Integrated Management

of Childhood Illness

(IMCI)

Dr. med. Carsten Krüger MIH, FRCPCH

Heidelberg, 14.10.2017

Acknowledgement

The following slides were provided by PD Dr.

M.W. Weber, MD, PhD, DTMH / WHO,

Copenhagen:

6, 10-17, 20, 21, 29-35, 47 (not all are shown

in this presentation, but are included in the

PDF file)

2

IMCI - Origin and Aims

• Developed by WHO and UNICEF in the early 1990s.

• Emerged from single intervention programmes such

as ARI, Control of Diarrhoeal Disease (CDD) and EPI

programmes.

• Aimed at countries with high U5MR > 40/1000.

• Intended for the outpatient departments in primary

health care facilities as most patients are seen there.

• Main aim: to reduce under-five mortality significantly.

• 1996 started in Tanzania and Uganda.3

• Concept based on existing knowledge and validated

by scientific studies.

• The studies demonstrated the practicability=efficacy

of IMCI.

• The studies demonstrated the efficiency of IMCI

(within the studies).

• Effectiveness in the community („the real world“) has

been evaluated (MCE).

IMCI - Origin and Aims (2)

4

Why IMCI? (1)

• Morbidity and mortality in

children < 5 years were still

unacceptably high (> 12 mio.

deaths in 1990, 6.6 mio.

deaths in 2012).

• Many children presented

with more than one symptom

and/or suffered from several

diseases at the same time.

• Many (vertical) intervention

programmes worked outside

the normal health system.

Liu L et al., Lancet

2012; 379: 2151-61

IMCI-MCE

Progress Report

2002

5

Presenting Complaints and Underlying

ConditionsPresenting complaint Possible cause or associated condition

Cough and/or fast breathing

Lethargy or unconsciousness

Dehydration

“Very sick” neonate/young infant

Pneumonia

Malaria, severe anaemia

Heart disease

Cerebral malaria

Meningitis

Severe dehydration

Very severe pneumonia

Gastroenteritis

Severe malaria

Severe pneumonia

Sepsis

Pneumonia

Meningitis

Sepsis 6

Why IMCI? (2)

• This new integrated approach should concentrate on

the most common and/or most serious diseases in

childhood presenting to the outpatient department at

first-level facilities.

– Pneumonia, diarrhoea, febrile illnesses (malaria,

measles), malnutrition, perinatal problems

• The diseases should be easy to diagnose and treat.

Referral to higher levels of care should be provided

in case that the child suffers from a life-threatening

condition.

8

Why IMCI? (3)

• The reality of the health systems (scarceness of all

kinds of resources) should be considered.

– Minimally-trained staff, limited laboratory facilities, scarce

drugs and equipment

– Many sick children are not properly treated, the parents

are poorly advised

9

Common Problems That Affected the

Quality of Care Provided to Sick Children

at First Level Health Facilities

• Health workers skills– incomplete examinations and counselling

– poor communication between health workers and parents

– irrational use of drugs

• Health system issues– location of health services and responsibility (centralisation)

– availability of appropriate drugs and vaccines

– supervision / division of labour / organization of work

– delayed care seeking

• Community and family practices (“community IMCI”)– poor knowledge of when to return to a health facility

– seeking assistance from unqualified providers

– poor adherence to health worker advice and treatment 10

IMCI Components and Intervention Areas

Improve health

worker skills

Improve health

systems

Improve family &

community

practices

Case management standards & guidelines

Training of facility-based public health care providers

IMCI roles for private providers

Maintenance of competence among trained health workers

6

6

6

6

Appropriate careseeking

Nutrition

Home case management & adherence to recommended treatment

Community involvement in health services planning & monitoring

6

6

6

6

District planning and management

Availability of IMCI drugs

Quality improvement and supervision at health facilities

Referral pathways and services

Health information system

6

6

6

6

6

WHO UNICEF

Technical support to countries

11

Interventions Included in the IMCI

Guidelines for First-Level Health Workers

Acute respiratory infections

Diarrhoea

Dehydration

Persistent diarrhoea

Dysentery

Meningitis

Sepsis

Malaria

Measles

Malnutrition

Anaemia

Ear infection

HIV/AIDS

Dengue haemorrhagic fever

Wheeze

Sore throat

Neonate

Conditions covered by

Case Management

Interventions

Immunisation during sick child visits

Nutrition counselling

Breastfeeding support

Vitamin A supplementation

Maternal health issues

Periodic deworming

Preventive Interventions

Generic Version

Using the IMCI

Adaptation Guide

12

IMCI Implementation (1)

• Inclusion of IMCI into the national health policy

programme.

• Adaptation of the standard IMCI guidelines to natio-

nal/local circumstances (e.g. special diseases like

dengue fever, drugs, language, etc.).

• Training of health personnel in diagnosis, treatment and

counselling (initially 11-day training course).

• Improvement of supply with drugs and medical

equipment in health institutions.

• Improvement of health care in the district and referral

hospitals. 18

IMCI Implementation (2)

• Prevention campaigns in the communities.

• Family counselling and training in prevention,

hygiene, early recognition and treatment of

common childhood diseases at home.

• Family counselling about the necessity to bring

sick children early enough to the attention of health

personnel in health centres and/or hospitals.

19

Time Frame

Steps for introduction of IMCI at country

level

12 to

18 months

> 5 years

}Introduction

Early implementation

Expansion of the range of

activities and geographical

coverage

20

Implementation of IMCI early 1996

Brazil

Bolivia

Ecuador

Peru

Ethiopia

Madagascar

Niger

Tanzania, U.R.Uganda

Zambia

Nepal

Philippines

Indonesia

Viet Nam

14 Countries

21

Implementation of IMCI Dec. 2006

25

Implementation of IMCI Dec. 2009

27

The IMCI Approach

• Focus on children < 5 years.

• Signs and symptoms are asked for systematically (danger

signs first).

• Thorough physical examination of each child with simple

equipment.

• Classification according to IMCI charts.

• Diseases are treated systematically.

• Immunisation and nutrition counselling are integrated.

• Counselling of the caretaker.

• Follow-up visits are pre-defined.

• Referral criteria to a higher level of care are defined. 28

YELLOWTreatment & follow-up

Assess for DANGER SIGNS:

Convulsions

Lethargy/Unconsciousness

Inability to Drink/Breastfeed

Vomiting everything

Assess for OTHER PROBLEMS

Assess MAIN SYMPTOMS:

Cough/Difficulty Breathing

Diarrhoea

Fever

Ear Problems

Assess NUTRITION, IMMUNIZATION

STATUS & POTENTIAL FEEDING

PROBLEMS

CLASSIFY CONDITIONS

& IDENTIFY TREATMENT ACTIONS

OUTPATIENT HEALTH FACILITY

The Integrated Case Management Process

34

Urgent

attention &

referral

PINKReferral

GREENHome

Finding Classification Treatment

Danger signs Severe disease Urgent referral

Cough or difficulty in

breathing Severe disease Urgent referral

Diarrhoea Disease with specific

therapy

Specific medical treatment

Fever

Ear problem Disease without specific

therapy

Symptomatic treatment

Nutritional status/

anaemia

Vaccination status Complete/incomplete Vaccinate

Assess and Classify

35

36

Which signs have the highest prediction of

severe neonatal illness?

• 12 symptoms:

- sensitivity 87%

- specificity 74%

The Young Infants Clinical Signs Study

Group, Lancet 2008; 371: 135-42

• 7 symptoms:

- sensitivity 85%

- specificity 75%

37

38

39

Advanced Treatment Guidelines

40

• 10-20% of children seen in outpatient settings

need referral to hospitals for inpatient care.

• Mainly for severe infections, severe malnutrition

and neonatal problems.

• WHO guidelines for hospital care in children

ensure high-quality care.

• Smartphone App

– Android phones:

https://play.google.com/store/apps/details?id=au.org.rch.

hospital CareForChildren

– iTunes, iPhone and iPads:

http://appshopper.com/medical/who-e-pocketbook-of-

hospital-care-for-children

WHO 2012 WHO 2005 + 2013WHO 2000

Advanced Treatment Guidelines

41

Results of IMCI

• In several countries successes and failures of IMCI

were analysed in order to improve the approach and

outcome.

• Results from Bangladesh, Brazil, Peru, Tanzania

and Uganda available.

• Besides medical analyses, health systems, cost and

management analyses were conducted, too.

Multi-Country Evaluation

(MCE)

42

IMCI improves the quality of health

workers

Paryio G, Schellenberg J et al., MCE-IMCI

19

69

56

72

16

65

13

29

0

20

40

60

80

100

% c

hild

ren

co

rrectl

y m

an

ag

ed

Bangladesh NE Brazil Tanzania Uganda

Non-IMCIIMCI

43

IMCI in Tanzania

• 1996/1997 started in 2 districts.

• Very good scientific evaluation.

• Despite large investments and good

infrastructure U5MR reduced by 13% only

(instead of > 50% as anticipated; n.s.).

Schellenberg JA et al., Lancet 2004; 364: 1583-94

44

IMCI in Tanzania

IMCI-MCE Progress Report 2001 46

IMCI in

Bangladesh

Arifeen et al., Lancet 2004; 364: 1595-602

• Index for correct

assessment/classifi-

cation in IMCI area

73 compared to 17

in non-IMCI area.

• Index for correct

treatment in IMCI

area 54 compared

to 9 in non-IMCI

area.

48

• Use of IMCI facilities increased from 0.6 visits/

child/year to 1.9 after 21 months of IMCI

implementation.

• 19% of children in

IMCI area were

taken to trained

health care provi-

der compared to

9% in non-IMCI area (data not shown).Arifeen SE et al., Lancet 2004; 364: 1595-602 49

IMCI in Bangladesh

IMCI in Bangladesh

Arifeen SE et al., Lancet 2009; 374: 393-403

• Mortality rates per 1000 live births for children aged 7 days to

59 months dropped in IMCI and comparison areas strongly.

• In last 2 years in IMCI 13% less mortality (n.s.). 50

• Proportion of

children ill

during the

last two

weeks who

were taken

to an

appropriate

health care

provider

IMCI in Bangladesh

Arifeen SE et al., Lancet 2004; 364: 1595-602 51

IMCI in Peru

• Introduced in 1996, early implementation

phase 1997, expansion 1998.

• Still IMCI not institutionalised in Peru, parallel

system to ARI/diarrhoea control.

• Trained health staff in IMCI only about 10%.

• Districts with intense training in clinical

component not the same as those with

training in community component.

Huicho L et al., Health Policy & Planning 2005; 20: 14-24 54

Is IMCI failing? - Tanzania

Walter ND et al., Bull WHO 2009; 87: 99-107 56

Is IMCI failing? - South Africa

Horwood C et al., PLOS ONE 2009; 4: e5937 58

Achievements

• Reduction of under-five mortality (not significant).

• Health workers’ performance significantly better.

Sustainable over 3 years.

• Improved standard and increased utilisation of the

health system in some countries.

• Reduced use of antibiotics.

• No increased costs.

59

Shortcomings (1)

• Neonatal care and HIV/AIDS initially not included.

• Epidemiology of HIV, malaria and other infectious

diseases as the main killer diseases has changed

significantly.

• Adaptation process often too slow.

• Sub-optimal staff adherence to the guidelines for

diagnosis, treatment and referral.

• Referral for more severely ill children often

difficult.

60

Shortcomings (2)

• Training of insufficient numbers of staff.

• Rapid change of staff at the sites.

• Lack of supervision and re-training.

• Health system improvement difficult.

• Exclusion of non-governmental health care

institutions during the training process detrimental

to access rates to IMCI-trained providers.

• Only minimal implementation of the community

component of IMCI which would improve care-

seeking behaviour. 61

Summary and Conclusions (1)

• IMCI can improve health care for children if

health systems are reasonably functioning.

• Quality and utilisation of health institutions must

be improved further immediately (supervision of

staff, improvement of health systems etc.).

• IMCI expansion is mandatory.

• Accessibility for poor groups must be improved.

• Education, counselling and training of parents

and families must be advanced.62

Summary and Conclusions (2)

• The community-component of IMCI and health

system quality are critical components for

success or failure of the strategy.

• Other reasons for failure

– Lack of political commitment to importance of IMCI

– Lack of funding

– Lack of coordinated training (medical/nursing

schools etc.)

See also: Chopra M et al. Integrated management of childhood illness: what

have we learnt and how can it be improved? Arch Dis Child 2012; 97: 350–35463

Key Messages

• The IMCI approach to reduce under-five mortality is

evidence-based and works in principle.

• Implementation and improvement of all three basic

components (health workers’ performance and

quality of care; health systems; family and

community practices) is mandatory.

• Renewal of political and stakeholder support is

essential for long-term success.

64