The past and future of IMCI

An analytic review of IMCI, which took place a few years ago, 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 gloomy view

Looking forward: optimism from evidence

 Conclusions

The main challenges

The gloomy view

The radical move from a “vertical”, “programme-oriented” approach towards 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. 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.

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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”; anda 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 came from the 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. A recent analysis of data from implementation of IMCI in Egypt also suggests a plausible effect of IMCI on under-five 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.

Alternative in-service training approaches to the standard 11-day IMCI course have been adopted by some countries in the Region where doctors are assigned at primary health care facilities. These approaches, need to be evaluated. The findings from IMCI follow-up visits are encouraging.

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Conclusions

Some positive conclusions can be drawn at this stage:

The IMCI framework, with its emphasis on curative and preventive care and health promotion remains a valid framework and can continue to serve as a guide for primary child health care in the Region.

IMCI can improve health providers’ case management skills, rationalize the use of drugs—especially antibiotics, improve the quality of outpatient child health services— without an increase in child care costs, and increase caretaker satisfaction.

IMCI can increase the utilization of health services, also by those who most need them.

The pace of IMCI implementation is much faster during expansion, provided that adequate resources are made available within a supportive political environment.

IMCI can contribute to strengthening planning capacity at district level and selected health system support elements, as experience in the Region has indicated in countries with functional health systems.

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The main challenges

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 maintain political support and 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 has been 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. 

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