enable health providers at primary health care level to acquire or strengthen the clinical and communication skills needed to use the guidelines. The guidelines represented a major step ahead compared with single-condition guidelines. They provided the means of detecting more than one problem in a child during the same consultation and managing those problems through an integrated approach. This is particularly important, as many children present with more than one condition at the same time and the management of the child at first-level health facilities is eventually the responsibility of the same health provider, who should deal with the child rather than one illness at a time. Much emphasis was also given to assessing feeding practices in children during their most vulnerable years—the first two years of life—, and in those found not to be thriving well—even before obvious clinical signs of malnutrition would be visible— and to counsel their mothers accordingly. A link with maternal care was also established. The clinical approach therefore included dealing not only with ill conditions but also with risks, and promoting health (e.g., good feeding practices, including breastfeeding). Opportunities for immunization were increased, by including in the IMCI protocol routine screening for immunization status of all sick children seen, this representing one of the added values of IMCI to existing immunization programme (EPI) activities. The advantage of delivering all this content packaged in just one course was also substantial, since the target health provider offering those services at primary health car level was the same. Much attention was given to the quality of clinical training, setting a number of key quality indicators and emphasizing adequate, supervised clinical practice. Intrinsic to capacity-building was a mechanism of follow-up visits to reinforce the acquired skills and at the same time improve health system support, to enable health providers trained in IMCI to deliver quality care in their own facilities according to the IMCI guidelines. Conceptual framework and tools Next, the conceptual framework of IMCI was conceived, expanding the concept and proposing a new vision for public child health, within the spirit of primary child health care, encompassing both the health system and the community, and including curative, preventive and promotion elements. Gradually, WHO developed other instruments—in addition to the training package—to assist countries in translating the “concept” into implementation, including a planning guide for the introduction and initial implementation of IMCI in a country, an adaptation guide to guide the clinical adaptation process in detail, a drug supply management training course, and an IMCI health facility survey manual to evaluate the quality of outpatient child care services at primary health care facilities implementing IMCI. More recently, guidelines for referral care were also developed to improve care at the referral point. A rich IMCI reference library of selected materials was also made available to provide detailed background to the IMCI clinical guidelines for country adaptations and for use by medical and paramedical teaching institutions and interested professionals. However, many countries kept their focus on clinical training and mortality reduction, calling for WHO to assist them in: strengthening health systems to deliver quality services according to the IMCI quality standards; establishing a stronger partnership with the community; and developing effective links between the health systems and the community. As part of its efforts to respond to country needs, the Regional Office developed a planning tool for the community component and a guide to the situation analysis for the development of national child health policies. Top IMCI was also seen as a dynamic framework, meant to respond to new challenges and priorities as they emerged, and include more interventions as they became available. As such, IMCI was not meant to be restrictive and limited to its original “presentation”: it was a public health umbrella for primary child health care, bound to evolve over the years to respond to needs. For more information on the rationale for IMCI and other aspects, an “IMCI information package” developed by HQ is available. The Region is committed to using a quality assurance approach to improve the performance of health providers, the quality of health services delivered to children through the health system and child care provided in the community. It has been promoted in the Region also as a key strategy to contribute to achieving the child health related Millennium Development Goals. Top I. “Integrated” refers to a number of characteristics of the strategy, in addition to the proposed management approach. The ultimate aim of this “integration” is for children under-5 to receive holistic care, whether at home, in the community or at the health facility. It is “integrated” because:
M. “Management” here should be seen as having both a clinical and public health meaning. The IMCI clinical management adopts a syndromic approach, where signs and symptoms are the entry point: cases are “classified” into defined categories of severity based on the presence or absence of a few key signs and symptoms. The main emphasis is on the resulting action: the classifications have the purpose of enabling the primary health care provider to select a management plan rather than make a precise diagnosis, which would often be impossible at that level based only on clinical grounds and the assessment of a few signs. Thus, a sick child is “classified” into one of three main categories, highlighted with a colour code: a) “red”, indicating severe conditions which need urgent referral to an inpatient facility; b) “yellow”, indicating situations that can be managed at the health centre—often with drugs—but that require definite follow-up; and c) “green”, indicating mild conditions which require simple home care. Apart from the clinical management of sick children, many things have to be in place to deliver child care, both in the health system and in the community: these aspects of health care represent the public health meaning of management. C. “Childhood” here refers to children below 5 years of age, which is the child age group most vulnerable to illness and death. Investing in this age group gives also great rewards for their future development and the society as a whole. They are the current targets of IMCI. It is the same age group that was originally targeted by such programmes as the control of diarrhoeal diseases and acute respiratory infections. At the beginning, the global IMCI clinical guidelines did not cover the first week of life, but several countries in the Region decided to include this period also in their adapted guidelines. Much work is currently being undertaken to address the issue of neonatal health. I. “Illness” is used in public health terms, to address conditions that are first of all a major cause of death, severe illness or disability in children under-5, such as acute respiratory infections including pneumonia; diarrhoeal diseases including dehydrating diarrhoea, dysentery and persistent diarrhoea; meningitis and sepsis; malaria; HIV/AIDS; measles; ear infections; malnutrition; and anaemia . IMCI therefore is not comprehensive paediatrics but focuses on public child health priorities in under-fives. In the Eastern Mediterranean Region, the acronym “IMCI” has remained but “illness” has been replaced with the more holistic concept of “health”. Top
The IMCI brought about many significant changes compared with the vertical programmes from which it evolved. It was meant to be managed by a committee or working group, rather than a programme manager, cutting across key child health-related and health system programmes. The committee was to be chaired by a senior official of the ministry of health with decision-making authority, and to be supported in its work by a focal point acting as its secretariat. The committee also oversaw and coordinated a technical process of adaptation of the IMCI guidelines to the country, bringing in the best expertise available in the country to build a consensus in the scientific and public health community. Although time consuming as a process, this created a strong foundation for partnerships within the ministry of health and with academia in many countries in the Region. A potential constraint of the management approach proposed was the lack of visibility of a specific management structure such as that developed for vertical programmes that could be allocated also a budget line for its operations. Some countries therefore appointed a ‘programme manager’ also for IMCI (e.g. Egypt, Sudan, Syrian Arab Republic and Tunisia), while establishing their IMCI steering committees and working groups. In countries in the Region, IMCI was usually placed in the Primary Health Care department. Top
Another important aspect of the IMCI strategy is the guided process for adaptation of its guidelines to the local epidemiological, policy, health system and community context. Through this process, IMCI has proved to be a flexible strategy, able to adapt itself to the diversity of such contexts as those of both the low-income and middle-income countries in the Region. As of the end of 2004, IMCI had been introduced in 17 countries in the Region, with two more expressing interest in it (see implementation). Top
IMCI is meant to move along the two tracks of the health system and community, respectively, while promoting the establishment of strong links between the two. Much emphasis is given to capacity-building. Traditionally, then, IMCI is presented as a strategy which has three components, aiming to:
IMCI introduction in a country follows three phases: a) Introduction; b) Early implementation; and c) Expansion
In the Eastern Mediterranean Region as many as 1.5 million children under the age of 5 still die every year, almost one death every 20 seconds: most of these deaths are preventable through existing, effective interventions included in IMCI. The IMCI strategy had proposed a model that was very appealing to countries and international partners to address this situation. IMCI was therefore introduced in the Region in 1996. The evolution of IMCI in the Region reflected the characteristics of its countries. In fact, the Region was characterized by a distinct socioeconomic, cultural, and epidemiological diversity. While in some countries under-5 mortality reduction was a priority, in others where downward mortality trends had been substantial in the past decades, child health care had to go beyond survival and take up the challenge of addressing newly emerging problems, e.g. injuries, and child development. This challenge brought about a change in the way of thinking at regional level: the foundation of “child health”—as opposed to only “child survival”— was seen as a requisite for a child care strategy in any country, whether the priority was to reduce deaths, reduce child vulnerability to illness or promote healthy growth and development. Interventions had to improve the quality of children’s life. The new concept wanted to address the child as a whole and emphasize the importance of a more holistic approach contributing to building stronger children rather than just waiting for them to get sick in order to treat them. Much attention was given in the Region to the health system, to support the delivery of quality child health services, as documented also in the IMCI analytic review. Many medical and some paramedical schools in the Region started a process to incorporate IMCI elements into their teaching (see pre-service education). Both approaches, i.e. addressing the healthy and sick child, had to go hand in hand, if sustainable and persisting achievements over time were to be made. With this understanding, IMCI has since evolved gradually in the Region to encompass both illness and healthy growth and development of children, especially in most recent years. It has therefore been re-named “Integrated Management of Child Health” in the Eastern Mediterranean Region, to better reflect its original objectives, which go beyond illness, and underline its emphasis also on prevention and health promotion. The acronym “IMCI” has to date been retained as this is how it has been widely known worldwide. Top
In recent years, an analytic review of IMCI has taken place in the international community. This has generated a dynamic debate, which has helped clarify some issues about perceptions and realities related to IMCI. The child survival series by leading public health specialists published in The Lancet in 2003 brought more impetus to the debate of child health, including IMCI. The radical move from a “vertical”, “programme-oriented” approach toward a “horizontal”, “strategy-oriented” approach was very challenging to countries and many had some difficulty in translating the concept into action. A question commonly asked concerned IMCI placement, visibility and funding: “Where is IMCI in the structure of the ministry of health?”, “Is there a budget line for it?” After the child survival revolution of the 1980s, funding for child health programmes and initiatives such as IMCI lost specificity in the 1990s, and funding mechanisms for broad social and health sector reforms, wide sector approaches and poverty alleviation strategies were promoted. Government budgets for child health-related programmes ‘shrank’. New “vertical” funding initiatives were also launched in other areas globally, increasing the competition for resources. Introduction of IMCI in a country was often a lengthy process, which disappointed partners’ expectations. A major global WHO-supported multi-country evaluation to document the effectiveness, cost and impact of IMCI when implemented under routine circumstances required years before it could start answering the question on whether IMCI worked in the field: so, while many valid assumptions were made in support of IMCI, also by the World Bank, and country pre- and post-intervention assessments documented a clear improvement in the performance of health providers trained in IMCI, the much wanted cost and impact data were not ready initially to the scientific and donor community. Initially, the focus on process rather than intermediate outcomes and the lack of IMCI outcome-oriented indicators and targets in planning made it difficult to relate interventions to outcomes. Furthermore, some countries implemented IMCI as a ‘training programme’ rather than an integrated strategy, failing to strengthen those key health system elements necessary to deliver quality care and establish links with partners and the community. This helped generate confusion about what IMCI was and what it was achieving. The serious constraints of decreased financial resources for child health in the Region prevented countries from embarking on the type of communication interventions that had characterized diarrhoeal disease control programmes in the past, and contributed to delays in implementation of the community component. Top Looking forward: optimism from evidence However, a more careful and updated review of the situation after a few years into advanced IMCI implementation provides an encouraging and promising insight, which fully supports the adoption of IMCI as a framework and its important role in primary child care in the future. It also helps highlight the main challenges, which often go “beyond IMCI”. Evidence has been growing slowly but consistently showing that IMCI works and makes a difference. Initially, information came from pre- and post-intervention studies and repeat IMCI follow-up visits. These showed an improvement in IMCI-trained health providers’ clinical and communication performance, a more rationale use of drugs—especially antibiotics—, an improvement in the quality of child care services provided in “IMCI facilities”, and a good level of caretakers’ satisfaction with these services. Selected health systems support elements were also strengthened in countries in the Region. These findings were then confirmed by more structured surveys on the quality of outpatient child health services in facilities implementing IMCI (see Surveys and follow-up). Further evidence is now coming from the preliminary results of the global IMCI multi-country evaluation, showing that IMCI introduction can be associated with sustained improvement of health providers’ clinical and communication skills, and of the quality of outpatient child health services, at a cost similar to or lower than non-IMCI case management. This has been accompanied by an increased utilization of facility-based outpatient child health services. All-cause under-five mortality has been reduced during implementation of the three IMCI components, with a plausible effect of IMCI on mortality. Enhancing the teaching of child health elements in medical and paramedical pre-service education, an initiative spearheaded by the Region, is a promising approach toward sustainability and to address in part the issue of turnover of trained staff, but still needs to be evaluated. Similarly, alternative in-service training approaches to the standard 11-day IMCI course, which have been adopted by some countries in the Region where doctors are assigned at primary health care facilities, need to be evaluated. The findings from IMCI follow-up visits are encouraging. Some positive conclusions can be drawn at this stage:
From an implementation perspective, the three main challenges today are: 1. How to deliver existing, effective interventions which are part of IMCI to those who need them most in the community, especially the most vulnerable; 2. How to accelerate implementation to reach maximum coverage while sustaining the achievements made and keeping the quality of interventions; and 3. How to make resources available to support implementation. This applies particularly to countries with less developed health systems, although disparities in health care exist in most countries. More needs to be done to monitor outcomes and achieve behavioural changes in the community. Creating a supportive environment through clear child health policies is critical and the Regional Office is supporting countries in this domain. Such policies should also commit adequate financial and human resources. The global community should take advantage of this momentum to assist in providing the resources needed to translate commitment into action. Some other technical and operational issues also need to be addressed, such as adopting a problem-solving approach at district level for IMCI to be responsive to the local needs during implementation; managing children with severe conditions at primary health care level if they can not be referred; making pre-referral and other essential drugs—needed for IMCI—regularly available at health facilities and accessible to the patients; implementing the community component with a supporting health system; reporting more on outcome indicators to monitor progress.
The EMRO view The conceptual framework of IMCI is very close to the ideology of primary health care, as defined in the Alma-Ata Declaration on Primary Health Care, to the extent that in many countries in which IMCI has been introduced IMCI has been seen as “primary child health care”. It is currently promoted in the Region as such. IMCI is public child health: it is “essential health care” in that it aims to address the “main health problems” of under-five children in a country, based on epidemiological evidence. While leading causes of under-five mortality have been targeted as a priority and reduction of under-five morbidity and disability have remained key objectives of the strategy, attention has increasingly been placed also on child development. IMCI is based on “scientifically sound methods”, following a thorough process which relies on expert opinion and research. IMCI promotes a technology that is affordable and does not require sophisticated laboratory facilities, equipment and supplies. IMCI proposes an “integrated” approach, to bring together the main elements of child care instead of vertical programmes. The IMCI community component advocates for community participation, in line with the PHC principles, as a means of achieving sustainability. IMCI focuses on “the first level of contact of the community with the national health system”. It promotes a close-to-client approach to provide access to quality child health care, especially for those who need it most—the poor and most disadvantaged. The child health interventions that are promoted under the IMCI umbrella include those that have widely been recognized as most effective by the international scientific community. These interventions aim not only at curing illness, but also at preventing it and promoting health. In the same way as PHC has developed differently in different countries, IMCI experiences have differed in different countries and evolved according to country capacity and needs in our Region (e.g. going beyond illness to promote healthy growth and development in children in countries in which under-5 deaths have been decreasing steadily over the years). The critical role played by policies has been recognized and an initiative has been launched in the Region to support countries in developing national child health policies. IMCI strives to promote a public health response that provides cost-effective and evidence-based child health care services. “Child health care” is one of the core activities included in the Alma-Ata definition of primary health care. Many challenges remain, including the achievement of universal access and coverage, financing and closer collaboration with partners and the private sector. Top
Because of the characteristics described above, IMCI is considered a key strategy to achieve the child health-related MDGs in the Region. More information is provided in the section on MDGs. Top
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