Principles
The adaptation of the IMCI (Integrated Management of Childhood Illness) 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.
Leading causes of mortality and morbidity
Sensitive and specific clinical signs
Minimum number of clinical signs
Minimum number of essential drugs
Best care possible for severe cases
Leading causes of mortality and morbidity
Including leading causes of mortality and (severe) morbidity in the WHO guidelines has been a key guiding principle.
The inclusion of other conditions than those covered in the WHO 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.
Sensitive and specific clinical signs
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 avoid over-treatment and over-referral of cases which do not have the condition.
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.
In principle, new clinical decision rules should first be validated in clinical settings before being included and integrated in the guidelines, rather than be only derived from expert opinion (see “Research”).
Minimum number of clinical signs
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.
Requiring simple skills
The guidelines should require simple skills to be used.
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.
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.
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.
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.