Academic journal article Bulletin of the World Health Organization

Integrated Management of Childhood Illness by Outpatient Health Workers: Technical Basis and Overview

Academic journal article Bulletin of the World Health Organization

Integrated Management of Childhood Illness by Outpatient Health Workers: Technical Basis and Overview

Article excerpt


Infant and young child mortality remains unacceptably high in developing countries, with about 12 million deaths occurring annually in under-5-year-old children; 7 in every 10 of these deaths are due to diarrhoea, pneumonia, measles, malaria or malnutrition, and often a combination of these conditions (Fig. 1), which are also the reason for seeking care for at least three out of four sick children who come to a health facility. Staff in such facilities are already treating these conditions and adequate clinical skills are essential to improve the care. Since potentially fatal illnesses in children are often brought to the attention of health workers at first-level health facilities, the initial focus of the integrated management of childhood illness (IMCI) has been on improving their performance through training and support.


The lessons learned from disease-specific control programmes have been used to develop a single efficient and effective approach to managing childhood illness. A number of programmes in WHO(a) and UNICEF(b) have collaborated in developing this approach, which is described as integrated management of childhood illness (IMCI) but has also been referred to as integrated management of the sick child (1, 2). These efforts are coordinated by WHO's Division of Child Health and Development (CHD). The guidelines and training materials that have been developed are appropriate for application in the majority of developing countries where infant mortality is [is greater than] 40 per 1000 live births and where there is transmission of Plasmodium falciparum malaria. They represent an attempt to express as simply as possible what needs to be done in a first-level outpatient health facility by any health worker -- doctors, medical assistants, nurses and literate paramedical workers, to treat children in order to reduce mortality or to avert significant disability (Table 1). In addition to the IMCI clinical training course, a course has been developed to improve drug supply management at first-level health facilities.(c) Improvements in other aspects of health service infrastructure that are needed for effective management of childhood illness are also envisaged within the IMCI strategy. At the same time, work is ongoing on approaches to changing family behaviour in relation to sick children and the development of guidelines and training materials for hospital care at the referral level.

Table 1: Child health interventions included in integrated
management of childhood illness

Case management interventions          Preventive interventions
  * Pneumonia                            * Immunization during
  * Diarrhoea                               sick child visits (to
  -- Dehydration                          reduce missed
  -- Persistent diarrhoea                 opportunities)
  -- Dysentery
  * Meningitis, sepsis                  * Nutrition counselling
  * Malaria                             * Breastfeeding support
  * Measles                               (including the
  * Malnutrition                          assessment and
  * Anaemia                               correction of
  * Ear infection                         breastfeeding

The IMCI guidelines rely on detection of cases based on simple clinical signs, without laboratory tests, and offer empirical treatment. A careful balance has been struck between sensitivity and specificity using as few clinical signs as possible, which health workers of diverse backgrounds can be trained to recognize accurately. The guidelines for the assessment and classification of childhood illness (often referred to as an algorithm) have been refined through research and field tests in the Gambia (3), Kenya (4), Ethiopia (5), and United Republic of Tanzania (6), as well as studies on the usefulness of certain clinical signs in the detection of anaemia (9, 10) and malnutrition (11). …

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