Integrated Management of Childhood Illness (IMCI)
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Source: HEALTH-L, THE ZAMBIAN ELECTRONIC MAILING LIST ON HEALTH ISSUES
WHY AN INTEGRATED APPROACH TO MANAGEMENT OF THE SICK CHILD?
Every year some 12 million children die before they reach their fifth
birthday, many of them during the first year of life. Seven in every 10 of
these child deaths are due to diarrhoea, pneumonia, measles, malaria or
malnutrition - and often to a combination of these conditions. Every day,
millions of parents seek health care for their children, taking them to
hospitals, health centres, pharmacists, community health care providers and
traditional healers. At least three out of four of these children are
suffering from one of these five conditions.
Because there is considerable overlap in the signs and symptoms of several
of the major childhood diseases, a single diagnosis for a sick child is
often inappropriate. Focusing on the most apparent problem may lead to an
associated, and potentially life-threatening, condition being overlooked.
Treating the child may be complicated too by the need to combine therapy
for several conditions.
What are the advantages of this approach?
Integrated management of the sick child leads to more accurate
identification of illnesses in outpatient settings, ensures more
appropriate and, where possible, combined treatment of all the major
illnesses and speeds up referral of severely ill children. Health workers
are trained in how to communicate key health messages to mothers, thus
helping them understand how best to ensure the health of their children.
This situation argues for child health programmes that address not single
diseases but the sick child as a whole. A lot has been learned from
disease-specific control programmes in the past 15 years. The challenge is
to combine these lessons into a single more efficient and effective
approach to managing childhood illness. A number of programmes in WHO and
UNICEF have responded to this challenge by developing an approach now
referred to as integrated management of the sick child. Already a number of
other agencies, institutions and individuals are contributing to this
initiative.
Evidence from surveys of health worker performance and of management of
illness in the home suggest that, in both these areas, improvements can be
made that are likely to reduce mortality significantly. As potentially
fatal illnesses in children are often brought to the attention of health
workers at first-level health facilities, the initiative for integrated
management of the sick child is focusing first on improving their
performance through training and support. At the same time work has started
on approaches to changing family behaviour in relation to sick children
including when and where families seek care outside the home.
The approach gives attention to prevention of childhood disease as well as
to treatment. It emphasizes the importance of immunization, vitamin A
supplementation if necessary, and improved infant feeding, including
exclusive breastfeeding.
Integrated management of the sick child means efficiency in training, and
in the supervision and management of outpatient health facilities. Wastage
of resources is reduced because children are treated with the most cost-
effective intervention for their condition. The approach avoids the
duplication of effort that may occur in a series of separate disease
control programmes.
According to the World Bank's World Development Report 1993, management of
the sick child is the intervention likely to have the greatest impact in
reducing the global burden of disease. This approach alone is calculated to
be able to prevent 14% of that burden in low-income countries. According to
the same report, management of the sick child ranks among the most cost-
effective health interventions in both low-income and middle-income
countries.
Why integrated management of the sick child is a priority?
The health system and the services it delivers should:
1. Address major health problems
2. Respond to the demands of the population
3. Have a significant impact on health status
4. Address prevention as well as cure
5. Cost effective
6. Improve equity
Integrated management of the sick child meets all of these criteria.
1. Addressing a major health problem:
Pneumonia, diarrhoea, measles, malaria and malnutrition together account
for 7 out of 10 of the 33,000 deaths that occur daily among the children
of the developing world.
2. Responding to a demand:
Every day millions of parents take their children for care to hospitals
and health centres, pharmacists and community health care providers. At
least 3 out of 4 of these sick children is suffering one of these five
conditions.
3. Impact on health status:
The World Bank's World Development Report 1993, "Investing in Health"
identified management of the sick child as the intervention likely to
have the greatest impact on the global burden of disease, potentially
averting 14% of that burden in low income countries or more than twice
the amount averted by the next most effective intervention, childhood
immunization.
4. Prevention as well as cure:
While management of the sick child focuses on treatment. It also
provides the opportunity for, and emphasizes, the two most important
preventive interventions for child health: immunization and improved
nutrition, especially breastfeeding.
5. Cost-effectiveness:
The same World Bank report ranked management of the sick child among the
10 most cost-effective interventions in both low and middle income
countries. Inappropriate management of childhood disease is wasteful of
scarce resources, for example, intravenous fluids and antibiotics.
Control programmes specific to a single disease have been effective but
can be inefficient because of duplication of effort. Integrated
management of the sick child addresses both of these concerns and should
result eventually in cost-saving although an initial increased
investment will be needed for training and reorganization.
6. Improving equity:
Virtually all children of the developed world and most well-off children
in the developing world have ready access to the simple affordable
treatments needed to protect them from death due to these five diseases.
However, most children of the developing world do not have access to
this life saving care. Given that this is one aspect of inequity which
can be addressed immediately, with proven, inexpensive interventions, it
should not be addressed as a matter of urgency.
What tools are being developed?
Case management guidelines
Integrated outpatient management of the sick child at the first-level
health facility has been described on four wallcharts which will also be
available in booklet form. These guidelines are based on experience to date
and on the findings of some focused research studies. The charts are
titled, respectively:
- Assess and classify the sick child age 2 months up to 5 years
- Treat the child
- Counsel the mother
- Assess, classify and treat the sick young infant age 1 week up to 2
months.
The guidelines focus on detecting and managing the most common potentially
fatal illnesses and associated conditions. They do not attempt to cover all
childhood illnesses.
The assessment process uses a colour-coded triage system with which many
health workers are already familiar through use of the WHO case management
guidelines for diarrhoea and acute respiratory infections (ARI).
This procedure classifies each illness according to whether it requires:
- urgent referral,
- specific medical treatment and advice, or
- simple advice on home management.
The first step in the process is to look for non-specific danger signs that
indicate the child is severely ill and needs urgent referral. Following
this, for all children, the health worker asks questions about four main
presenting symptoms.
The child presenting with cough or difficult breathing is handled according
to the previous WHO/ARI management charts. The illness is classified as
"severe pneumonia or other very serious disease" (requiring referral),
"pneumonia" or "cough and cold".
A child presenting with diarrhoea is managed according to the already
widely used WHO diarrhoea management charts. The child's dehydration status
is classified, as are persistent diarrhoea and dysentery if present.
Treatment is defined accordingly.
If fever is among the presenting complaints, a classification of "severe
febrile illness" indicates that urgent referral is needed. Depending on the
other symptoms present and the risk of malaria, this disease may be
diagnosed. Fever may also be the starting point for a classification of
measles with or without complications.
Mastoiditis and chronic or acute ear infection are the classifications that
can be made from the examination of an ear problem.
In addition to these classifications based on presenting symptoms,
nutritional status is assessed for all children. Severe malnutrition or
severe anaemia indicate the need for referral while less severe
deficiencies result in treatment and/or advice in the health facility.
Each child's immunization status is also checked and vaccinations given as
needed.
Finally the health worker is reminded to assess and treat any other
problems detected.
Management of childhood illness: a training course
The case management guidelines constitute the technical core of a training
course that has been developed for first-level health facility workers.
This course consists of a set of six training modules for participants,
still-photo exercises, video film and detailed instructions for the course
director and course facilitators. It emphasizes hands-on practice of the
skills taught.
A pretest of the course in Gondar, Ethiopia, in August 1994, followed by
several weeks of observation of the trained health workers, yielded very
promising results.
A guide to local adaptation of the training materials is also in
preparation. This will include guidance on modification of such things as
foods and fluids to be included when counselling the mother, antimicrobials
of choice in a particular epidemiological context, and other policy
decisions.
On-the-job training in management of drug supplies
Guidelines for conducting a training workshop followed by supervised
practice in the place of work have been developed in collaboration with
BASICS to help health workers better manage the drugs essential for
management of sick children.
Other materials under development
Two other sets of guidelines - on improving health workers' performance and
on assessing and changing family behaviours related to care for sick
children - are being developed with the help of specialists in these areas.
As many sick children require referral to a hospital, a further training
course is being developed on inpatient case management of the sick child.
Work has also begun on a survey manual for assessing health worker
performance, based on those already available for diarrhoea and ARI.
Guidelines for introducing the integrated approach in countries are also
being put together.
Research on the management of the sick child
Research is an essential component of all programmes to reduce mortality
and morbidity in children. Several research studies have already been
carried out to provide information for finalizing the four sick child case
management charts. These include evaluation of the Assess and classify
chart in Gambia and Kenya, and studies on the clinical predictors of
anaemia in India and Malawi. The studies have led to modification or
validation of the following aspects of the protocol:
- the clinical signs for classifying children as requiring antimalarials in
low-risk areas have been refined;
- the clinical signs for classifying children as having severe anaemia
requiring referral have been improved for greater specificity;
- detection of fever by touch was shown to be sufficiently sensitive and
specific to justify the recommendation to "feel the child for fever" if
no thermometer is available;
- visible severe wasting was found to be adequate to detect most children
with very low weight-for-height for referral to hospital;
- the rate of referral and antibiotic use with the revised protocol were
found to be acceptable.
A multicentre study on persistent diarrhoea in Bangladesh, India, Mexico,
Pakistan, Peru and Viet Nam has provided important findings that have been
used to update the recommendations for management of persistent diarrhoea.
Findings from a study on pneumonia, sepsis and meningitis in Ethiopia,
Gambia, Papua New Guinea and the Philippines have also been used to
complete the recommendations for diagnosis and treatment in young infants.
WHO has drawn up a list of future research priorities related to management
of the sick child. In addition to improving the detection and treatment of
the five major illnesses, areas where more information is needed include:
- detection and management of anaemia and meningitis nutritional management
- management specific to the sick young infant
- reasons why mothers do not seek health care for sick children
- identification of high-risk children
- adequacy of clinical management in first-level health facilities.
While much research is concerned with biomedical questions, there is also a
need for further behavioural research on, for example, communication with
mothers, including the adaptation of advice on feeding to local conditions.
Research has been carried out by a number of collaborating institutions and
coordinated by the WHO Division of Diarrhoeal and Acute Respiratory Disease
Control and the WHO Special Programme for Research and Training in Tropical
Diseases. In 1993 and 1994 a series of consultations were organized to
obtain expert advice on various topics, to review research findings and to
redefine research priorities. Two research and development coordination
meetings have also been held with participation of a wide range of current
or potential collaborators.
Plans for implementation
The concept of the integrated approach to childhood illness has been
welcomed by many countries. In some it will fit well into reorganizations
of health service management that are already under way. In others,
organizational changes or clearly defined collaborative arrangements
between existing disease-specific programmes will be needed.
WHO, UNICEF and their collaborative partners will work with countries to
help adapt the new materials to the country context, to plan how
implementation of activities can best be managed and to evaluate the
experience. Particularly close monitoring of initial experience will be
carried out in a small number of countries.
Collaborating partners
Many institutions are collaborating in this initiative as listed in the
attached table.
Bilateral aid agencies from many countries, the World Bank, UNDP and UNICEF
are supporting these efforts through their funding of WHO Programmes. Funds
specifically designated for this initiative have been provided to WHO by
the Governments of Norway and Switzerland and by the US Agency for
International Development.
Collaborating institutions
In addition to the Ministries of Health in countries where activities
related to integrated management of the sick child have been carried out,
the following institutions have collaborated:
World Health Organization
- Division of Diarrhoeal and Acute Respiratory Disease Control (CDR)
- Division of Communicable Diseases (CDS)
- Division of Control of Tropical Diseases (CTD)
- Action Programme on Essential Drugs (DAP)
- Global Programme for Vaccines (GPV)
- Maternal and Child Health and Family Planning (MCH)
- Nutrition (NUT)
- Oral Health (ORH)
- Programme for the Prevention of Blindness (PBL)
- Special Programme for Research and Training in Tropical Diseases (TDR)
World Bank
- Department of Population, Health and Nutrition
UNICEF
- Child Survival Unit
- Bamako Initiative Unit
Other institutions
Ethiopia:
- Addis Ababa University
- Gondar Medical College
The Gambia:
- Medical Research Council
Italy:
- Instituto "Burlo Garofalo"
Kenya:
- Kenya Medical Research Institute
- Wellcome Trust
South Africa:
- The South African Institute for Medical Research
- University of Cape Town
Tanzania:
- Tanzanian Food and Nutrition Unit
UK:
- Cambridge University
- London School of Hygiene and Tropical Medicine
- Liverpool School of Tropical Medicine
- Medical Research Council
- Save the Children Fund
- University of Edinburgh
USA:
- Academy for Educational Development, USAID/SARA
- Center for Disease Control and Prevention
- Johns Hopkins University, USAID/Child Survival Project
- Harvard Institute for International Development, USAID/ADDR
- Michigan State University
- The Partnershiop for Child Health Care, Inc., USAID/ BASICS
- University of Colorado
- University Research Corporation, USAID/Quality Assurance Project
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Joost Hoppenbrouwer
mailto:joost@zamnet.zm
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