10444882 summary

Policy and Practice

Integrated Management of Childhood Illness:a summary of first experiencesT. Lambrechts,1 J. Bryce,2 & V. Orinda3

The strategy of Integrated Management of Childhood Illness (IMCI) aims to reduce child mortality and morbidity indeveloping countries by combining improved management of common childhood illnesses with proper nutrition andimmunization. The strategy includes interventions to improve the skills of health workers, the health system, and familyand community practices. This article describes the experience of the first countries to adopt and implement the IMCIinterventions, the clinical guidelines dealing with the major causes of morbidity and mortality in children, and thetraining package on these guidelines for health workers in first-level health facilities. The most relevant lessons learnedand how these lessons have served as a basis for developing a broader IMCI strategy are described.

Voir page 592 le resume en francais. En la pagina 593 figura un resumen en espanol.

Introduction

The strategy of Integrated Management of ChildhoodIllness (IMCI) is aimed at reducing child mortality andmorbidity in developing countries. It combinesimproved management of common childhood ill-nesses (e.g. pneumonia, diarrhoea, malaria, measles,ear problems, and anaemia) with proper nutrition andimmunization. In 1995, guidelines for the integratedmanagement of childhood illnesses at first-levelfacilitiesa were finalized in a collaborative effort, whichwas led by WHO and supported by a programme ofresearch (1). WHO and UNICEF promoted a trainingcourse based on these guidelines in 1996, which wastargeted at health workers in first-level facilities (2),and issued a joint statement on IMCI in July 1997 (3).

Following this training effort, a broad strategywas developed to encompass both preventive andcurative interventions for promoting child health anddevelopment. The three components of theseinterventions were as follows: improving the skills of health workers; improving the health system to support IMCI; and improving family and community practices.

IMCI implementation in a country proceeds in threephases. In the first phase are activities for the

introduction of IMCI, which leads to a decision by theministry of health on whether to move forward withfurther preparations and planning. The second phaseis for early implementation, in which each country adaptsthe generic IMCI clinical guidelines to its ownepidemiological and cultural characteristics andbegins implementation in a limited number of areas(e.g. districts). This experience is carefully documen-ted and analysed. The third phase, which is focusedon expansion, draws on the experience gained duringearly implementation to introduce a broad range ofIMCI activities and increase access to them. Fig. 1shows the countries engaged in IMCI and their phaseof implementation (as of December 1998).

This article, which draws on information froma number of sources, describes the experiences ofseveral countries in implementing IMCI as well asWHOs recommendations that evolved from theseexperiences. WHO has documented the process ofIMCI implementation in six countries Indonesia,Nepal, Peru, Philippines, Uganda, and the UnitedRepublic of Tanzania (4). This involved completingdetailed forms by WHO staff and consultantstogether with country personnel, in collaborationwith UNICEF and other partners, which were usedas the basis for interviews and document reviews.The results and preliminary conclusions reportedhere have been reviewed by WHO staff at all levels, aswell as with country personnel implementing IMCI,to ensure that they are complete and correct. Theexperiences of additional countries are includedwhere possible, drawing on reports from the staffin the ministry of health and other institutionsimplementing IMCI, and on presentations made atthe First Global Review and Coordination Meetingon Integrated Management of Childhood Illness (5).

1 Medical Officer, Child and Adolescent Health and Development ,World Health Organization, 1211 Geneva 27, Switzerland.Requests for reprints should be addressed to this author.2 Scientist, Child and Adolescent Health and Development ,World Health Organization, Geneva, Switzerland.3 Senior Adviser, Child Health, UNICEF, New York.a First-level refers to a health facility which has a trained healthprofessional who is recognized by the ministry of health as capableof providing outpatient care to children.

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This retrospective summary attempts to give anaccurate report based on what was learned and thechanges effected during the early period of IMCIimplementation covered by this documentation effort(199597). When the first plans for implementation atcountry level were made 4 years ago (1995), it was notpossible to anticipate the changes that would be madeto the strategy as a result of what was learned duringIMCIs progressive implementation in the countriesand regular reviews by ministries of health. Forexample, the third component in the strategy(improving family and community practices) hasrecently been defined more clearly in terms of focusand approaches, but despite ongoing programmesin most countries there is very limited experienceabout how best to coordinate these activities within abroader IMCI strategy. It would therefore bemisleading to apply the current conceptual frameworkfor IMCI implementation to these early experiences.In consequence, we have tried to describe accuratelythe initial plans and how the experience gained led tomodification of the IMCI strategy.

This article is divided into three sections. In thefirst, we highlight the process of introducing IMCI;the second describes the experiences gained duringearly implementation in countries, focusing on thethree IMCI components; and the third highlights theissues and challenges in planning for the expansionphase of IMCI. Within each section, we describe the

initial plans, country experiences, and currentrecommendations for countries implementing IMCI.

First phase: introduction of IMCIat country level

For many countries, the introduction of IMCIprovides an opportunity to review child healthpolicies and to reorganize their services and inter-ventions. The IMCI clinical guidelines are not entirelynew; for example, the recommendations for casemanagement of diarrhoeal diseases (CDD) and acuterespiratory infections (ARI) are very close to thosethat have been promoted by WHO over the past10 years. However, the integrated approach in healthservice delivery and community interventions for allthe needs of each child and carer requires new levelsof coordination and shared responsibility amongthose implementing specific disease programmes andthe supporting services in most countries.

One objective of the introductory period in acountry is to ensure that key personnel in the ministryof health understand the IMCI strategy and itsimplications as the basis for deciding whether toproceed with planning and preparations for itsimplementation. The activities to meet this objectivewere initially focused on an orientation meeting

Fig.1. Status of IMCI implementation, as of December 1998

Integrated Management of Childhood Illness: first experiences

583Bulletin of the World Health Organization, 1999, 77 (7)

designed to serve as a starting point for decision-making about IMCI. Experience has shown thatvarious types of activities are needed to meet thisobjective, including one or more orientation meet-ings. In the six countries collaborating with WHO ondocumentation, national meetings were held in eachcountry except in the Americas, where there was aregional orientation meeting organized for fourcountries, including Peru. Meetings varied in lengthfrom one to four days and, in three of the sixcountries, more than one national meeting was held.In all countries, formal orientation meetings werecomplemented by numerous smaller meetings andindividual discussions with representatives of specificprogrammes or partner agencies.

The participation of key ministry of health staffand paediatricians in an IMCI training course at anearly stage of the introductory period appeared tofoster the ministrys commitment and realisticplanning for IMCI. IMCI training and, wherepossible, participation in the adaptation process in aneighbouring country were identified as key inter-ventions to achieve this objective of the introductoryphase.

A second objective of the introductory phase isto establish a structure for planning and managingIMCI activities. The recommendation from WHOwas to avoid major structural changes initially bycreating an ad hoc working group. All countriesimplementing IMCI to date have defined a national-level working group to plan and coordinate theactivities. In most countries, the group includesrepresentatives of the programmes dealing with themajor health conditions addressed by IMCI (diar-rhoea, acute respiratory infections, malaria, immuni-zation, and malnutrition). In addition, workinggroups in some countries included representativesof one or more of the following units: essential drugs,planning, medical training, supervision, health educa-tion and health information systems. Implementationand coordination of the strategys activities appear tobe more successful when the IMCI working groupincludes representatives of all the key units involvedin programme implementation. In many countries,the IMCI working group is coordinated by a focalpoint, which is often the CDD, ARI or CDD/ARIprogramme. In instances where ministry of healthofficials having responsibilities above the level ofindividual programmes have been involved in IMCI

planning and management, the decisions have beenimplemented more readily.

A third objective for the introductory phase,which was defined through experience, is the earlyinvolvement of major partners and donors to allowthem to make an informed decision about their role in(and level of support for) IMCI. In countries whereinternational agencies were more actively recruited toparticipate in the introductory activities, their supportappears to have been stronger and better coordinatedwith ministry of healths efforts. Current recommen-dations for the process of introducing IMCI atcountry level are shown in Box 1.

Second phase: early implementation

In the second phase, staff in the ministry of healthplan and prepare for implementation and then carryout IMCI activities in a limited number of districts;this experience is carefully monitored as the basis forfuture planning.

Improving health workers skillsDiscussed below are adaptations of the IMCIguidelines, training of first-level health workers incase management, and referral care.

Adaptation of the IMCI guidelines. The IMCIguidelines for case management of childhood illnessat first-level health facilities are generic, and must beadapted before use in countries. Step-by-stepguidance is provided in the IMCI adaptationguide (6), which recommends that a subgroup beformed within the IMCI working group to carry outthe adaptation steps in consultation with experiencedadvisers. All countries must complete the adapta-tions, including the identification of first- andsecond-line treatments for selected diseases and theselection of appropriate foods to be recommendedfor children of various ages. Countries are alsoexpected to identify local terms to facilitate commu-nication with carers, and are encouraged to developa card for use by the health worker in counsellingmothers. In addition to these essential steps,countries may decide to adapt the guidelines toreflect specific national policies, guidelines, or dis-ease conditions. In the Philippines, for example, theguidelines were adapted to deal with denguehaemorrhagic fever. The adapted guidelines are then

Box 1. Current recommendations for IMCI implementation: the introduction of IMCI at country level

. Conduct several meetings, for individuals and groups, so that senior ministry of health officials, leading paediatricians, donors,and partner agencies will become well acquainted with IMCI as a basis for making an informed decision to move forward withIMCI planning and preparations.

. Expose key ministry of health personnel to IMCI training, planning and adaptation procedures.

. Establish a structure for planning and managing IMCI activities with representatives of existing specific disease programmesencompassed by IMCI, as well as programmes in nutrition, essential drugs, health education and health information systems.

. Ensure that high-level ministry of health officials are involved in IMCI planning and management.

. Develop coordination mechanisms with interested partner agencies to ensure that they are involved in and informed about IMCIplanning and preparations.

Policy and Practice

584 Bulletin of the World Health Organization, 1999, 77 (7)

used to modify the IMCI training materials for healthworkers in first-level facilities.

An important feature is the building ofconsensus on the IMCI clinical guidelines amongmanagers of technical programmes and leadingpaediatricians. In cases where consensus was notachieved and existing national policies for disease-specific programmes were not updated, continuingdiscussions and negotiations were necessary toensure full support for IMCI implementation. As ofDecember 1998, 28 countries had completed theadaptation process. The estimated time needed forcountries to complete this process is 612 months.

The generic IMCI guidelines led to consider-able debate on two points. First, few countries to datehave accepted the generic WHO recommendation touse co-trimoxazole (sulfamethoxazole + trimetho-prim) as first-line treatment for children with bothpneumonia and fever in areas where there is a risk ofmalaria and no resistance to sulfadoxinepyrimetha-mine. The reasons were concern over patientcompliance with the 5-day course of co-trimoxazoleand a reluctance to change the national policy basedon the limited evidence available. It was also oftendifficult to achieve a consensus on the recommenda-tion to give vitamin A to children with measles orsevere malnutrition during clinic visits during theearly phase of implementing IMCI in countries. Thereasons may be that the WHO recommendation (7)in this area usually requires a policy change, andconcern about overdoses in countries with vitamin Asupplementation programmes.

Common adaptations that were not usuallycontroversial included the extension of the recom-mended duration of exclusive breastfeeding, the needto incorporate guidelines for areas where there is nomalaria risk, and the addition of hepatitis B vaccine tothe immunization schedule. In some countries themanagement of children with symptoms of wheezingor throat problems was also added to the guidelines.In countries that had undertaken adaptations up tothe end of 1997, no changes were made in the genericguidelines to account for children infected with thehuman immunodeficiency virus (HIV). However,the IMCI adaptation guide does include a section onpossible adaptations in settings with high HIVprevalences among women and children (6).

Experience indicates that adaptations to thegeneric IMCI guidelines should be limited andfocused only on the major causes of mortality andmorbidity for which effective treatment and/orpreventive practices have been identified. Somecountries field-tested their national adaptation duringan early central-level training course before finalizingthe guidelines. Another essential adaptation is theidentification of appropriate age-specific feedingrecommendations for under-5-year-olds. Countriesare also encouraged to conduct studies of local termsto ensure effective communication with mothers;guidance for such studies is included in the IMCIadaptation guide.

Multiple adaptations are sometimes requiredbecause of subnational or regional differences inepidemiology or language and culture. In Brazil, forexample, there are three subnational sets of guide-lines to reflect different patterns of malaria pre-valence. In Uganda, the mothers counselling card isavailable in eight languages and several feeding-pattern studies were conducted to identify locallyavailable foods.

Although the adaptation process is primarilydesigned as a basis for preparing appropriate trainingmaterials, the experience from early implementationsuggests that adaptation is an important interventionby itself. The process brings together a broad range ofprogrammes and national medical experts in childhealth, and requires that they work together to reviewand revise their standards and national policies onchild health. The result is an updated, technicallysound set of national standards for the case manage-ment of children, which can have lasting positiveeffects on child health programmes. Current recom-mendations on the adaptation process are shown inBox 2.

Training first-level health workers in casemanagement. Because the IMCI clinical guidelinesand the in-service training course for health workerswho manage children in first-level facilities were thefirst IMCI interventions to be made available tocountries, this is the area where most experience hasbeen gained to date. The methods and materials forthe standard 11-day course have been describedelsewhere (8). Approximately 30% of instructionaltime is spent in supervised clinical practice, wheretrainees visit clinics to practise their skills and receivefeedback from trained clinical instructors. Theclassroom component of the training uses videos,readings, reviews of photographs and demonstra-tions, and a variety of other interactive trainingmethods.

By the end of 1997, at least 42 IMCI trainingcourses for health workers managing children in first-level facilities had been conducted in four of the sixcountries collaborating with WHO. An average of20 participants attended each course. A broad rangeof health workers with different levels of readingability from health assistants, enrolled nurses andmidwives to physicians have been trained.Assessments of skills at the close of training andduring follow-up visits have not found cleardifferences in performance by type of health worker,although a definitive answer must await morerigorous operational research. Peru adapted theWHO training materials and agenda to conducttraining over seven consecutive days. The Philip-pines, Uganda, and the United Republic of Tanzaniaused the 11-day agenda. Participants spent 2030hours in clinical practice. Reports from country staffindicate that IMCI training of acceptable quality canbe carried out at the district level. Based on thisexperience, a set of quality criteria that should betaken into account when planning for IMCI training



of first-level health workers have been defined andare included in Box 2.

Difficulties encountered during the firsttraining courses by several countries included thefollowing: identifying, training and maintaining participation

by appropriate course facilitators; ensuring that an appropriate number of ill

children, with an appropriate range of clinicalsigns, were available for clinical practice by courseparticipants; and

dealing with the duration and cost of in-servicetraining courses.

Countries have developed local solutions to addressthese difficulties, some of which have been incorpo-rated into the IMCI planning guidelines. Forexample, to ensure that participants have adequateclinical practice in the full range of IMCI classifica-tions despite seasonal variations and the relativelyrare presentation of certain conditions (e.g. severedehydration), training course directors are asked tocompensate for this by conducting group demon-strations for rare signs or classifications, and super-visors are asked to pay special attention to childrenwith these conditions during their visits to healthfacilities. Further experience may yield additionalsolutions to this problem.

An innovative aspect of IMCI training is that itincludes a follow-up visit to each health workermanaging children in a first-level health facility within46 weeks of training. The objectives of the visit areto help the health worker initiate IMCI in their healthfacility, reinforce skills learned during training, andidentify and solve problems in IMCI implementation.The visit also provides an opportunity to recordmonitoring information.

In countries that have carried out follow-upvisits, staff report that visiting trained workers can

Box 2. Current recommendations for IMCI implementation: improving health worker skills

Adaptation. Adapt the IMCI guidelines to local epidemiological and cultural conditions. The adaptation process involves a review and revision

of existing national policies and guidelines for outpatient paediatric care. IMCI guidelines may require subnational adaptationsand periodic revision or updates.

. Build and maintain consensus on the adapted guidelines among technical programmes related to child health. Consensus mustbe achieved to ensure successful and continued IMCI implementation.

In-service training. Plan IMCI training at district level so that all targeted health workers from the same facility are trained within a brief time period.. Define a strategy to develop and sustain a pool of experienced course facilitators.. Plan for quality training, using the following criteria: a ratio of participants to facilitators no more than 4 to 1; completion of all

training modules; distribution of a copy of the IMCI chart booklet to each trainee to keep as a reference; a minimum of 30%clinical practice and 20 sick children managed by each trainee; and no more than 24 participants.

. After the training, conduct a follow-up visit to health workers managing children in first-level facilities. The objectives of this visitshould include assisting the health worker in the transition to IMCI at the facility, skill reinforcement and problem solving.

Referral care. Assess all referral possibilities (public and private) in districts planning for IMCI.. Identify possible problems with existing referral facilities and plan for improvement.

Fig. 2. Number of sick children correctly treated by first-level healthworkers 46 weeks after their training in IMCI, Uganda, 199697(78 IMCI-trained health workers were observed managing one sickchild in 78 facilities)

Fig. 3. Number of mothers of children treated by an IMCI-trained health worker who reported correctlyhow to administer the treatment when leaving the facility,United Republic of Tanzania, 199697 (number of mothers interviewedvaried depending on whether the child received drugs and/or oralrehydration salts (ORS))

Policy and Practice


support the transfer of IMCI skills to routine work infacilities. As shown in Fig. 2 and Fig. 3, informationcollected during follow-up visits suggests that healthworkers who have been trained in IMCI areperforming well. Staff also report that the quality ofIMCI implementation is higher in facilities wheremore than one health worker is trained in the strategy.

Early experience with IMCI implementationalso indicates an urgent need for training in pre-servicesettings. If paramedical and medical workers leavetheir basic training with skills in IMCI, improved casemanagement will be available in both public andprivate settings, and the costs of the training will bereduced. Several countries have begun experimentingwith pre-service training. These experiences are beingmonitored and will serve as the basis for thedevelopment of global recommendations and, whereappropriate, materials. Current recommendations forIMCI training are summarized in Box 2.

Referral care. Ensuring appropriate and timelycare for severely ill children at the referral level is anessential part of the strategy. IMCI guidelines for first-level health facilities help health workers identify andrefer severely ill children after administering appro-priate pre-referral treatment. Health workers are alsotaught how to explain and help mothers to solveproblems with timely referral. Issues related to referralwere not fully addressed when planning for IMCI inthe six countries described in this article, but problemswith referral were identified during early implementa-tion. Current recommendations are shown in Box 2.Countries and districts are now encouraged to assesspossible problems in referral pathways in the earlystages of IMCI planning. Guidelines on referral-levelcare, including recommendations for triage andemergency care, and on the management of severemalnutrition are being developed. A training course inbreastfeeding counselling is already available (9) andcan be used to prepare selected health workers towhom mothers with breastfeeding problems can bereferred by staff trained in IMCI.

Improving health system supports for IMCIIMCI focuses on essential elements of the healthsystem that must be in place to ensure theeffectiveness of child health interventions. Earlyexperience with IMCI implementation led to greaterawareness of the need to improve drug availability,support effective planning and management atdistrict and national levels, and address issues relatedto the organization of work at health facilities. In allcountries with significant experience to date, IMCIhas served as a catalyst for the identification ofsubstantial weaknesses in the public health system.More experience is needed to define how thiscatalytic potential can be utilized for health systemimprovement.

Drug availability. Effective case managementrequires appropriate access to drugs every day in thefirst-level facilities. Although IMCI requires only alimited set of drugs (e.g. from 16 to 20 in selected

national adaptations, as shown in Fig. 4), the complexand interrelated issues of drug procurement and drugdistribution have proved to be a serious challenge inall countries implementing the strategy.

In the six countries collaborating with WHO,early planning for IMCI usually did not or could notfully address drug availability. Ensuring the avail-ability of second-line treatments and pre-referraldrugs has presented a special challenge in thesecountries. Although temporary solutions can befound, such as the use of district funds to purchasethe needed drugs in limited quantities or theestablishment of special distribution systems forIMCI drugs, Fig. 5 shows that these measures were

Fig. 4. Essential drugs needed for the national adaptationsof the IMCI guidelines for first-level facilities

Fig. 5. Availability of selected drugs in facilities implementing IMCI(findings from follow-up and first supervision visits, Uganda, 199697)



not sufficient to ensure regular drug availability inUganda. Other countries have faced similar chal-lenges. In the future, practical strategies for improv-ing drug availability will need to be identified. Thesemight include links with a health information systemor use of revolving drug funds.

Vigorous efforts are needed, both internation-ally and at the country level, to improve the availabilityof drugs not only for IMCI but for all first-level care.Recommendations that may help address this issue atcountry level are presented in Box 3.

IMCI planning and management. Althoughthe IMCI strategy encompasses interventions atmultiple levels (first-level care, referral-level care,health system, family and community), the only toolsavailable in 1996 were the IMCI clinical guidelinesand the course for the in-service training of first-levelhealth workers. Plans for IMCI implementation inthe six countries therefore focused mainly on theadaptation of the clinical guidelines and the firsttraining activities. Early experience has demonstratedthe importance of planning for implementation ofthe three components of the IMCI strategy from thestart, even if some specific interventions may not bedeveloped and/or implemented immediately.

Many countries have chosen to initiate plan-ning for IMCI activities during a planning workshop.These workshops, which vary in length from two tofive days, have consistent objectives across countries i.e. the development of a concrete plan for IMCIduring the early implementation period, including theadaptation of the IMCI guidelines; the selection ofinitial districts for implementation; the planning oftraining, supervision and monitoring; and theidentification of steps to be taken to ensure that thedrugs, supplies and other health system supportsneeded for IMCI are in place in the districts involved.Throughout the planning process, emphasis is placedon the need to recognize and build upon existingstructures and programmes and to involve otherrelevant sectors as needed.

The involvement of district staff early in theplanning process was limited in the six countries.Experience has shown that strong district capacityand a clear definition of the roles of central anddistrict levels in IMCI activities are critical. Districtstaff should be involved in IMCI planning as early aspossible. Central-level involvement in IMCI districtactivities, although highly recommended during the

Box 3. Current recommendations for IMCI implementation: improving the health system to support IMCI

Drug availability. Involve national drug authorities early in IMCI planning.. Work to have IMCI drugs included in the national Essential Drugs List and approved for use at the appropriate level of the health

system by IMCI trained staff.. Identify temporary solutions in districts starting IMCI while working for system change to improve drug availability.

IMCI planning and management. Organize national planning for IMCI in collaboration with all ministry of health divisions and interested partners to ensure correct

understanding of major steps.. Involve districts early in the planning process. Define the roles of central and district levels in district activities.. Help districts integrate IMCI into their development plans, building upon and strengthening existing management structures and

ongoing programmes.. Learn about supervisory systems at national and district levels and strengthen existing supervisory activities by providing training

in IMCI for existing district supervisors. Seek to involve staff with good clinical skills in supervision.. Plan and budget for strengthening or developing monitoring at district level, including how to use the information collected to

solve problems and improve planning.

Organization of work at health facility level. Assess clinic organization and job descriptions during IMCI planning to ensure that all IMCI tasks will be performed adequately

(including immunization of ill children and counselling on feeding). Identify possible problems and plan for solutions.. Consider training all health workers in a facility within as short a time period as possible.

Health information systems. In the early stages of IMCI planning, start collaboration with the ministry of health division responsible for HIS. Based on national

IMCI and HIS classifications, consider developing a table to help health workers to convert the IMCI classifications into HISclassifications.

. Develop recommendations and procedures to help health workers meet the HIS reporting requirements adequately after trainingin IMCI.

Health sector reform. Identify health sector reforms under way or planned in the country.. Educate the national authorities responsible for reforms and their involved partners about IMCI, and advocate the inclusion of

IMCI as part of health sector reform efforts.. Coordinate the implementation of health sector reforms (e.g. cost-recovery) with IMCI implementation.

Policy and Practice


first district training, is unlikely to be sustainable inthe longer term.

Although important for sound planning, reli-able cost estimates for IMCI activities were extremelydifficult to obtain in the six countries. Many IMCIinterventions benefit the overall health system, andthe portion of the cost attributable to IMCI is notalways easy to determine. Operations research hasdocumented large potential savings related to drugswith the introduction of IMCI (10, 11). Furtherinvestigations of the costs of implementing IMCI arebeing planned.

Supportive supervision is assumed to have apositive effect on the sustainability of health workersperformance over time, but is a challenge in manycountries. The IMCI strategy recommends thatdistrict-level supervisors be trained in the strategyand its facilitation techniques, and that they beinvolved in the follow-up visits to health workersafter training. In most settings, however, supervisorsare responsible for multiple programme activities anddo not always have clinical skills, and it will be acontinuing challenge to incorporate IMCI into theirexisting supervisory activities.

In the six countries collaborating with WHO,IMCI monitoring at district and national levels waslimited to the collection of monitoring information

during training and follow-up visits to health workersafter training. Based on first experiences, the overallapproach to IMCI monitoring has been simplifiedand a limited set of key indicators defined (seeTable 1). Experience has indicated the need for abalance between the primary objectives of any visit tohealth workers (assisting and reinforcing the healthworker, and solving problems) and the need to collectand use monitoring information. Current recom-mendations on planning and managing IMCIactivities are presented in Box 3.

Organization of work at health facility level.Countries have learned through visits to trainedhealth workers that the organization of tasks at thehealth facility may make it difficult for children toreceive the full scope of IMCI care. In larger facilities,often located in urban settings, IMCI tasks may beperformed by several different workers. It iscommon, for example, for one worker to beresponsible for weighing the child and taking ahistory, a second to assess and classify the child, and athird (often in a dispensary) to provide drugs andcounsel the carer. Although the IMCI guidelinesrecommend training within as short a time as possibleall health workers who manage children, the availabletraining course is inappropriate for some of thelower-level workers who perform only selected tasks.

Table 1. Topical list of key indicators for IMCI

Health worker skillsAssessment Child is checked for four general danger signs.

Child is checked for the presence of cough, diarrhoea and fever.Childs weight is checked against a growth chart.Childs vaccination status is checked.Carer of under-2-year-old child is asked about breastfeeding and complementary foods.

Correct treatment and counselling Child needing referral is referred.Child needing oral antibiotic and/or an antimalarial is prescribed the drug(s) correctly.Carer of the sick child is advised to give extra fluids and continue feeding.Child leaves the facility with all needed vaccinations.Carer of the child who is prescribed oral rehydration salts and/or oral antibiotic and/or

an antimalarial can describe how to give the treatment.

Health system support for IMCISupervision Health facility has received at least one supervisory visit that included observation of case

management during the previous 4 months.Drugs, equipment and supplies Health facility has all the essential equipment and materials for IMCI.

Health facility has all the essential drugs available for IMCI.Health facility has the equipment and supplies to provide full vaccination services.

IMCI training coverage Health facility has at least 60% of its health workers who manage children trained in IMCI.

Carers satisfactiona This has to be determined at country level.

Family and community practicesa

Nutrition Child

Among the options to address this issue that arebeing explored at both country and global levels arethe following: expanding the role of the IMCI-trainedhealth worker to include the training of selected co-workers (e.g. those who dispense drugs); andconducting specially tailored training for cadres ofworkers who perform specific IMCI tasks. Currentrecommendations on addressing the organization ofwork at health facility level are presented in Box 3.

Health information systems (HIS). Theimplementation of IMCI in countries has shownsome inconsistencies between the IMCI classifica-tions and the disease categories used in routinereporting. Differences in the IMCI and HISclassifications may confuse health workers andadversely affect the implementation. In somecountries those responsible for HIS have changedtheir reporting categories or included some of theIMCI classifications in the existing HIS; others werenot able to do this, and are now training healthworkers to transform the IMCI classifications intoexisting HIS categories. Some countries are alsoconsidering the modification of patient registers.Each country will need to address this issue duringplanning and early implementation of IMCI. WHO isdeveloping recommendations on options to link theIMCI classifications to HIS (12). The currentrecommendations on IMCI and health informationsystems are presented in Box 3.

IMCI and health sector reform. Health sectorreforms in many countries now include the decen-tralization of management and services, introductionof policies recommending the delivery of a minimumpackage of services in first-level facilities, introduc-tion of cost-recovery mechanisms, and redistributionof activities between the public and private sectors.At the end of 1998, 29 countries had included IMCIin health reform projects supported by the WorldBank. Current recommendations on IMCI and healthsector reform are shown in Box 3.

Improving child care at familyand community levelsNo strategy for improving child health and develop-ment will be effective unless it addresses thebehaviour of families and communities. The IMCIstrategy builds on the experiences with CDD andARI and seeks to identify and strengthen ongoingcommunity-based actions aimed at improving childhealth and nutrition. Early implementation of IMCIwas focused on improving health workers skills. Thelessons learned through this experience will bevaluable in implementing efforts directed towardsfamilies and communities.

The IMCI guidelines for first-level care aredesigned to improve communication with mothers.The adaptation process includes the identification ofappropriate local terms and culturally appropriatefeeding recommendations. During training in IMCI,health workers are taught the fundamentals ofcounselling and practise these skills under super-

vision. An important aspect of IMCI is its focus onnutrition. Every child receives a nutritional assess-ment and, when appropriate, the carers are givenindividual advice and counselling on the properfeeding of the child at home, including breastfeeding.

Anecdotal reports from all countries imple-menting training indicate that the quality of interac-tions between health workers and carers has improvedafter IMCI training, and that the carers are respondingpositively to this change. For example, the results fromexit interviews with 66 carers in Peru suggest thatmothers benefit from the services they receive and are,in general, satisfied with them (Fig. 6). This informa-tion must be interpreted with caution. Several studieshave shown that the reports from carers of overallsatisfaction with the services received are notassociated with return rates or the objective qualityof these services (13, 14).

Some countries report significant increases inservice utilization on days when or in facilities wherehealth workers trained in IMCI are working.Anecdotal supervision reports indicate that the carersare pleased and surprised by the health workersinterest in their feeding practices, health problems,and ability to comply with instructions. The simplecards designed to support communications withmothers are highly appreciated by both healthworkers and carers, and are now being used byhealth workers whether or not they have already beentrained in IMCI. Formal documentation of theseeffects is being planned.

Early experience has heightened awareness ofthe need to plan and implement other interventionstargeting family and community behaviours relatingto child health. One immediate step that can be taken,once the IMCI guidelines have been adapted, is toensure that existing and future activities in commu-nity education and behaviour change are consistentwith the messages included in the adapted IMCIguidelines. Countries are now encouraged to prior-itize issues that should be addressed to improve care-seeking behaviour and to include these priorities intheir national IMCI strategy. UNICEF has taken thelead in coordinating the IMCI work relating to childcare at family and community levels.

In conclusion, IMCI in the community mustnot be implemented as a new and separate initiative.Existing community-based child health and nutritionprogrammes will be among the major entry points forIMCI. Some recommendations for improving familyand community practices related to IMCI arepresented in Box 4.

Third phase: expansion of IMCI

The phase of IMCI expansion includes efforts toincrease access to interventions initiated during theearly implementation phase and to broaden the rangeof IMCI interventions. The current recommendationis for the IMCI working group and key partners todevelop medium-term plans for moving forward with

Policy and Practice


the strategy, based on reviews of early experience. Inthis phase, problems identified during early imple-mentation are addressed, priorities for interventionsare agreed upon, and strategies for expanding accesswhile maintaining quality are developed.

By the end of 1998, nine countries (Bolivia,Brazil, Dominican Republic, Ecuador, Nepal, Peru,Uganda, United Republic of Tanzania, and Zambia)had entered the expansion phase. A number of othercountries will reach this phase in 1999 and aremeeting the challenges of expansion, based on theexperience gained during implementation. Some ofthe most important challenges facing countries (seeBox 5) are discussed below.. One important challenge will be to build district

ownership and capacity for IMCI planning andmanagement, including the strengthening ofroutine monitoring and the negotiation andadvocacy skills needed to mobilize resources forchild health. IMCI staff at the central level willhave to find sustainable ways to support districtsas they move forward with implementation of thestrategy. Concrete recommendations on effectiveways to do this must wait until further experiencehas been accumulated.

. A second challenge will be to develop a sustainableorganizational structure for IMCI at the nationallevel. The recommendation to create an IMCIworking group during the introduction and earlyimplementation phases is based on an assumptionthat ministries of health have to be familiar with theIMCI strategy and its implications for child healthprogramming before undertaking structural ororganizational changes. Within a very short time,however, each country will face difficult decisionsabout how best to provide a leadership andmanagement structure that will support effectiveimplementation. Several countries that have movedfrom early implementation to the expansion phasehave already recognized that there is an urgent needfor this high-level structural change.

. A third challenge will be to determine anappropriate pace for expansion, which meets theneed for a rapid increase in access whilemaintaining the quality of the interventions.Several countries are facing pressure from theirministries of health, from donors, and fromdistricts to expand IMCI implementation rapidly.In some countries, the districts have identifiedtheir own resources for IMCI implementation.For ministries of health that are now moving

through the period of early implementation, therehas not been enough time to strengthen central-level capacity to support district planning andimplementation or to establish monitoring andevaluation plans. Districts and ministries of healthwill need to resist pressures to expand trainingcoverage rapidly, if they cannot give adequateemphasis to the other two critical components inthe strategy improving health system supportfor IMCI and improving child care at family andcommunity levels. This pressure may lessen withfurther experience and as countries develop anduse additional district-level planning tools.

. A fourth challenge will be to incorporate IMCI intoongoing district and national efforts to improvechild health, and to link it with other healthinitiatives. Efforts have begun at the global levelto link IMCI with the Safe Motherhood Initiative,by developing consistent approaches for deliveringcare and training providers. Interventions toimprove breastfeeding counselling practices havebeen made fully consistent with IMCI, andcountries are encouraged to engage in joint planningfor their IMCI and breastfeeding activities.

. A fifth and final challenge will be to demonstratethe cost-effectiveness of IMCI as a servicedelivery strategy for child health. This is theobjective of a global evaluation effort consisting ina set of studies linking efficacy and effectiveness inseveral countries (15).

Conclusions

Early experiences with IMCI prove that this strategyis feasible at district level and that it is welcomed by

Box 4. Current recommendations for IMCI implementation: improving child care at family andcommunity levels

. Existing community-based child health and nutrition programmes should be utilized in the implementation of IMCI in thecommunity.

. When developing the national IMCI strategy, one has to identify, prioritize and plan the implementation and evaluation ofcommunity interventions to improve care-seeking and home-care practices.

. Appropriate messages consistent with the IMCI strategy should be developed by building on CDD, ARI, and nutrition informationand education materials, as well as on local terms and feeding recommendations formulated during the IMCI adaptation process.

Fig. 6. Mothers reports of services and satisfaction(findings of IMCI follow-up visits, Peru, 1997)



many countries undergoing health sector reforms.There is therefore a high level of interest in countriesand international agencies.

Introduction of the IMCI strategy presents anopportunity for countries to develop or update theirnational policies for the case management of sickchildren. Implementation of the strategy, whichbrings together a broad range of programmes andnational medical expertise relating to child health, hasserved as a catalyst for the identification of substantialweaknesses in the public health system in somecountries. n

AcknowledgementsStaff in the ministries of health, district health teams,and health workers in the countries reported in thisarticle not only met the challenge of implementingIMCI, but also provided WHO with importantinformation. We thank them, as well as the WHOconsultants, and staff at WHO in Geneva and WHORegional Offices who helped in the preparation ofthis article and made valuable comments on earlierdrafts. We are grateful to Ms Chandrika John forexpert secretarial assistance in finalizing the manu-script.

Resume

Prise en charge integree des maladies de lenfant : recapitulatif des premie`resdonnees dexperienceLa strategie relative a` la prise en charge integree desmaladies de lenfant (PCIME) vise a` reduire la mortalite etla morbidite juveniles dans les pays en developpement enassociant une prise en charge amelioree des maladiescourantes de lenfant a` une nutrition et une vaccinationappropriees. La strategie est dabord axee sur lelabora-tion de lignes directrices cliniques integrees et dunmodule de formation a` lintention des agents de santequi prennent en charge les enfants dans les etablisse-ments de premier recours, ensuite sur lelargissementdinterventions a` la fois preventives et curatives afin defavoriser la sante et lepanouissement de lenfant. Lastrategie PCIME comprend des interventions visant a`perfectionner les agents de sante, le syste`me de sante etles pratiques familiales et communautaires. Cet articledecrit lexperience acquise par les premiers pays a` avoirmis en uvre la PCIME, lenseignement quils en ont tireet comment celui-ci a permis delargir la strategie enquestion.

Larticle comprend trois parties. La premie`re decritlintroduction de la PCIME, y compris les demarches quipermettent aux ministe`res de la sante de decider sil fautpoursuivre ou non lapplication de la strategie, lesstructures gestionnaires creees pour la PCIME et lespartenaires interesses. La deuxie`me traite de la phaseanticipee de mise en uvre, au cours de laquelle les paysplanifient et preparent lapplication de la PCIME,adaptent les lignes directrices cliniques generales a` leurpropre situation epidemiologique, entreprennent les

premie`res activites liees a` la PCIME dans un nombrelimite de districts, et etudient de pre`s les donneesdexperience quils ont obtenues et sur lesquellessappuiera la mise en uvre proprement dite. Ledegagement dun consensus au sujet de ladaptationdes lignes directrices cliniques est indispensable ausucce`s de la PCIME dans un pays donne. Parmi les autresquestions essentielles se trouvent la place de la PCIMEdans les reformes du secteur de la sante en cours,lexistence de medicaments essentiels, les voies dorien-tation-recours, la supervision, lorganisation dactivitesdans les etablissements de sante, le suivi et les syste`mesdinformation sanitaire. La troisie`me partie decrit lesefforts deployes par les pays pour ameliorer lacce`s auxinterventions entreprises au cours de la phase anticipeede mise en uvre et elargir la gamme des interventionsde la PCIME.

Les principaux proble`mes lies a` lamelioration de laPCIME et aux strategies relatives a` la croissance et audeveloppement de lenfant dans un proche avenir fontegalement lobjet dun examen. Il sagit de donner lesmoyens et les capacites voulus concernant la planifica-tion et la gestion de la PCIME aux niveaux districal etnational, daccrotre la couverture tout en maintenant laqualite et la vaste portee de la strategie PCIME, etdintegrer celle-ci dans les mesures prises aux niveauxdistrical et national pour ameliorer la sante de lenfant.Enfin, lOMS a pris la tete dune initiative collective visanta` evaluer limpact mondial de la strategie PCIME.

Box 5. Challenges in IMCI expansion

. Building district-level capacity and ownership for IMCI implementation.

. Making structural changes within the ministry of health to support IMCI.

. Responding to pressures for rapid increases in training coverage, while maintaining the quality and broad scope of IMCIinterventions.

. Incorporating IMCI into ongoing district and national efforts to improve child health, and linking it with other health initiatives(e.g. Safe Motherhood Initiative).

. Demonstrating the cost-effectiveness of the IMCI strategy.

Policy and Practice


Resumen

Atencion integrada a las enfermedades prevalentes de la infancia: resumen delas primeras experienciasLa estrategia de Atencion Integrada a las EnfermedadesPrevalentes de la Infancia (AIEPI) aspira a reducir lamortalidad y la morbilidad infantiles en los pases endesarrollo combinando un mejor manejo de enferme-dades comunes de la infancia y una nutricion einmunizacion adecuadas. El objeto primordial de laestrategia es ante todo el desarrollo de directrices clnicasintegradas y de un modulo de adiestramiento para losagentes de salud que tratan a los ninos en losestablecimientos de salud del primer nivel, pero tambienla ampliacion de intervenciones tanto preventivas comocurativas de promocion de la salud y el desarrollo delnino. La estrategia de AIEPI incluye intervencionesencaminadas a mejorar las aptitudes de los agentes desalud, el sistema de salud y las practicas familiares ycomunitarias. En este artculo se describen la experienciade los primeros pases que han aplicado la AIEPI, laslecciones aprendidas y el uso que se ha hecho de esaslecciones para formular una estrategia de AIEPI masamplia.

El artculo consta de tres partes. En la primera sedescribe la introduccion de la AIEPI, haciendosereferencia a las medidas adoptadas para ayudar a losministerios de salud a tomar la decision de aplicar o no laestrategia, a las estructuras de gestion creadas para laAIEPI y a los interlocutores implicados. La segunda tratade la fase inicial de ejecucion, durante la cual los pasesplanifican y preparan la puesta en marcha de la AIEPI,adaptan las directrices clnicas genericas a la situacion

epidemiologica nacional, llevan a cabo las primerasactividades de la AIEPI en un numero limitado de distritosy vigilan atentamente sus experiencias como base para laejecucion futura. La creacion de consenso respecto a lasdirectrices clnicas adaptadas es decisiva para el exito dela AIEPI en un pas. Otros aspectos cruciales son el lugarde la AIEPI en el marco de las reformas en curso del sectorde la salud, la disponibilidad de medicamentosesenciales, los circuitos que conducen a la atencion dereferencia, la supervision, la organizacion del trabajo enlos establecimientos de salud, la vigilancia y los sistemasde informacion sanitaria. En la tercera parte se describenlos esfuerzos desplegados por los pases para aumentarel acceso a intervenciones emprendidas durante la faseinicial de ejecucion y para ampliar la gama deintervenciones de la AIEPI.

Se examinan tambien los retos principales conmiras a mejorar la AIEPI y las estrategias de crecimiento ydesarrollo de los ninos en un futuro proximo. Ello incluyeel fomento de un sentimiento de apropiacion y decapacidad para la planificacion y la gestion de la AIEPI anivel distrital y nacional; una mayor cobertura, mante-niendo la calidad y el amplio alcance de la estrategia dela AIEPI, y la incorporacion de la AIEPI en los esfuerzosdistritales y nacionales en curso destinados a mejorar lasalud infantil. Por ultimo, la OMS esta dirigiendo unesfuerzo colaborativo para evaluar la repercusionmundial de la estrategia de AIEPI.

References

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13. Vaessen MT. Needs in program measurement: the DHSperspective. In: Tsui A, ed. The evaluation project: future needsfor evaluating family planning programs. Chapel Hill, NC, CarolinaPopulation Center, University of North Carolina, 1992: 3138.

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Policy and Practice


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