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Integrated approach to child health in developing countries

Rationale for integrated strategy

The extent of childhood morbidity and mortality in the developing world caused by the five conditions mentioned above is not in itself a rationale for an integrated approach to dealing with them. However, most sick children present with signs and symptoms related to more than one of these conditions. This overlap means that a single diagnosis may not be possible or appropriate and treatment may be complicated by the need to combine therapy for several conditions.

In 1990, WHO drew attention to

Interventions and components of IMCI

At the core of the IMCI strategy is integrated case management of the most common childhood problems seen in developing countries with a focus on the most important causes of death. The strategy includes a range of other preventive and curative interventions, which aim to improve practices both in the health facilities and at home (figure 1). The generic WHO/UNICEF guidelines and the IMCI adaptation guide also address other common conditions as well as the leading causes of death in children.

Case-management guidelines

In developing the generic integrated case management guidelines the primary objective was effective treatment of acute respiratory infections (ARI), diarrhoea, measles, malaria, and malnutrition by health workers at first-level health facilities. At this level, in developing countries, diagnostic supports such as radiology and laboratory services are minimal or non-existent. The health worker must rely on history and signs and symptoms, and the IMCI guidelines are built around a series of

Progress in improving health-worker skills

Implementation of the IMCI strategy began in 1995 when a small number of countries expressed interest in trying out the approach. By the end of June, 1998, 63 countries had started to implement the strategy. 20 countries were just starting to explore the process while 31 were already adapting the generic materials to their needs or had completed this step and were training health workers in selected districts. 12 countries had moved into a phase of expansion with the aim of achieving broad

Issues and challenges

Most of the effort in IMCI implementation has been aimed at improving the skills of health workers at the first level of care and, as mentioned above, expanding coverage while maintaining the quality of training will be a major challenge. Better health worker skills alone will, however, have a limited impact if efforts are not made to improve family and community practices related to child health and to strengthen fundamental aspects of the health system.

Health-system constraints include

Does IMCI work and is it cost-effective?

These are, not surprisingly, the questions most commonly asked by decision makers and those who are funding the implementation of IMCI. They are not easy to answer.

Most of the individual therapeutic and preventive elements that go to make up the IMCI treatment guidelines are accepted, and often proven, practices. This is true for antibiotic management of pneumonia and dysentery, oral and intravenous rehydration therapy, malaria treatment, vitamin A supplementation, immunisation, and

Risks of integration

Development of approaches such as IMCI, the integrated management of pregnancy and childbirth, and the adult lung health initiative (the last two currently under development by WHO) are helping to rationalise important elements of primary health care. Further integration may seem desirable but it will not be helpful to end up with a “package” either too cumbersome to implement or too superficial to be effective. It will be important to ensure the compatibility and consistency of the various

Conclusion

The integrated approach to child health embodied in IMCI focuses on the diseases of childhood that cause the greatest global burden, while allowing for the content to be adapted to an individual country's needs. An integrated approach is justified by good clinical practice; it is important to treat the child as a whole and not simply his or her most obvious disease. The strategy involves not only curative care but also interventions to promote healthy growth and development and to prevent