1 Policy and programme lessons from the Multi-Country Evaluation (MCE) of IMCI The MCE Team.
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Transcript of 1 Policy and programme lessons from the Multi-Country Evaluation (MCE) of IMCI The MCE Team.
1
Policy and programme lessons from the Multi-Country Evaluation (MCE) of IMCI
The MCE Team
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IMCI*:Good health for children
Health systems
Health worker performance
Families and communities*Integrated Management of Childhood Illness
Neonatal, 33%
Diarrhea, 22%
Pneumonia, 21%
Malaria, 9%
AIDS, 3%
Measles, 1%
Others, 11%
Malnutrition52%
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MCE Objectives
Document IMCI implementation
Measure IMCI impact on health and nutrition
Evaluate the cost-effectiveness of IMCI
Provide feedback to policy makers
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Major impact on child health and nutrition was expected at country
level
Improved health/nutrition
Reduced mortality
Improved household
compliance/care
Improved careseeking &
utilization
Improved quality of care in
health facilities
Improved preventive practices
Training of health workers
Health system improvements
Family and community
interventions
Increased coverage for curative & preventive interventions
Introduction of IMCI
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MCE in-depth studies
• Bangladesh: – efficacy RCT of 10 IMCI x 10 comparison areas
• Tanzania: – pre-post comparison of 2 IMCI x 2 comparison
districts
• Brazil: – comparison of 32 IMCI x 32 comparison municipalities
• Uganda: – pre-post dose-response analysis of IMCI strength of
implementation in 10 districts
• Peru: – as in Uganda, for 25 departments
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MCE step-wise approach
Are adequate services being provided?
at health facility level?
at community level?
Are these services being used by the population?
Have adequate coverage levels been reached in the population?
Is there an impact on health and nutrition?
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IMCI leads to improvementsin health worker performance
Source: Paryio G, Schellenberg J et al
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69
56
72
16
65
13
29
0
20
40
60
80
100
% c
hil
dre
n c
orr
ec
tly
ma
na
ge
d
Bangladesh NE Brazil Tanzania Uganda
Non-IMCIIMCI
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And can improve care quality at no extra cost
Total spending on child health, Tanzania ('000s 1999 US$)
393
496
IMCI Non-IMCI
Results from the Brazil MCE confirm thatIMCI does not cost more than routine care
Cost per child correctly managed, Tanzania (1999 US$)
$4
$25
IMCI Non-IMCI
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Is IMCI being provided at health facility level?
High training coverage has been reached in defined geographical areas
Quality of training is usually good
Difficulties in going to scale in relation to staff turnover and maintaining of quality of training
Need for health systems supportDrugs
Supervision
Referral
District management skills
10
41
15
8
Tanzania
Uganda
Bangladesh
Utilization is often too low to achieve impact through
facility-based services alone
% sick children who were taken first to a government facility
Source: Arifeen S, Paryio G, Schellenberg J et al
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In Bangladesh, IMCI is associated with increases
in health facility utilization
Data source: MCE-Bangladesh, Routine MIS and GoB MIS
But no other MCE site was able to replicate this effect……
0
1
2
3
4
5
Jul
Sep
No
v
Jan
Mar
May Ju
l
Sep
No
v
Jan
Mar
May Ju
l
Sep
No
v
Jan
Mar
May Ju
l
Sep
No
v
Jan
Mar
May
Sic
k U
5 C
hild
ren
pe
r c
hild
pe
r y
ea
r
IMCI Intervention IMCI Comparison
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But coverage for key community interventions
remains low in most countries
Population coverage for key family practices
Uganda MCE – 10 districts
40
11
3336
15
32
0
25
50
75
100
Child with feverreceived antimalarials
Child slept underbednet last night
Measles vaccination
2001 2002
Source: Paryio G et al
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In Peru, facility and communityIMCI were not implementedin the same departments
0
20
40
60
80
100
120
0 10 20 30 40 50 60
Trained clinical health workers (%)
Trai
ned
CHW
s pe
r 10,
000
child
ren
Source: Huicho L et al
Each dot representsone department
Departmental coverage of IMCI-trained clinical and
community workers (2003)
Similar resultsin Tanzania
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Is IMCI being provided at community level?
Implementation is spotty and uncoordinated with health worker training
Community case-management interventions not included
Community IMCI includes too many messages
These findings have helped generate increased focus on the implementation of community component of IMCI
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Did IMCI have an impact on mortality?
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10
15
20
25
30
35
1999-00 2001-02
An
nu
al
mo
rta
lity
ra
te
Morogoro (IMCI) Rufiji (IMCI)
Ulanga Kilombero
Tanzania: underfive mortalitywas 13% lower in the
two IMCI districts
Source: Schellenberg J et al
Full IMCIin HF
End ofstudy
13% difference95% CI: -7%, 30%
Significant impact on stunting
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IMCI clinical training coverage (%) and underfive mortality reduction
0
10
20
30
40
50
60
0 20 40 60 80
Training coverage
Mo
rta
lity
re
du
cti
on
(%
)IMCI: No apparent impact in Peru
r= 0.048P= 0.824
Similar results in Brazil and Uganda
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Summing up (1)
• IMCI improves quality of care• IMCI does not increase overall costs
– Either for providers or out-of-pocket
• IMCI dramatically reduces cost per child managed correctly
• IMCI is the gold standard for facility care of children aged 7 days – 5 years
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• IMCI can have an impact on mortality and nutrition
• But this requires:– Strengthening health systems– Reaching out to the community
• IMCI was least likely to be implemented well where it was needed most
Summing up (2)
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What the MCE has contributed
• Feedback at national level
• Repositioning IMCI in the context of child survival by WHO and other agencies
• Lancet Child Survival Series + 30 papers
• Increased advocacy for child survival
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What the MCE has contributed
• The MCE showed that having interventions is not enough
• The real challenge is how to deliver these interventions to those who need them most
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IMCI and child health
• From MCE we know IMCI works in facilities!
• Requires adequate attention to health systems support and community coverage
• MCE was not able to evaluate the effectiveness of the community component of IMCI
• IMCI, as originally constructed, may not be the answer in every setting
• IMCI is evolving!
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Scaling up IMCI The Bangladesh experience
• Since these results first came out, IMCI has been scaled up to almost a fifth of Bangladesh, especially in high mortality areas
• Quality of training and performance outcomes have been maintained
• Initial focus on facility-based services, with increasing inclusion of health systems support and community interventions
• Shift from strategy to programme
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IMCI and child health
IMCI
CHILDHEALTH AND NUTRITIONSTRATEGY