Post on 10-Mar-2018
Integrated Management
of Childhood Illness
(IMCI)
Dr. med. Carsten Krüger MIH, FRCPCH
Heidelberg, 14.10.2017
Acknowledgement
The following slides were provided by PD Dr.
M.W. Weber, MD, PhD, DTMH / WHO,
Copenhagen:
6, 10-17, 20, 21, 29-35, 47 (not all are shown
in this presentation, but are included in the
PDF file)
2
IMCI - Origin and Aims
• Developed by WHO and UNICEF in the early 1990s.
• Emerged from single intervention programmes such
as ARI, Control of Diarrhoeal Disease (CDD) and EPI
programmes.
• Aimed at countries with high U5MR > 40/1000.
• Intended for the outpatient departments in primary
health care facilities as most patients are seen there.
• Main aim: to reduce under-five mortality significantly.
• 1996 started in Tanzania and Uganda.3
• Concept based on existing knowledge and validated
by scientific studies.
• The studies demonstrated the practicability=efficacy
of IMCI.
• The studies demonstrated the efficiency of IMCI
(within the studies).
• Effectiveness in the community („the real world“) has
been evaluated (MCE).
IMCI - Origin and Aims (2)
4
Why IMCI? (1)
• Morbidity and mortality in
children < 5 years were still
unacceptably high (> 12 mio.
deaths in 1990, 6.6 mio.
deaths in 2012).
• Many children presented
with more than one symptom
and/or suffered from several
diseases at the same time.
• Many (vertical) intervention
programmes worked outside
the normal health system.
Liu L et al., Lancet
2012; 379: 2151-61
IMCI-MCE
Progress Report
2002
5
Presenting Complaints and Underlying
ConditionsPresenting complaint Possible cause or associated condition
Cough and/or fast breathing
Lethargy or unconsciousness
Dehydration
“Very sick” neonate/young infant
Pneumonia
Malaria, severe anaemia
Heart disease
Cerebral malaria
Meningitis
Severe dehydration
Very severe pneumonia
Gastroenteritis
Severe malaria
Severe pneumonia
Sepsis
Pneumonia
Meningitis
Sepsis 6
Why IMCI? (2)
• This new integrated approach should concentrate on
the most common and/or most serious diseases in
childhood presenting to the outpatient department at
first-level facilities.
– Pneumonia, diarrhoea, febrile illnesses (malaria,
measles), malnutrition, perinatal problems
• The diseases should be easy to diagnose and treat.
Referral to higher levels of care should be provided
in case that the child suffers from a life-threatening
condition.
8
Why IMCI? (3)
• The reality of the health systems (scarceness of all
kinds of resources) should be considered.
– Minimally-trained staff, limited laboratory facilities, scarce
drugs and equipment
– Many sick children are not properly treated, the parents
are poorly advised
9
Common Problems That Affected the
Quality of Care Provided to Sick Children
at First Level Health Facilities
• Health workers skills– incomplete examinations and counselling
– poor communication between health workers and parents
– irrational use of drugs
• Health system issues– location of health services and responsibility (centralisation)
– availability of appropriate drugs and vaccines
– supervision / division of labour / organization of work
– delayed care seeking
• Community and family practices (“community IMCI”)– poor knowledge of when to return to a health facility
– seeking assistance from unqualified providers
– poor adherence to health worker advice and treatment 10
IMCI Components and Intervention Areas
Improve health
worker skills
Improve health
systems
Improve family &
community
practices
Case management standards & guidelines
Training of facility-based public health care providers
IMCI roles for private providers
Maintenance of competence among trained health workers
6
6
6
6
Appropriate careseeking
Nutrition
Home case management & adherence to recommended treatment
Community involvement in health services planning & monitoring
6
6
6
6
District planning and management
Availability of IMCI drugs
Quality improvement and supervision at health facilities
Referral pathways and services
Health information system
6
6
6
6
6
WHO UNICEF
Technical support to countries
11
Interventions Included in the IMCI
Guidelines for First-Level Health Workers
Acute respiratory infections
Diarrhoea
Dehydration
Persistent diarrhoea
Dysentery
Meningitis
Sepsis
Malaria
Measles
Malnutrition
Anaemia
Ear infection
HIV/AIDS
Dengue haemorrhagic fever
Wheeze
Sore throat
Neonate
Conditions covered by
Case Management
Interventions
Immunisation during sick child visits
Nutrition counselling
Breastfeeding support
Vitamin A supplementation
Maternal health issues
Periodic deworming
Preventive Interventions
Generic Version
Using the IMCI
Adaptation Guide
12
IMCI Implementation (1)
• Inclusion of IMCI into the national health policy
programme.
• Adaptation of the standard IMCI guidelines to natio-
nal/local circumstances (e.g. special diseases like
dengue fever, drugs, language, etc.).
• Training of health personnel in diagnosis, treatment and
counselling (initially 11-day training course).
• Improvement of supply with drugs and medical
equipment in health institutions.
• Improvement of health care in the district and referral
hospitals. 18
IMCI Implementation (2)
• Prevention campaigns in the communities.
• Family counselling and training in prevention,
hygiene, early recognition and treatment of
common childhood diseases at home.
• Family counselling about the necessity to bring
sick children early enough to the attention of health
personnel in health centres and/or hospitals.
19
Time Frame
Steps for introduction of IMCI at country
level
12 to
18 months
> 5 years
}Introduction
Early implementation
Expansion of the range of
activities and geographical
coverage
20
Implementation of IMCI early 1996
Brazil
Bolivia
Ecuador
Peru
Ethiopia
Madagascar
Niger
Tanzania, U.R.Uganda
Zambia
Nepal
Philippines
Indonesia
Viet Nam
14 Countries
21
Implementation of IMCI Dec. 2006
25
Implementation of IMCI Dec. 2009
27
The IMCI Approach
• Focus on children < 5 years.
• Signs and symptoms are asked for systematically (danger
signs first).
• Thorough physical examination of each child with simple
equipment.
• Classification according to IMCI charts.
• Diseases are treated systematically.
• Immunisation and nutrition counselling are integrated.
• Counselling of the caretaker.
• Follow-up visits are pre-defined.
• Referral criteria to a higher level of care are defined. 28
YELLOWTreatment & follow-up
Assess for DANGER SIGNS:
Convulsions
Lethargy/Unconsciousness
Inability to Drink/Breastfeed
Vomiting everything
Assess for OTHER PROBLEMS
Assess MAIN SYMPTOMS:
Cough/Difficulty Breathing
Diarrhoea
Fever
Ear Problems
Assess NUTRITION, IMMUNIZATION
STATUS & POTENTIAL FEEDING
PROBLEMS
CLASSIFY CONDITIONS
& IDENTIFY TREATMENT ACTIONS
OUTPATIENT HEALTH FACILITY
The Integrated Case Management Process
34
Urgent
attention &
referral
PINKReferral
GREENHome
Finding Classification Treatment
Danger signs Severe disease Urgent referral
Cough or difficulty in
breathing Severe disease Urgent referral
Diarrhoea Disease with specific
therapy
Specific medical treatment
Fever
Ear problem Disease without specific
therapy
Symptomatic treatment
Nutritional status/
anaemia
Vaccination status Complete/incomplete Vaccinate
Assess and Classify
35
36
Which signs have the highest prediction of
severe neonatal illness?
• 12 symptoms:
- sensitivity 87%
- specificity 74%
The Young Infants Clinical Signs Study
Group, Lancet 2008; 371: 135-42
• 7 symptoms:
- sensitivity 85%
- specificity 75%
37
38
39
Advanced Treatment Guidelines
40
• 10-20% of children seen in outpatient settings
need referral to hospitals for inpatient care.
• Mainly for severe infections, severe malnutrition
and neonatal problems.
• WHO guidelines for hospital care in children
ensure high-quality care.
• Smartphone App
– Android phones:
https://play.google.com/store/apps/details?id=au.org.rch.
hospital CareForChildren
– iTunes, iPhone and iPads:
http://appshopper.com/medical/who-e-pocketbook-of-
hospital-care-for-children
WHO 2012 WHO 2005 + 2013WHO 2000
Advanced Treatment Guidelines
41
Results of IMCI
• In several countries successes and failures of IMCI
were analysed in order to improve the approach and
outcome.
• Results from Bangladesh, Brazil, Peru, Tanzania
and Uganda available.
• Besides medical analyses, health systems, cost and
management analyses were conducted, too.
Multi-Country Evaluation
(MCE)
42
IMCI improves the quality of health
workers
Paryio G, Schellenberg J et al., MCE-IMCI
19
69
56
72
16
65
13
29
0
20
40
60
80
100
% c
hild
ren
co
rrectl
y m
an
ag
ed
Bangladesh NE Brazil Tanzania Uganda
Non-IMCIIMCI
43
IMCI in Tanzania
• 1996/1997 started in 2 districts.
• Very good scientific evaluation.
• Despite large investments and good
infrastructure U5MR reduced by 13% only
(instead of > 50% as anticipated; n.s.).
Schellenberg JA et al., Lancet 2004; 364: 1583-94
44
IMCI in Tanzania
IMCI-MCE Progress Report 2001 46
IMCI in
Bangladesh
Arifeen et al., Lancet 2004; 364: 1595-602
• Index for correct
assessment/classifi-
cation in IMCI area
73 compared to 17
in non-IMCI area.
• Index for correct
treatment in IMCI
area 54 compared
to 9 in non-IMCI
area.
48
• Use of IMCI facilities increased from 0.6 visits/
child/year to 1.9 after 21 months of IMCI
implementation.
• 19% of children in
IMCI area were
taken to trained
health care provi-
der compared to
9% in non-IMCI area (data not shown).Arifeen SE et al., Lancet 2004; 364: 1595-602 49
IMCI in Bangladesh
IMCI in Bangladesh
Arifeen SE et al., Lancet 2009; 374: 393-403
• Mortality rates per 1000 live births for children aged 7 days to
59 months dropped in IMCI and comparison areas strongly.
• In last 2 years in IMCI 13% less mortality (n.s.). 50
• Proportion of
children ill
during the
last two
weeks who
were taken
to an
appropriate
health care
provider
IMCI in Bangladesh
Arifeen SE et al., Lancet 2004; 364: 1595-602 51
IMCI in Peru
• Introduced in 1996, early implementation
phase 1997, expansion 1998.
• Still IMCI not institutionalised in Peru, parallel
system to ARI/diarrhoea control.
• Trained health staff in IMCI only about 10%.
• Districts with intense training in clinical
component not the same as those with
training in community component.
Huicho L et al., Health Policy & Planning 2005; 20: 14-24 54
Is IMCI failing? - Tanzania
Walter ND et al., Bull WHO 2009; 87: 99-107 56
Is IMCI failing? - South Africa
Horwood C et al., PLOS ONE 2009; 4: e5937 58
Achievements
• Reduction of under-five mortality (not significant).
• Health workers’ performance significantly better.
Sustainable over 3 years.
• Improved standard and increased utilisation of the
health system in some countries.
• Reduced use of antibiotics.
• No increased costs.
59
Shortcomings (1)
• Neonatal care and HIV/AIDS initially not included.
• Epidemiology of HIV, malaria and other infectious
diseases as the main killer diseases has changed
significantly.
• Adaptation process often too slow.
• Sub-optimal staff adherence to the guidelines for
diagnosis, treatment and referral.
• Referral for more severely ill children often
difficult.
60
Shortcomings (2)
• Training of insufficient numbers of staff.
• Rapid change of staff at the sites.
• Lack of supervision and re-training.
• Health system improvement difficult.
• Exclusion of non-governmental health care
institutions during the training process detrimental
to access rates to IMCI-trained providers.
• Only minimal implementation of the community
component of IMCI which would improve care-
seeking behaviour. 61
Summary and Conclusions (1)
• IMCI can improve health care for children if
health systems are reasonably functioning.
• Quality and utilisation of health institutions must
be improved further immediately (supervision of
staff, improvement of health systems etc.).
• IMCI expansion is mandatory.
• Accessibility for poor groups must be improved.
• Education, counselling and training of parents
and families must be advanced.62
Summary and Conclusions (2)
• The community-component of IMCI and health
system quality are critical components for
success or failure of the strategy.
• Other reasons for failure
– Lack of political commitment to importance of IMCI
– Lack of funding
– Lack of coordinated training (medical/nursing
schools etc.)
See also: Chopra M et al. Integrated management of childhood illness: what
have we learnt and how can it be improved? Arch Dis Child 2012; 97: 350–35463
Key Messages
• The IMCI approach to reduce under-five mortality is
evidence-based and works in principle.
• Implementation and improvement of all three basic
components (health workers’ performance and
quality of care; health systems; family and
community practices) is mandatory.
• Renewal of political and stakeholder support is
essential for long-term success.
64