Elsevier

The Lancet

Volume 364, Issue 9445, 30 October–5 November 2004, Pages 1583-1594
The Lancet

Articles
Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania

https://doi.org/10.1016/S0140-6736(04)17311-XGet rights and content

Summary

Background

The Integrated Management of Childhood Illness (IMCI) strategy is designed to address major causes of child mortality at the levels of community, health facility, and health system. We assessed the effectiveness of facility-based IMCI in rural Tanzania.

Methods

We compared two districts with facility-based IMCI and two neighbouring comparison districts without IMCI, from 1997 to 2002, in a non-randomised study. We assessed quality of case-management for children's illness, drug and vaccine availability, and supervision involving case-management, through a health-facility survey in 2000. Household surveys were used to assess child-health indicators in 1999 and 2002. Survival of children was tracked through demographic surveillance over a predefined 2-year period from mid 2000. Further information on contextual factors was gathered through interviews and record review. The economic cost of health care for children in IMCI and comparison districts was estimated through interviews and record review at national, district, facility, and household levels.

Findings

During the IMCI phase-in period, mortality rates in children under 5 years old were almost identical in IMCI and comparison districts. Over the next 2 years, the mortality rate was 13% lower in IMCI than in comparison districts (95% CI –7 to 30 or 5 to 21, depending on how adjustment is made for district-level clustering), with a rate difference of 3·8 fewer deaths per 1000 child-years. Contextual factors, such as use of mosquito nets, all favoured the comparison districts. Costs of children's health care with IMCI were similar to or lower than those for case-management without IMCI.

Interpretation

Our findings indicate that facility-based IMCI is good value for money, and support widespread implementation in the context of health sector reform, basket funding, good facility access, and high utilisation of health facilities.

Introduction

Every year, more than ten million children worldwide die,1 and 95% of these deaths occur in just 42 less developed countries. The inequity in children's survival between rich and poor countries is unacceptably vast, as are the differences in survival between richer and poorer children within most countries.2 Although children's survival worldwide has improved over the past 30 years, the rate of increase peaked around 1980 and there has been virtually no further improvement since then in sub-Saharan Africa. In some countries, children's survival has even declined, and HIV/AIDS is only a partial reason.3 The main causes of death of children worldwide are neonatal disorders, diarrhoea, pneumonia, and malaria, although HIV/AIDS accounts for at least 10% of deaths in some African countries.1 Undernutrition is a major underlying cause and has been estimated to contribute to more than half of all deaths in children.1

Effective interventions are available that could prevent more than 60% of all deaths in children.4 Yet mothers and children are not receiving these interventions: coverage remains unacceptably low.5 The Integrated Management of Childhood Illness (IMCI) is a strategy for improving children's health and development through the combined delivery of essential child-health interventions. Originally, IMCI consisted of case-management guidelines for sick children in peripheral first-level health facilities, to be adapted for each country.6 Later, the strategy expanded to include guidelines from WHO and UNICEF for delivering interventions to increase children's survival at household, community, and referral levels, with three components: improvements in case-management; improvements in health systems; and improvements in family and community practices. By the end of 2003, the first two components of IMCI were in the early implementation or expansion phase in 108 less developed countries, including virtually all African countries south of the Sahara.7 The Multi-Country Evaluation of IMCI seeks to generate information on the effectiveness, cost, and impact of IMCI that can be used to strengthen the delivery of child-health interventions and the implementation of the IMCI strategy; it includes in-depth studies in Bangladesh, Brazil, Peru, Tanzania, and Uganda.8

In Tanzania, the mortality among children younger than 5 years is 147 per 1000 births, resulting in almost 250 000 deaths each year.9 The country has a gross domestic product of US$501 per head10 and is undergoing health-sector and local-government reforms. As districts gain more control over their health budgets, IMCI is one of the strategies recommended by the Ministry of Health to address major children's health problems such as malaria, pneumonia, malnutrition, and diarrhoea, which together account for more than 83% of postperinatal deaths before the age of 5 years (unpublished data from the Tanzania Essential Health Interventions Project). Here, we report the effectiveness of facility-based IMCI, by which we mean the first two components of the strategy, on children's health and survival in rural Tanzania. We compared children's health, behaviours at household level relating to children's health, and children's survival in two districts with facility-based IMCI and two neighbouring comparison districts without IMCI over the period from 1997 to 2002.

Section snippets

Design

We used a non-randomised controlled trial, or “plausibility” design,11 in which there is monitoring of process measures to improve the internal validity of the study and of contextual factors to check whether any apparent effect of the intervention is due to other factors. We compared children's health and survival in four neighbouring rural districts of Morogoro and Coast Regions, southern Tanzania, in 1999 and 2002. The two IMCI districts, Morogoro Rural and Rufiji, started to implement IMCI

Quality of care

The introduction of facility-based IMCI was associated with improved quality of care as measured through the health-facility survey in August, 2000, after the end of the IMCI phase-in (figure 1). More than twice as many children were checked for cough, diarrhoea, and fever in the IMCI facilities as in the comparison districts (p<0·0001; table 1).12 Sick children were 1·7 times more likely to be correctly classified in IMCI districts than in comparison districts (p<0·0001). Drug availability was

Discussion

Our effectiveness evaluation to estimate the impact of a programme that was selected and implemented by district health staff in rural Tanzania showed evidence that case-management was improved, the mortality rate in children younger than 5 years was 13% lower in districts with IMCI than in comparison areas, and that costs of children's health care with IMCI were similar to or lower than those with conventional case-management, suggesting that facility-based IMCI is highly cost effective. Our

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