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Child and Adolescent Health and Development |
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Integrated Management of Child Health |
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The generic version of the guidelines therefore concentrates on the outpatient management of the following conditions:
The generic guidelines need to be adapted in countries, to take into consideration local epidemiology, existing policies, drug resistance patterns, essential drugs availability, feasibility of implementation through the existing health system, and local terminology used in communities to refer to common illness entities. Recommendations on foods and fluids also need to be adapted. WHO has developed an “Adaptation Guide” to facilitate the adaptation process. Top
The adaptation of the IMCI guidelines should rely as much as possible on evidence and be guided by a number of public health principles. The generic guidelines are meant to target the leading causes of mortality and (severe) morbidity in children below five years of age, who are a particularly vulnerable age group. The guidelines therefore intentionally cover only priority public health conditions rather than all paediatric conditions. In the same way, country adaptations must follow a number of principles, which are described below. The ultimate product of the adaptation process should be guidelines that are safe and effective when used at primary health care level.
The inclusion of other conditions than those covered in the generic version must be based on a solid justification, including the expected advantages from a public health perspective. For example, the argumentation in favour of including the management of streptococcal pharyngitis in some countries has been the need for a rationalisation of drug use for children presenting with sore throat, and the expectation that the availability of standard guidelines would help reduce health care costs for both the health system and the users. There are conditions that are not a major cause of mortality but are included because they are a preventable cause of long-term or life-long disabilities (e.g., ear infections, which may result in hearing problems). The number of conditions must be limited, so that they can be covered properly in a quality short training course such as IMCI. At the end of the examination of the child, the guidelines remind the health provider to look for any “other problems” not specifically listed in the chart and to manage these problems according to the pre-service training they have received. Top
The guidelines in most cases rely just on clinical signs, as laboratory, X-ray or other diagnostic facilities are most often unavailable at primary health care level in developing countries. The signs and symptoms selected in the algorithm must be sensitive and specific. The concern is to avoid missing cases which have the condition while at the same time avoiding over-treatment and over-referral of cases which do not have the condition. In principle, new clinical decision rules should first be validated before being included in the guidelines, rather than be only derived from expert opinion (see “Research”). Top
The
guidelines must be practical to be used reliably by primary health care
providers and must then include a limited number of clinical signs that
can be learnt during a short training course. It should be emphasised
that the guidelines are action-oriented: rather than leading to specific
diagnoses, the guidelines aim at assisting the health provider in
identifying (“classifying”) conditions in three main groups: those which
require urgent referral, treatment or counselling on home care. Any
additional signs which do not improve the performance of the guidelines
should not be included.
Top Requiring simple skills The
guidelines are meant to be used by a wide range of health providers
working at primary health care level. Their skills vary and guidelines
requiring simple skills are more likely to be used properly than those
relying on more complex skills.
Top Possible to teach and learn
The assessment of signs and treatment approaches
should be easy to teach—and to be learnt— within the short duration of
an in-service training course.
Top Minimum number of essential drugs
The
guidelines should rely on a minimum number of drugs that can be made
available and used safely at primary health care level and that are the
least expensive.
Top Best care possible for severe cases However simple the guidelines may appear, they must enable the delivery of the best possible care, especially the detection, pre-referral treatment and urgent referral of the most severe cases. Top
The duration of the process varies from country to country, from a few months to a year or more. This process is however very important, playing an advocacy role and giving a sense of ownership, and is therefore key to future implementation of the IMCI strategy. This is because it brings together representatives of the Ministry of health, professional societies and academe, including medical schools, international and bilateral organizations, to generate an output by broad consensus. This consensus promotes further collaboration during implementation and reinforces the foundation of the strategy in the country. For example, senior, highly respected paediatricians in countries have joined in-service IMCI training courses as facilitators, participated in follow-up visits after training and eventually played a leading role in the introduction of the IMCI approach in medical schools. The adaptation process concerns not only the clinical guidelines, but also the feeding recommendations and the care-seeking process, by identifying local terminology used in communities to refer to illness entities and to be used in health communication initiatives. The complete IMCI Adaptation Guide Version 5, with a description of tasks, the technical basis for the generic guidelines, the process and instruments is available at the WHO/HQ CAH website. Top
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French
Afghanistan
Iraq
Morocco
Oman
Saudi Arabia
Syrian
Tunisia
Yemen