Management of childhood illness in AfricaBMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7235.594 (Published 04 March 2000) Cite this as: BMJ 2000;320:594
Early evaluations show promising results
- Doyin Oluwole, IMCI medical officer.,
- Elizabeth Mason, IMCI medical officer.,
- Anthony Costello (), reader in international child health.
- World Health Organisation Africa Region, BP BP 1504 Lome, Togo
- World Health Organisation, Southern Africa Subregion, Harare, Zimbabwe
- Institute of Child Health, University College, LondonWC1N 1EH
The integrated management of childhood illness strategy (IMCI) has now been introduced into 28 countries in Africa. The strategy aims to improve the skills of health workers, the health system itself, and also the knowledge and practices of families in relation to their young children (see box).1 It has been operating for about three years, and most evaluations show positive results.
The strategy arose from criticism of disease specific control programmes like those targeted at diarrhoea and acute respiratory infections. Primary healthcare workers usually deal with children whose symptoms have overlapping causes and no single diagnosis. For example, cough and tachypnoea may be caused by pneumonia but also by severe anaemia or malaria. A “very sick” young infant may have pneumonia, septicaemia, and meningitis. Misclassification of illness by health workers is common: a study in Kenya showed that only 8% correctly diagnosed severe pneumonia.2
Component one of the strategy aims to improve health workers' performance by training them to use a clinical algorithm to detect the commonest causes of childhood illness (pneumonia, diarrhoea, malaria, measles, otitis media, and malnutrition) and by providing desktop guidelines for history taking and examination. Generic guidelines developed by the World Health Organisation are adapted by national experts in child health to take account of local epidemiology and to create versions of the “mother's counselling card” in local languages. Involving national paediatricians also helps to ensure institutional sustainability.
What has been the experience so far? The benefits of the training appear to include more rational drug use, increased attendances (an evaluation in Tanzania showed a 20% rise in attendances), improved provider morale, and improved perceptions of quality of care by mothers. An evaluation in Uganda showed that health workers trained through the programme shared their knowledge and skills with other staff, immunisation services improved, weighing of children increased from below 5% to 85% after training, and that, despite problems with drug supply, the use of first line drugs increased.3 Health workers felt more confident because their skills and classification of disease had improved.
In Zambia health workers correctly managed less than 5% of cases of diarrhoeal disease before training. After training they correctly managed 82% of cases at three months' follow up and 60% after one year.4 Mothers also liked being given the first dose of treatment on site, that their children were examined thoroughly, and that health workers counselled them on home care for their children.
A positive effect of the training on outcomes such as child mortality is more difficult to demonstrate, although studies are in progress in Tanzania and Uganda. We should not be disappointed if the effects are initially small. Up to 80% of childhood deaths in Africa occur at home, before the child reaches a health facility.5 Tackling this problem needs development of the third component of the strategy—community level promotion of preventive activities and prompt seeking of help by carers.
Important activities suggested by the World Health Organisation and Unicef for promotion at community level6 include exclusive breastfeeding, appropriate complementary feeding, micronutrient supplementation, full immunisation, continued feeding during illness, early care seeking, use of insecticide treated bed nets, improved home hygiene, promotion of a child's mental and social development, and adequate antenatal and delivery care for mothers. In Africa prevention of injury and child abuse, care of children with HIV and AIDS, and greater involvement of men in child care have been included. Partnerships with groups such as local councils, women's groups, community and religious leaders, and the mass media will be crucial for success.
Integrated management of childhood illness: aims
To improve case management skills of health workers through training with locally adapted guidelines
To improve the health system, including provision of essential drugs
To optimise family and community practices in relation to child health, particularly care seeking behaviour.
Introduction to a country involves:
Orientation of national decision makers and the establishment of an IMCI working group
Early implementation in a few districts, including adaptation of the guidelines, training of health workers, and health system support
Scaling up, including community level activities
Undoubtedly difficulties exist with the integrated management of childhood illness strategy, especially when resources are scarce. The training lasts 11 days, and trainees require follow up and supervision, which present logistical and budgetary challenges when the strategy is scaled up. Preservice training is more cost effective in the longer term, but in-service training remains essential for rapid improvements in quality of care. Some of the costs may be offset by more rational prescribing, 7 but in all African countries supplies of essential drugs have been a major problem.
Adaptation of guidelines by national experts has also raised questions. Diagnostic guidelines for pneumonia rest heavily on an increased respiratory rate, but with rising rates of asthma there is a danger of underdiagnosis of asthma and bronchiolitis and overdiagnosis of pneumonia. A recent study in Delhi seems to confirm this.8 The strategy has concentrated on illness in infants aged 1 week or more, yet neonatal mortality accounts for over 60% of infant deaths. Linkages with “safe motherhood” professionals about newborn care guidelines are essential developments.
The algorithm used by the strategy may result in overclassification of fever as malaria and hence overuse of antimalarials. This needs to be balanced against the risk of severe complications and death if malaria is underdiagnosed. Links between the strategy, national malaria programmes, and the World Health Organisation's “roll back malaria” programme in monitoring drug sensitivity patterns is important as resistance to chloroquine and sulphadoxine-pyrimethamine grows.9 Changes in drug policy that result could be made through the adaptation process. The follow up of children with fever who do not respond to treatment also provides opportunities for referral and clinical diagnosis at a higher level. Increased investment in better malaria diagnostic facilities will promote appropriate treatment and prevent unnecessary childhood deaths. Indeed, the integrated management of childhood illness programme is potentially a pathfinder for the success of “roll back malaria” because most deaths occur in early childhood.
Finally, HIV is devastating child health in sub-Saharan Africa and its incidence is rising in Asia. Three countries in Africa have incorporated guidelines for when to test and how to treat HIV positive children, which are under evaluation.
The integrated management of childhood illness strategy should not be seen as a magic bullet to suddenly lift the unacceptable burden of childhood illness in Africa, but proper implementation should contribute to a steady reduction in childhood mortality.
Conflict of interest: DO and EM both work for the WHO and AC has received funding from WHO for a project in Nepal.