The main objective of IMCI (Integrated Management of Child Health) pre-service training in the Region is to strengthen the teaching of outpatient and home child care in paediatrics and community and family medicine, in order to produce in a sustainable way competent cadres of health providers capable of delivering quality child care services also in settings with very limited resources.

The introduction of IMCI elements into pre-service education is a public health approach.

The focus

The focus of IMCI pre-service training in the Region is currently on outpatient care. It is based on the availability of standard and practical guidelines widely tested and formally adopted in the public health system.

This focus is also justified by the notion that most child care is provided at primary health care level: improving the quality of care at that level, while enhancing child survival and development, should also reduce the need for hospital care and overall child care costs.

The objective of IMCI pre-service training is achieved by providing students with knowledge and developing skills and attitudes which respond to the priority public health needs of their own country.

The guidelines to be promoted in teaching are based on basic clinical aids and essential medicines which are—or should be—available at primary health care level. This is to enable the future health graduates to perform efficiently also in settings where very limited diagnostic tools and therapeutic options are available, once they start their practice whether in the public or private domains.

This approach requires not only the incorporation of theoretical concepts (e.g. guidelines) in teaching programmes, but also the adoption of more active teaching methods and supervised practice of clinical and communication skills for students to master them, as pursued in IMCI in-service training courses.

This spin-off effect is like a little revolution in the way teaching is often practised and can benefit other areas of pre-service education in schools which have successfully adopted the new teaching methods.

Advantages

There are many practical and substantial advantages of introducing the IMCI (Integrated Management of Child Health) public health approach into pre-service education. These potential benefits form the rationale for this intervention.

Planting deeper roots in students

Students are usually more receptive to new knowledge and skills than already practising (“in-service”) health professionals: the training received in schools often “plants deeper roots” and it takes more efforts to update it later on, especially if it concerns major changes in medical knowledge, attitudes and practices.

By exposing students to this approach since their medical or health-related studies, pre-service education offers the major advantage of preparing them for the “world outside” and the tasks ahead since then, reducing the gap between the educational and outside settings.

Easing in-service training burden

This is expected to ease the burden of long, time-consuming and resource-intensive in-service training after they qualify and start providing health services.

Sustainability

Since pre-service education is already part of the education system to produce human resources, initiatives which incorporate public health approaches into pre-service teaching curriculum have the potential to be more sustainable than those which rely only on continuous in-service training.

The impact of the high staff turnover—a chronic problem in many developing countries’ public health systems—is reduced.

What this approach does

The IMCI pre-service training approach then:

Gives priority in teaching to the most common child health problems which represent a major cause of childhood mortality and morbidity in the country;

Provides a direct link between the academic setting and the real-life situation in which the future graduates will operate, often with limited diagnostic and therapeutic options. The “syndromic approach” proposed in IMCI is also believed to be more relevant to clinical practice than the traditional “textbook-oriented” type of teaching alone;

Increases student exposure to supervised clinical practice in outpatient settings;

Employs standard protocols which enable prompt identification of severe cases, are action-oriented, represent a practical guide to outpatient management and home care of young children, rationalize the use of medicines and reduce treatment costs;

Promotes active learning;

Introduces in teaching the development of additional, essential skills, such as feeding assessment and counselling, and counselling on psychosocial development, to improve family home child care;

Promotes a health care approach which is effective, feasible and affordable, while ensuring quality care;

Has the potential to reduce the costs of in-service training of health providers, qualifying as a sustainable intervention, by producing health cadres already familiar with the guidelines on outpatient child care. These cadres should later require only short, re-fresher in-service courses (as in continuing medical education). This will also contribute to reducing the overall burden that pre-service training has on ministries of health limited resources;

Prepares health cadres who will be operating both in the public and private sectors, unlike in-service training courses which predominantly reach the public health system;

Establishes a clearer link between curative and preventive care;

Improves collaboration on child-related care and research between academic and professional institutions on one side and ministries of health and other key partners on the other side.

Students appreciate it

Preliminary information from informal field visits and observations suggests that this approach is highly appreciated by students as it provides them with the tools to confront real-life situations and a more active learning process.

Students enjoy practising their clinical and communication skills in outpatient settings and learning how to deal with the most common causes of consultation.

Benefits

There are therefore also benefits for the academic institutions, which among other things see their reputation further enhanced by these changes.

Some have argued that the benefits described above are only theoretical and have yet to be proved. The Regional Office has developed standard instruments and methodology to evaluate the IMCI pre-service training experience in the Region. The findings from structured evaluations will provide the evidence base for IMCI pre-service education, help identify issues and suggest ways to further strengthen the approach followed to date.

Lessons from the past

The IMCI (Integrated Management of Child Health) pre-service training initiative is not a new undertaking. In fact, it much relies on the experience gained with the introduction of other public health programmes in pre-service education and builds on the lessons learnt from that.

Past experiences

This experience especially includes the Expanded Programme on Immunization—or EPI (especially for health professional allied schools), the Control of Diarrhoeal Diseases—or CDD—and promotion of breastfeeding, and the Acute Respiratory Infection control programme—or ARI—.

Lessons

From those past experiences on pre-service training, positive lessons have been drawn, concerning:

the closer collaboration between ministries of health and academic institutions;

the setting up of national IMCI task forces;

the structured format of the high quality orientation workshops held for medical and paramedical schools;

the introduction of standardized clinical protocols and increased attention paid to priority public child health problems in undergraduate teaching; and

interest in research oriented to solve implementation issues.

Issues

At the same time, many factors have been identified which were inadequately addressed and thus adversely affected the impact and long-term sustainability of those initiatives. Most of the emphasis was placed on the orientation workshop, with less attention given to the setting up of a coordinating structure within the concerned teaching institutions. Only one or two representatives from each concerned school participated in the orientation workshops, too few to bring about major changes and receive adequate support when they returned to their schools. The lack of a standard approach to institutionalizing the innovative teaching approach within each school had an adverse impact on its long-term sustainability.

The need

However, the need for a pre-service approach in child health was so logically and strongly felt by ministries of health in the Region that the WHO Regional Office involvement was a natural response to this call, despite the lack of global guidelines and scepticism among some partners. A similar demand followed also in other Regions.

A new approach

The lessons learnt from the past were carefully reviewed in the Region to develop the IMCI pre-service education initiative, leading to a regional framework, a recommended step-by-step approach and an IMCI pre-service education package. This approach is described in “Phases of IMCI pre-service training”.

Related link:

IMCI pre-service education package