Integrated approach to child health in developing countries

Abstract

Childhood mortality in the world, as a whole, continues to fall. Despite increases in population, the estimated annual number of deaths among children less than 5 years of age has decreased by almost a third since efforts to improve child survival found a more prominent place on the development agenda at the end of the 1970s. Even in the face of the HIV/AIDS epidemic childhood deaths have decreased by about 15% since 1990. This is good news but no reason to be complacent. Progress has been very uneven; in some countries rates of childhood mortality are rising and in many, especially in sub-Saharan Africa, they remain shockingly high. In 1998, more than 50 countries still had childhood mortality rates of over 100 per 1000 live births. In nine countries, one in every five children born alive did not survive to the age of 5 years.1World Health Organisation World health report 1999 making a difference. WHO, Geneva1999Google Scholar We are a very long way from being able to claim that the issue of child survival has been adequately addressed. It is no surprise to find that the children who are most commonly and severely ill, who are malnourished, and who are most likely to die of their illness, are those of the most vulnerable and underserved populations of the developing world. Childhood mortality is a sensitive indicator of the inequity in health and health care so frequently mentioned in international health meetings and policy documents. By the end of this year almost 11 million children will have died before their fifth birthday, many during the first year of life. Seven in ten of these deaths are due to acute respiratory infections (mostly pneumonia), diarrhoea, measles, malaria, or malnutrition, or a combination of these. Projections based on the 1996 analysis The global burden of disease2Murray CJL Lopez AD The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. WHO, Geneva1996Google Scholar indicate that these conditions will continue to be major contributors to child deaths in the year 2020 unless significantly greater efforts are made to control them. In some countries, three in four episodes of childhood illness are caused by one of these five conditions. Every day, millions of parents seek health care for sick children, taking them to hospitals, health centres, pharmacists, community health care providers, and traditional healers. Surveys of the management of sick children reveal that many are not properly assessed and treated and that their parents are poorly advised.3World Health Organization Report of the Division of Child Health and Development 1996–1997. WHO, Geneva1998Google Scholar 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 the fact that success in reducing diarrhoea mortality could not rely on oral rehydration therapy alone. While appropriate as the first line of treatment for acute watery diarrhoea, oral rehydration would have little effect on the estimated 35% of the diarrhoea deaths due to persistent diarrhoea or the 15% due to dysentery. For the first an approach based on dietary management was emerging4Black RE Persistent diarrhea in children of developing countries.Pediatr Infect Dis J. 1993; 12: 751-761Crossref PubMed Scopus (112) Google Scholar and for the second, treatment with an effective antibiotic was needed. Efforts to address diarrhoea mortality through oral rehydration therapy needed to be incorporated into a more comprehensive approach. Research in the early 1990s showed the overlap in clinical features of pneumonia and malaria in African children and suggested that co-trimoxazole could be effective for both infections.5O'Dempsey TJ McArdle TF Laurence BE Lamont AC Todd JE Greenwood BM Overlap in the clinical features of pneumonia and malaria in African children.Trans R Soc Trop Med Hyg. 1993; 87: 662-665Summary Full Text PDF PubMed Scopus (170) Google Scholar, 6Bloland PB Redd SC Kazembe P Tembenu R Wirima JJ Campbell CC Co-trimoxazole for childhood febrile illness in malaria-endemic regions.Lancet. 1991; 337: 518-520Summary PubMed Scopus (44) Google Scholar, 7Daramola OO Alonso PL O'Dempsey TJ Twumasi P McArdle TF Greenwood BM Sensitivity of Plasmodium falciparum in The Gambia to co-trimoxazole.Trans R Soc Trop Med Hyg. 1991; 85: 345Summary Full Text PDF PubMed Scopus (25) Google Scholar Around the same time those responsible for the Expanded Programme on Immunisation at WHO recognised that the 1990 goal of reducing deaths due to measles by 90% by the end of the decade would not be achieved by immunisation alone. Even with high immunisation coverage some children would contract measles, and in some countries it would prove difficult to achieve and sustain high coverage levels. The programme sought, therefore, to complement its immunisation activities with better management of the malnutrition, diarrhoea, and respiratory infections that are the usual underlying causes, or final insults, that lead to death attributed to measles. This evidence suggested that a more integrated approach to managing sick children was indicated and that child-health programmes needed to go beyond single diseases and address the overall health of the child. To many paediatricians this conclusion came late and as no surprise. It might be argued, however, that the specific attention to diarrhoeal diseases stimulated by the advent of oral rehydration therapy was enormously important in drawing international attention to child survival. Ten programmes of WHO, working with UNICEF and many other agencies, institutions and individuals, have responded to this challenge by developing the strategy known as Integrated Management of Childhood Illness (IMCI). The following sections describe briefly its content and its progress but also draw attention to the constraints faced in implementing such a strategy. Although the major stimulus to the development of IMCI may have come from the needs of curative care, the strategy combines improved management of childhood illness with aspects of nutrition, immunisation, and other important disease prevention and health promotion elements. The objectives are to reduce deaths and the frequency and severity of illness and disability and to contribute to improved growth and development. 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. The three components of the IMCI are: •Improvements in the case-management skills of health staff through the provision of locally adapted guidelines on integrated management of childhood illness and activities to promote their use•Improvements in the health system required for effective management of childhood illness•Improvements in family and community practices These components are supported by programme planning, including the selection of indicators and the setting of targets, and by evaluation. 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 simple questions to the child's caretaker and use of easily recognisable signs and symptoms. All sick childen are examined for “danger signs” suggesting that immediate referral or admission to hospital is needed. If those are absent, the child's mother or other caretaker is asked about the presence of cough, diarrhoea, fever, and ear problems in addition to the presenting complaint. In response to any positive reply the health worker asks further questions and examines for specific signs. The health worker is taught to proceed systematically to arrive at one or more disease classifications. These are not necessarily specific diagnoses but they indicate to the health worker what action needs to be taken. The classifications are colour coded: red calls for hospital referral or admission, yellow for initiation of treatment, and green means that the child can be sent home with careful advice on when to return. An example, for a child with cough, is shown in figure 2. The child's nutritional status is classified in a similar way and immunisation status is reviewed and updated as necessary. Finally the health worker assesses any other problems and asks the caretaker, usually the mother, about her own health. The treatment associated with each classification is clearly spelled out in a separate chart and uses a minimum of affordable essential drugs. Considerable emphasis is given to counselling in the IMCI approach. This includes age-specific counselling about breastfeeding and complementary feeding, home care for illness, and when the child should be brought in for follow-up. The mother's understanding of the advice is checked and, whenever possible, administration of the first dose of treatment is shown to the caretaker before the child is taken home. During development of the IMCI guidelines several elements were improved or validated by research and field-testing. These activities have been summarised in a series of 12 articles.8World Health Organization Integrated management of childhood illness: a WHO/UNICEF Initiative.Bull WHO. 1997; 75 (suppl)Google Scholar In addressing the main causes of child death it is essential to consider other causes of severe acute illness, such as meningitis and sepsis, and causes of fever such as ear infections. The assessment of malnutrition and measles both lead to eye examination and, if needed, to the management of vitamin A deficiency and conjunctivitis. These are examples of how the generic IMCI guidelines go well beyond the management of the five major diseases. The generic guidelines are not designed for immediate use. A guided process of adaptation ensures that the guidelines, and the training materials that go with them, are adapted to the needs of each country. The IMCI adaptation guide, developed by WHO, summarises the evidence behind the generic guidelines and gives some options that might be considered in different circumstances. It includes, for example, modifying the classification process in light of the local epidemiology of malaria, selecting first and second line antimicrobials taking into account local resistance patterns, the specification of appropriate foods and fluids, and the introduction of local terms for communicating clearly with caretakers. The adaptation process may also bring into consideration additional diseases. In south-east Asia, for example, most country adaptations have included dengue haemorrhagic fever in the section of the guidelines dealing with fever. In other instances management of the child with wheeze has been incorporated. The adaptation guidelines also consider the context where HIV/AIDS prevalence is high. Because application of the IMCI approach at first-level health services leads to the hospital referral of children, it is important also to improve care at the first referral level. WHO is currently completing a treatment manual, including inpatient care, for this level of the health services. It focuses on management of serious infections and severe malnutrition. 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 coverage with training and of introducing the other components of the strategy. Over 6000 health workers were trained in 68 countries during 1998. This is only a fraction of the health workers who need to be trained and a major challenge is how to achieve broad coverage with effective training. Most training has been given over 11 days using a locally adapted version of the WHO/UNICEF training course.9World Health Organization UNICEF Integrated management of childhood illness: training course for health workers at first-level health facilities (modules A-L). WHO, Geneva1997Google Scholar This emphasises hands-on practice in managing sick children and course facilitators monitor trainees' exposure to the most important clinical signs. In a well-planned course trainees have ample opportunity to practise classifying and treating larger numbers of sick children. Some countries implementing IMCI are experimenting with other training formats to replace or complement the 11-day course. Most trained health workers receive a follow-up visit at their place of work. This visit helps them apply their new skills, solve problems and collect information on initial performance. In some countries trained health workers have now been followed up for at least 6 months. Information collected shows that performance can be maintained at a reasonably high level but underlines the importance of periodic supportive supervisory visits. 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 availability of essential drugs, organisation of health-service delivery, incentives for and monitoring of health-worker performance, and the system of referral. A challenge for the coming years is to work with those responsible for these aspects of the health system to ensure that there is an environment in which health workers can apply their skills in child care. Perhaps the most pressing task is to strengthen activities directed towards the family and community. All families should know how to feed their children, how to prevent disease, how to respond to common illnesses (including knowing when to seek care), and how to follow treatment advice given by health workers. For the IMCI strategy to have an impact, improvements in the health services must be complemented by well-targeted interventions, of proven efficacy, in the community. This is all the more critical because treatment of sick children often starts in the home using locally purchased medicines. A common observation from countries implementing IMCI is that, although it is a significant advance for the health problems that it covers, this is not enough. More specifically, and especially in countries where good progress has been made in reducing childhood mortality, many of the child deaths still occurring are in the perinatal period. IMCI addresses a minority of these. Work is currently being done to improve the management of the sick young infant under the IMCI guidelines. In parallel guidelines on integrated management of pregnancy and childbirth are being developed which should also help address deaths in the first days of life. Another similar concern is that IMCI does not cover trauma and surgical conditions. A necessary starting point for developing this area of work is better documentation of the frequency of specific conditions and of the feasibility and effectiveness of simple approaches to dealing with them in developing countries. A significant threat to the impact of the IMCI on child mortality is HIV. Gains in some countries, especially in Africa, are now being eroded by the effects of AIDS on parents and on children themselves through mother-to-child transmission of the virus. Many of the episodes of acute childhood illness associated with HIV can be addressed through the IMCI approach. More needs to be done, however, to take this into account when implementing IMCI in countries of high HIV/AIDS Prevalence. 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 antihelminthic treatment, for example. Perhaps for this reason the question of whether IMCI works comes less often from those responsible for managing sick children day to day. They generally agree with the treatment guidelines and appreciate the systematisation of what constitutes a large part of their daily work. One question then may be-does training health workers in this way change their practices? The answer would seem to be yes, if training is well done and followed up. Early findings on selected case management indicators from three countries are summarised in the panel. However, high-quality in-service training is seen as expensive. Many countries are now interested in incorporating IMCI into the pre-service training of doctors, nurses, and other health professionals; 18 countries have started work on this.Panel 1Changes in selected indicators of health-worker performance after IMCI training Tabled 1Children assessed for changing health workers' practiceTiming of evaluationMoroccoVlet NamBoliviaDanger signsBefore training0/70N/A2/58 (3%)First follow-up32/36 (89%)19/55(36%)n/a5 mo latern/a30/48 (60%)n/a2 yrs of IMCIn/an/a31/80 (39%)All main symptomsBefore training12/70 (17%)n/a0/58First follow-up33/36 (92%)41/55 (75%)n/a5 mo latern/a37148 (77%)n/a2 years of IMCIn/an/a74/80 (93%)Nutritional/feeding statusBefore training14/70 (20%)n/a16/58 (28%)First follow-up32/36 (89%)17/55 (29%)n/a5 mo latern/a29/48 (66%)n/a2 years of IMCIn/an/a70/80 (88%)*n/a=not available, Sources: unpublished Information collected by Minister of Health and USAID/BASICS Project of using draft instruments prepared by the Interagency Working Group on IMCI Monitoring and Evaluation. Open table in a new tab Tabled 1Children assessed for changing health workers' practiceTiming of evaluationMoroccoVlet NamBoliviaDanger signsBefore training0/70N/A2/58 (3%)First follow-up32/36 (89%)19/55(36%)n/a5 mo latern/a30/48 (60%)n/a2 yrs of IMCIn/an/a31/80 (39%)All main symptomsBefore training12/70 (17%)n/a0/58First follow-up33/36 (92%)41/55 (75%)n/a5 mo latern/a37148 (77%)n/a2 years of IMCIn/an/a74/80 (93%)Nutritional/feeding statusBefore training14/70 (20%)n/a16/58 (28%)First follow-up32/36 (89%)17/55 (29%)n/a5 mo latern/a29/48 (66%)n/a2 years of IMCIn/an/a70/80 (88%)*n/a=not available, Sources: unpublished Information collected by Minister of Health and USAID/BASICS Project of using draft instruments prepared by the Interagency Working Group on IMCI Monitoring and Evaluation. Open table in a new tab *n/a=not available, Sources: unpublished Information collected by Minister of Health and USAID/BASICS Project of using draft instruments prepared by the Interagency Working Group on IMCI Monitoring and Evaluation. Another question is whether health services can support the costs, both in time and financial, of IMCI. It is often said that health workers, because of their workload, can see patients for only a few minutes. Clearly it is impossible to treat most sick children effectively in such a short time. The IMCI approach, with experience, can be completed in 10-15 min although some cases take longer. Better organisation of the flow of patients, better initial triage and keeping facilities open and staffed for the scheduled hours can help ensure that this time is available. Early information on drug costs from several countries suggests that those associated with IMCI are less than the costs of current practice.10Kolstad PR Burnham G Kalter H Kenya-Mugisha N Black RE Potential implications of Integrated Management of Childhood Illness (IMCI) for hospital referral and pharmaceutical usage in western Uganda.Trop Med Int Health. 1998; 3: 691-699Crossref PubMed Scopus (17) Google Scholar A broader question is whether the strategy as a whole is cost-effective. This question only makes sense if we also ask—compared with what? Certainly there would seem to be little point in comparing IMCI with a series of disease-specific initiatives. The clinical rationale for an integrated approach is strong and neither developing country ministries of health nor governments, agencies, and donors who fund child-survival efforts seem willing to support activities that target a single disease, unless eradication (smallpox) or elimination is in prospect. WHO and UNICEF are now implementing a multicountry evaluation of IMCI. The study will document the effect of IMCI interventions on health-worker performance, health systems and family and community practices. It will determine whether, and to what extent, the strategy has an impact on health outcomes and it will describe the costs of implementation. This study will require several years to produce answers but, given the strong commonsense arguments in favour of IMCI, it is hoped that support will continue during this critical phase of early implementation and evaluation. In the meantime efforts are being made to put in place routine monitoring and evaluation mechanisms in all countries implementing IMCI. 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 approaches being promoted and, taking into consideration often severe resource constraints, to seek efficiency through better coordination of their implementation. It has been assumed by some that the driving incentive behind plans for integrated approaches coming from decision makers and funders is to save money. While improved efficiency is certainly desirable, it is rare in developing countries to find a situation that warrants a reduction in the overall level of support for child health activities. It is, therefore, sometimes feared that integration will simply produce demands to do more with the same, limited, budgets. There is some evidence to justify this concern. Integration of child health programmes at country level generally leads to a reduction of personnel, and funding of IMCI may be achieved simply by renaming a line in a ministry of health's budget previously earmarked for one disease, without any increase in resources. The risk is also real globally. The division of WHO Headquarters with primary responsibility for IMCI has its origins, in 1980, in the diarrhoeal disease control programme, the first disease-specific programme to target the reduction of childhood mortality. Despite the progressive expansion of the responsibilities of the division (now the Department of Child and Adolescent Health and Development), the level of funding available to it has remained, in real terms, almost unchanged for the past 15 years. This would certainly appear to support the hypothesis that integration is seen as an opportunity to cover more topics without increasing resources. From the perspective of those doing the work, this is an unfortunate consequence of following a course which, because it has a sound technical and programmatic basis, should be rewarded rather than penalised. 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 diseases. Often, these too are aimed at more than one disease.