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

The MCE Team 1

Health systems Health worker performance

Others, 11% Measles, 1% AIDS, 3% Malaria, 9%

IMCI*: Good health for children

Neonatal, 33% Pneumonia, 21% Diarrhea, 22%

*

I

ntegrated

M

anagement of

C

hildhood

I

llness

Families and communities

2

MCE Objectives

    Document IMCI implementation Measure IMCI impact on health and nutrition Evaluate the cost-effectiveness of IMCI Provide feedback to policy makers 3

Major impact on child health and nutrition was expected at country level

Introduction of IMCI Health system improvements Training of health workers Improved quality of care in health facilities Family and community interventions Improved household compliance/care Improved careseeking & utilization Improved preventive practices Increased coverage for curative & preventive interventions Improved health/nutrition Reduced mortality 4

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 5

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 improvements in health worker performance 100 80 60 69 56 72 65 40 20 19 16 0 Bangladesh NE Brazil

Source: Paryio G, Schellenberg J et al

Tanzania Non-IMCI IMCI 13 29 Uganda

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And can improve care quality at no extra cost Total spending on child health, Tanzania ('000s 1999 US$) 496 393 Cost per child correctly managed, Tanzania (1999 US$) $25 IMCI Non-IMCI $4 IMCI Non-IMCI Results from the Brazil MCE confirm that IMCI does not cost more than routine care

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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 support Drugs Supervision Referral District management skills 9

Utilization is often too low to achieve impact through facility-based services alone % sick children who were taken first to a government facility Bangladesh 8 Uganda 15 Tanzania

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

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10

In Bangladesh, IMCI is associated with increases in health facility utilization IMCI Intervention IMCI Comparison 5 4 1 0 3 2

Data source: MCE-Bangladesh, Routine MIS and GoB MIS But no other MCE site was able to replicate this effect…… 11

100

But coverage for key community interventions remains low in most countries Population coverage for key family practices Uganda MCE – 10 districts

75 50

40 2001 2002 36

25

15 11

0 Child with fever received antimalarials Source: Paryio G et al Child slept under bednet last night

33 32

Measles vaccination 12

In Peru, facility and community IMCI were not implemented in the same departments

120 100

Departmental coverage of IMCI-trained clinical and community workers (2003)

80 60 40 20 Each dot represents one department Similar results in Tanzania 0 0 10 20 30 40 Source: Huicho L et al

Trained clinical health workers (%)

50 60 13

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 14

Did IMCI have an impact on mortality?

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Tanzania: underfive mortality was 13% lower in the two IMCI districts

35 30 25 20 15 10 Full IMCI in HF 13% difference 95% CI: -7%, 30% 1999-00

Morogoro (IMCI) Ulanga

End of study 2001-02

Rufiji (IMCI)

Significant impact on stunting

Kilombero

Source: Schellenberg J et al 16

IMCI: No apparent impact in Peru

60 50 40 30 20 10 0 0

IMCI clinical training coverage (%) and underfive mortality reduction

Similar results in Brazil and Uganda 20 40

Training coverage

60 r= 0.048

P= 0.824

80 17

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 18

Summing up (2)

• 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 19

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 20

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 21

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 23

IMCI and child health CHILD HEALTH AND NUTRITION STRATEGY IMCI

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