ReviewNational implementation of Integrated Management of Childhood Illness (IMCI): Policy constraints and strategies
Introduction
Approximately nine million children die of preventable and treatable conditions every year [1], [2], [3]. Integrated Management of Childhood Illness (IMCI) is a strategy that attempts to reduce childhood deaths due to most of these conditions, including acute respiratory infections, diarrhea, measles, malaria, and malnutrition [4]. First introduced in 1996 with the specific objective of reducing mortality for children under-five in countries with infant mortality rates of at least 40 per 1000 live births [5], [6], it ultimately aims to improve pediatric health by strengthening three core components: health worker skills and training, health systems, and family and community practices [7].
Since its introduction, multi-country evaluations of IMCI (MCE-IMCI) in Uganda, Tanzania, Bangladesh, Brazil, and Peru have shown benefits in health service quality as well as reductions in mortality and health care costs [8]. Based on this evidence, over 113 countries have since introduced IMCI to their health systems with varying levels of comprehensiveness [9], [10]. However, MCE showed several constraints to national implementation of IMCI, including training, health system, and financial constraints. As a result, many countries have only implemented the training components of IMCI without complementary reform of health systems or policy to support national expansion.
This article reviews the empirical evidence to-date regarding various IMCI benefits, commonly identified implementation constraints, and the proposed strategies for policy reform and successful implementation of programs. Literature search was conducted with PubMed using the search terms “IMCI” and any of “mortality, morbidity, implementation, cost, constraint, impact, and policy.” Inclusion criteria were manuscripts that described pediatric mortality, morbidity, health care service quality, costs, compliance, training, implementation constraints, or interventions associated with IMCI.
Section snippets
Evidence of benefits
Evaluations of IMCI in Uganda, Tanzania, Bangladesh, Brazil, Peru, South Africa, China, Armenia, Nigeria, and Morocco have shown various benefits in health service quality, mortality reduction, and health care cost savings. This section describes the successes in implementation in the areas of morbidity, mortality, and health service quality improvement; equipment supplies; and health care cost savings.
Gaps and constraints to national implementation
Despite the evidence available regarding improved health outcomes and potential cost savings with IMCI, there have been several reported local and national constraints to IMCI implementation in most countries. These constraints – low HCW compliance with IMCI guidelines, perceived length and expense of training, inadequate counseling of child caregivers, weakness of health systems to support IMCI policy, and lack of institutionalization or governmental budget allocations for IMCI implementation
Strategies for national implementation
The WHO's World Health Report defined health systems as including “all the activities whose primary purpose is to promote, restore or maintain health” [33]. Since then there has been a growing consensus that effective health programs require strong, well-functioning health systems [34], [35]. Weak health systems have not only been noted to hinder implementation of IMCI, but also a variety of community health programs globally [29], [35]. In 2006, the WHO recommended that in order to strengthen
Conclusion
IMCI has been shown to be effective in improving pediatric health service quality, increasing health care cost savings, and possibly reducing pediatric mortality in developing countries. However, many countries have faced significant training, health system, political, and financial constraints to national implementation and, as a result, have not been able to observe sustained benefits over time. As IMCI continues to be implemented in various countries, health officials must continue to
Conflicts of interest
There are no conflicts of interest reported.
References (45)
- et al.
WHO estimates of the causes of death in children
Lancet
(2005) - et al.
Where and why are 10 million children dying every year?
Lancet
(2003) - et al.
Cost implications of improving the quality of child care using integrated clinical algorithms: evidence from Northeast Brazil
Health Policy
(2009) - et al.
G8 and strengthening of health systems: follow-up to the Toyako Summit
Lancet
(2009) - et al.
Levels and trends in under-5 mortality, 1990–2008
Lancet
(2009) Integrated Management of Childhood Illness: a WHO/UNICEF initiative
Bulletin of the World Health Organization
(1997)IMCI information package. Document WHO/CHS/CAH/98.1D
(1999)- Gove S. Integrated Management of Childhood Illness by outpatient health workers: technical basis and overview. The WHO...
IMCI information package: management of childhood illness in developing countries: rationale for an integrated strategy
(1999)Multi-country evaluations
(2009)