Description of the condition

More than 7.5 million children globally die each year before reaching the age of five. Most of these deaths occur in low‐ and middle‐income countries (LMICs) (Black 2003; Liu 2012), where interaction of common infections (including neonatal sepsis, measles, diarrhoea, malaria, and pneumonia) with poor nutritional status, combined with inadequate health infrastructure and poverty, results in poor health outcomes (Liu 2012; Tulloch 1999). Statistical projections over the past decade suggest that these common childhood illnesses will continue to be major contributors to the child morbidity and mortality burden until 2020 (Murray 1996). These projections have been uncannily accurate, as shown by recent mortality data (WHO 2012), providing a strong case for introducing new strategies to tackle problems contributing to poor outcomes.

In addition to overall high child mortality globally, there are large differences in mortality between countries, with earlier studies indicating that 95% of global mortality happens in 42 less‐developed countries (Victora 2003); there are also differences in mortality between socio‐economic groups within countries. Children who belong to the more underprivileged sections of society are more likely to suffer from malnutrition and to experience greater severity of illness and higher mortality (Black 2003; Victora 2003). These inequalities are reflected in the quality of health care received. Studies have shown that at first‐level health facilities in LMICs, assessment by health care workers is poor, treatment facilities are inadequate, and parents receive improper advice (Barros 2012; World Health Organization 1998).

Providing quality care to sick children in LMICs is important. Effective and affordable interventions have been known to reduce childhood morbidity and mortality for some time, but their availability, accessibility, and acceptability to the ultimate beneficiaries have been unacceptably low (Bryce 2003; Jones 2003).

Description of the intervention

Individual health interventions shown to be effective in reducing child mortality include exclusive breast feeding, improved vaccination coverage, oral rehydration therapy, pneumonia therapy, and early treatment for malaria in endemic areas (Bhutta 2008; Markowitz 1991; Mathew 2011; Thwing 2011). However, children presenting to first‐level health facilities seldom present with a single ailment. The presence of multiple and overlapping morbidities makes diagnosis and treatment difficult for the health care worker. Although each of these interventions has been individually shown to be effective, it has gradually become clear to health care planners that a more integrated approach is needed to achieve better outcomes. This has resulted in a policy push toward a multi‐pronged strategy aimed at integrating improved health care services with better case management skills and healthier community practices to reduce child mortality and morbidity (WHO 1996). Health care packages that aim to integrate these components of health care strategy have been designed and implemented at community, national, and international levels. In the mid‐1990s, the World Health Organization (WHO), in collaboration with the United Nations Children's Emergency Fund (UNICEF) and other agencies, developed a strategy known as integrated management of childhood illness (IMCI) in response to these challenges.

The IMCI strategy includes both curative and preventive interventions targeted at improving health practices at health care facilities, at home, and in the community. This strategy includes three main components (Tulloch 1999): (1) improvement in the case management skills of health care staff through provision of locally adapted guidelines on IMCI and activities to promote their use; (2) improvement in the overall health care system required for effective management of childhood illnesses; and (3) improvement in family and community health care practices.

In 1995, WHO technical programs and partners, supported by sound research, introduced case management guidelines for IMCI (WHO 1997), with a core intervention targeting five of the most important causes of child mortality: acute respiratory infection (ARI), diarrhoea, measles, malaria, and malnutrition. The following year, a training program was targeted at first‐level health care workers. These case management guidelines were adapted to local epidemiology and clinical practice, and training of the first health care workers started in 1995. This was followed by a short period of exploratory implementation and documentation in a small number of countries (Lambrechts 1999). After an initial pilot phase, IMCI was introduced in Tanzania and Uganda in 1996 (Bryce 2005). Results from these two countries were encouraging, with improvements noted in quality of care and health care worker practices (Lambrechts 1999). In the early phase of its implementation, IMCI was focused on training health care workers, with less attention paid to the other two components, namely, strengthening health care systems and improving community practices. Initial guidelines and training materials were considered appropriate for countries with an infant mortality rate greater than 40/1000 live births, and with documented transmission of Plasmodium falciparum malaria. The guidelines and training materials represented an attempt to outline what needed to be done at a first‐level health facility by any health worker ‐ doctor, nurse, or paramedical worker ‐ seeking to treat sick children while reducing mortality.

Upon receipt of an encouraging response from partner organizations, various countries, and the World Bank, the WHO provided a detailed blueprint of a three‐phase rollout for countries wishing to adopt IMCI (WHO 1999). The process consisted of the introduction phase, the early implementation phase, and the expansion phase. The purpose of the introduction phase is to ensure that policymakers understand IMCI. This involves initiating contact to provide information, holding orientation meetings, and building national capacity in IMCI. In the early implementation phase, health care staff conduct and monitor IMCI activities in a limited number of districts to study impact. Other issues studied during this phase include the relationship of IMCI to other health care sector activities, drug availability, and policy and supervision. The expansion phase involves increasing access to interventions introduced in the first two stages. The WHO and collaborating agencies provide technical assistance in preparation for early implementation of IMCI.

Anecdotal data, qualitative reviews, and systematic reviews from various countries suggest that IMCI has been effective in improving health service quality and increasing health care cost savings (Ahmad 2010; Amaral 2008). Since its introduction, IMCI has been taken up by numerous countries, initially as a pilot project, and later as a national program. The three components of IMCI have been implemented in various ways in different countries. Key features of IMCI include its evidence‐based approach to diagnosis and treatment and its flexibility in terms of adapting guidelines to local epidemiological situations. The adaptation process involves detailed comparisons of existing guidelines in a country with IMCI and application of the most effective components of both. Consensus is needed on the conditions that should be covered. Malaria can be removed from guidelines in which falciparum malaria is not a problem. Other countries have included dengue fever as an important problem. IMCI has already been adapted to include the neonatal period, and some countries, like India, have incorporated neonatal care in implementation of the program. Selection of antibiotics for ARI and diarrhoea is based on local sensitivity patterns and availability. Some countries have shortened the duration of training to reduce costs. In many countries, especially in sub‐Saharan Africa, HIV/AIDS contributes significantly to child morbidity and mortality, resulting in the need to include specific assessment and management of symptomatic HIV infection in IMCI guidelines. A draft HIV component of the IMCI guidelines, which included management of symptomatic HIV cases with referral for counselling and testing, was evaluated in South Africa. A revised version was then validated in Ethiopia and Uganda, where prevalence of HIV, malnutrition, and malaria is different from South Africa. IMCI materials were then adapted to include an HIV component (Qazi 2006). The WHO has formulated an Adaptation Guide to describe the process of adaptation by a country and facilitate continuous evolution of the program (WHO 1999a).

Large‐scale rollout and continuation of IMCI require money. In several countries, external donors have largely funded IMCI implementation. Within 10 years, donor support began to wane, leaving health departments of poor countries with inadequate funds (Duke 2009). Indeed the places where IMCI is needed most, and in which it provides the greatest impact, are those in which the health care system is weakest and implementation of the strategy often fades. Therefore, it is important to ensure adequate development along with the introduction of newer innovations. A global study conducted across 27 countries cited high cost as a major challenge to scaling up of the program (Goga 2011). Apart from modifications such as shortening of training duration, new technology such as the IMCI computerized adaptation and training tool (ICATT) is being introduced. Trials are currently under way to assess the effectiveness of these tools.

How the intervention might work

The IMCI clinical guidelines target children up to five years of age ‐ the age group that bears the greatest burden of death from common childhood diseases. These guidelines are derived from an evidence‐based, syndromic approach to case management and emphasize rational, effective, and affordable use of drugs and diagnostic tools (Gove 1997; Hill 2004). With well‐formulated guidelines and proper training of health care workers, it would be possible to systematically assess common symptoms and clinical signs, ultimately leading to rational and effective actions. Such an approach can help in diagnosing the clinical condition, assessing the severity of the condition, and implementing actions that can be taken to care for the child (e.g. refer the child immediately, manage within available resources, manage at home).

Initially, IMCI referred to case management of children. It later became a vehicle for WHO and UNICEF child survival strategies at household, community, health facility, and referral levels. Thus it incorporated health service strengthening on the one hand and, on the other hand, face‐to‐face nutrition and health advice provided through home visits and active involvement of family members and the community in the health care process (Gove 1997; Hill 2004). Thus, over the years, implementation of IMCI, called the IMCI strategy, has come to include three components.

• Training component: training of health care workers in clinical care with the use of IMCI guidelines.

• Systems component: investment in health care systems organization and management, including supplies, related specifically to delivery of IMCI.

• Community health component: Auxiliary health care staff and community health care workers attached to clinics conduct home visits and community health promotion to promote good child rearing practices, good nutrition, and access to services when the child is ill (Hill 2004).

Why it is important to do this review

Currently, more than 75 countries are implementing the IMCI strategy on a large scale. For years, individual aspects of child health, often contained within trials evaluating the efficacy of one intervention, have been carried out, for example, in vitamin A supplementation. Individual components of IMCI have often been tested and have proved effective in rigorously conducted randomised controlled trials and systematic reviews. However, it is unclear whether delivery of this package impacts hard outcomes such as mortality. As provision of IMCI is expensive, solid evidence of an impact on child health contributes to continued provision of political and financial support of this comprehensive child health strategy.

Global evaluation of IMCI, called "the multi‐country evaluation of IMCI," was started in the early 1990s to generate information on effectiveness, cost, and impact, alongside other initiatives, such as the IMCI evaluation by the Centers for Disease Control and Prevention (CDC) (Schellenberg 2004); investigators reported across five study sites (WHO 2002). Other reviews have described health care worker performance as the primary outcome indicator (Amaral 2008) or have assessed the impact of the duration of training for IMCI (Rowe 2008), thereby not analysing the impact of the intervention on beneficiaries. A comprehensive systematic review is therefore required to evaluate the effectiveness of IMCI in improving child health (as measured by mortality or nutritional status), its impact on the quality of care delivered, and whether basic healthy practices delivered by caregivers improve.