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Policy and programme lessons from the Multi-Country Evaluation (MCE) of IMCI

The MCE Team

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IMCI*:Good health for children

Health systems

Health worker performance

Families and communities*Integrated Management of Childhood Illness

Neonatal, 33%

Diarrhea, 22%

Pneumonia, 21%

Malaria, 9%

AIDS, 3%

Measles, 1%

Others, 11%

Malnutrition52%

3

MCE Objectives

Document IMCI implementation

Measure IMCI impact on health and nutrition

Evaluate the cost-effectiveness of IMCI

Provide feedback to policy makers

4

Major impact on child health and nutrition was expected at country

level

Improved health/nutrition

Reduced mortality

Improved household

compliance/care

Improved careseeking &

utilization

Improved quality of care in

health facilities

Improved preventive practices

Training of health workers

Health system improvements

Family and community

interventions

Increased coverage for curative & preventive interventions

Introduction of IMCI

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MCE in-depth studies

• Bangladesh: – efficacy RCT of 10 IMCI x 10 comparison areas

• Tanzania: – pre-post comparison of 2 IMCI x 2 comparison

districts

• Brazil: – comparison of 32 IMCI x 32 comparison municipalities

• Uganda: – pre-post dose-response analysis of IMCI strength of

implementation in 10 districts

• Peru: – as in Uganda, for 25 departments

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MCE step-wise approach

Are adequate services being provided?

at health facility level?

at community level?

Are these services being used by the population?

Have adequate coverage levels been reached in the population?

Is there an impact on health and nutrition?

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IMCI leads to improvementsin health worker performance

Source: Paryio G, Schellenberg J et al

19

69

56

72

16

65

13

29

0

20

40

60

80

100

% c

hil

dre

n c

orr

ec

tly

ma

na

ge

d

Bangladesh NE Brazil Tanzania Uganda

Non-IMCIIMCI

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And can improve care quality at no extra cost

Total spending on child health, Tanzania ('000s 1999 US$)

393

496

IMCI Non-IMCI

Results from the Brazil MCE confirm thatIMCI does not cost more than routine care

Cost per child correctly managed, Tanzania (1999 US$)

$4

$25

IMCI Non-IMCI

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Is IMCI being provided at health facility level?

High training coverage has been reached in defined geographical areas

Quality of training is usually good

Difficulties in going to scale in relation to staff turnover and maintaining of quality of training

Need for health systems supportDrugs

Supervision

Referral

District management skills

10

41

15

8

Tanzania

Uganda

Bangladesh

Utilization is often too low to achieve impact through

facility-based services alone

% sick children who were taken first to a government facility

Source: Arifeen S, Paryio G, Schellenberg J et al

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In Bangladesh, IMCI is associated with increases

in health facility utilization

Data source: MCE-Bangladesh, Routine MIS and GoB MIS

But no other MCE site was able to replicate this effect……

0

1

2

3

4

5

Jul

Sep

No

v

Jan

Mar

May Ju

l

Sep

No

v

Jan

Mar

May Ju

l

Sep

No

v

Jan

Mar

May Ju

l

Sep

No

v

Jan

Mar

May

Sic

k U

5 C

hild

ren

pe

r c

hild

pe

r y

ea

r

IMCI Intervention IMCI Comparison

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But coverage for key community interventions

remains low in most countries

Population coverage for key family practices

Uganda MCE – 10 districts

40

11

3336

15

32

0

25

50

75

100

Child with feverreceived antimalarials

Child slept underbednet last night

Measles vaccination

2001 2002

Source: Paryio G et al

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In Peru, facility and communityIMCI were not implementedin the same departments

0

20

40

60

80

100

120

0 10 20 30 40 50 60

Trained clinical health workers (%)

Trai

ned

CHW

s pe

r 10,

000

child

ren

Source: Huicho L et al

Each dot representsone department

Departmental coverage of IMCI-trained clinical and

community workers (2003)

Similar resultsin Tanzania

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Is IMCI being provided at community level?

Implementation is spotty and uncoordinated with health worker training

Community case-management interventions not included

Community IMCI includes too many messages

These findings have helped generate increased focus on the implementation of community component of IMCI

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Did IMCI have an impact on mortality?

16

10

15

20

25

30

35

1999-00 2001-02

An

nu

al

mo

rta

lity

ra

te

Morogoro (IMCI) Rufiji (IMCI)

Ulanga Kilombero

Tanzania: underfive mortalitywas 13% lower in the

two IMCI districts

Source: Schellenberg J et al

Full IMCIin HF

End ofstudy

13% difference95% CI: -7%, 30%

Significant impact on stunting

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IMCI clinical training coverage (%) and underfive mortality reduction

0

10

20

30

40

50

60

0 20 40 60 80

Training coverage

Mo

rta

lity

re

du

cti

on

(%

)IMCI: No apparent impact in Peru

r= 0.048P= 0.824

Similar results in Brazil and Uganda

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Summing up (1)

• IMCI improves quality of care• IMCI does not increase overall costs

– Either for providers or out-of-pocket

• IMCI dramatically reduces cost per child managed correctly

• IMCI is the gold standard for facility care of children aged 7 days – 5 years

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• IMCI can have an impact on mortality and nutrition

• But this requires:– Strengthening health systems– Reaching out to the community

• IMCI was least likely to be implemented well where it was needed most

Summing up (2)

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What the MCE has contributed

• Feedback at national level

• Repositioning IMCI in the context of child survival by WHO and other agencies

• Lancet Child Survival Series + 30 papers

• Increased advocacy for child survival

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What the MCE has contributed

• The MCE showed that having interventions is not enough

• The real challenge is how to deliver these interventions to those who need them most

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IMCI and child health

• From MCE we know IMCI works in facilities!

• Requires adequate attention to health systems support and community coverage

• MCE was not able to evaluate the effectiveness of the community component of IMCI

• IMCI, as originally constructed, may not be the answer in every setting

• IMCI is evolving!

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Scaling up IMCI The Bangladesh experience

• Since these results first came out, IMCI has been scaled up to almost a fifth of Bangladesh, especially in high mortality areas

• Quality of training and performance outcomes have been maintained

• Initial focus on facility-based services, with increasing inclusion of health systems support and community interventions

• Shift from strategy to programme

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IMCI and child health

IMCI

CHILDHEALTH AND NUTRITIONSTRATEGY