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Community component
The community component of the Integrated Management of Childhood Illness (IMCI) strategy addresses family and community child care practices. The family and the community where children live play a major role in child health and development. There is a longstanding need to involve the family and community actively and plan and implement child care interventions in both the health system and the community in parallel.
Initially, the main focus of the IMCI strategy was on improving clinical care provided at health facilities to outpatient sick children but increasingly attention has been given to fully integrated child care in the home.
In the Region the strategy broadened its scope to become known as the Integrated Management of Child Health, while still retaining its original acronym “IMCI”. Greater emphasis was placed on promoting good child care practices at home and in the community under the IMCI community component.
While many interventions and projects exist at community level which concern child health, there has been some delay in countries in integrating such interventions into a comprehensive primary child health care strategy that includes a well developed community approach effectively linked with the health system (i.e., the “IMCI community component”). Furthermore, interventions often fail to reach the most vulnerable.
WHO developed a training package on “Caring for sick children in the community” as part of a community health worker-based approach to child health care.
Framework for the community component of the integrated child care strategy [pdf 752kb] | Arabic [pdf 1.58 Mb] | French [pdf 955 Kb]
IMCI pre-service training
IMCI pre-service training or education introduces students to the IMCI strategy. Often what students learn in an educational establishment does not equip them to deal with the “real-world” situations at the different levels of practice. They need to develop common knowledge and skills that are applied in everyday practice. In addition, key paediatrics textbooks used as a reference by teachers and students in developing countries are often from developed countries. This can result in a teaching programme dealing with subjects and skills in an unbalanced way by focusing on rare diseases, sophisticated skills and modern tests while neglecting the most common conditions, skills and attitudes needed in a particular setting.
While many graduates will end up practising at primary health care, paediatric teaching in undergraduate training often tends to focus mainly on inpatient or hospital care, with little room for paediatric outpatient care and home care. Essential skills, such as communication skills, are rarely taught to students, despite the fact that most child care is delegated to families and takes place at home, and the quality of child care relies on the advice child caretakers have received.
As a result, many students may be exposed to information they may be unable to apply in the prevailing working environment in their country and, at the same time, may be unprepared to perform the more common tasks that will be required of them in their daily practice in the real world with the resources available.
Aim
The objective of pre-service training is to prepare a cadre of health providers prepared for the working environment.
Medical education aims at providing knowledge and developing skills and attitudes among students as part of a thorough “education” process, to enable them to think through a differential diagnostic process before formulating a diagnosis and prescribing treatment. Clinical decision rules and standard protocols, such as the IMCI guidelines, are meant to guide this process rather than replace it.
The involvement of departments of family and community medicine in IMCI pre-service training is also very important as it helps establish close links between teaching institutions and the community.
This is very relevant in the Eastern Mediterranean Region, as in many countries medical graduates are required to serve in rural areas before working with the ministry of health or registering with the medical council.
Phases
Introducing IMCI into pre-service education require action at the national and institutional levels. It can be characterized by 4 main phases:
- preparatory and orientation
- planning
- implementation, scaling up and monitoring
- review and re-planning
The preparatory and orientation phase for IMCI pre-service is essential for the sustainability of the initiative and aims at creating at both national and institutional levels a conducive supportive environment for implementation.
Related resources
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Guide to planning for implementation of IMCI at district level |
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IMCI pre-service education: orientation and planning workshop: facilitator guide |
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Triage, clinical management and counselling
Rationale
Situation analysis is essential to introduce a quality care intervention in a health facility and to plan for all its key supporting elements. The time taken to adhere to the IMCI protocol may be a constraint in a busy facility with a high case-load if carried out just by one health provider without shared responsibilities with others at the same facility.
One approach used in the Region has been the reorganization of work at a health facility where more than one health provider works — including physicians, medical assistants, nurses, midwives, health volunteers — redistributing tasks in order to deliver quality care efficiently within available resources.
3 key steps have been identified for this purpose: triage, clinical management and counselling.
Triage
When sick children are taken to a health facility, they should be quickly assessed to identify those who are severely ill and who need to be seen by the physician or medical assistant without delay. For example, a child who is lethargic or unconscious, unable to drink or breastfeed, is having convulsions or vomiting needs urgent attention.
The basic skills to perform these tasks can be taught in a training course for paramedical staff which specifically focuses on triage.
Other tasks can also be carried out before the child is seen by the clinician, such as weighing, taking the temperature, checking the immunization status, etc. Children who are (very) low weight-for-age and require feeding counselling are in this way identified in advance, as are those who are febrile and require assessment of specific signs and symptoms.
Selected categories of health providers have been trained in newly assigned tasks in shorter and competency-based courses in some countries of the Region.
The pre-screening of sick children, achieved through training and redistribution of tasks, saves time and may have a positive effect on the overall management of the child.
Clinical management
It is helpful to integrate clinical protocols as much as possible. The health provider who delivers services at primary health care level is usually the same person, irrespective of whether the guidelines come from one programme or another.
This effort towards integration of clinical management guidelines has been a characteristic of IMCI. IMCI uses a holistic approach to the management of the child and the guidelines guide the health provider through the key steps of the clinical process, from assessment to classification, treatment and counselling.
If triage of children is performed, the physician or medical assistant can then use his or her time to concentrate on clinically examining the sick child and prescribe treatment.
Country-adapted IMCI protocols are currently followed as the standard for the management of under-5 children in countries and areas in which IMCI is being implemented.
To emphasize the importance of counselling as a key task in case management, many countries in the Region request the physician or medical assistant to carry out this task as part of the IMCI approach, while in others this is delegated to paramedical staff. The decision as to who should carry out this task depends also on the staffing situation at the health facility.
Counselling
Counselling caretakers of children is a key aspect of the overall management. Most child care is delegated to child caretakers at home, whether it is related to the administration of medicines (antibiotics, antimalarials, oral rehydration salts, etc.), feeding, administration of fluids, or timely care-seeking. Thus, caretakers need to be properly counselled.
Counselling requires interpersonal communication skills that are often inadequately taught at medical and allied health professional schools. It is often perceived by health providers as a time-consuming and less important task.
The result is that caretakers are often poorly advised on how to care for their children at home and unlikely to care for them properly.
Despite the consultation with the health provider, the child may not receive proper care, the outcome may be poor, more consultations may be required if the child's condition does not improve, and family and health system resources wasted.
IMCI training and follow-up emphasize the importance of counselling. Counselling can be performed by the physician or medical assistant or by other staff available at the facility, such as nurses, nutrition educators, health volunteers after proper training.
