Session 2

IMCI Overview

1
 Learning Objectives
By the end of the session, the students will be
able to:
(1)explain the rationale for integrated
management of childhood illnesses;
(2) specify the objectives of IMCI;
(3) describe the different components of IMCI;
(4) enumerate the benefits of IMCI

2
 Distribution of 10.5 million
deaths among children less than 5 years
old in all developing countries, 1999

Malaria

Diarrhea

Undernutrition Measles
54%
Pneumonia

Perinatal

OTHERS
3
 Stagnating Decline in Childhood
Mortality Rates – Philippines, 2003 NDHS

Figure 1: Trend in Early Childhood Mortality Rates

80

72

60

52
46
43 42
40

34
28 31 30
26
19
20
19 18 17 17
16 1
14
2 12
13

1988 1993 1998 2003

Neonatal Mortality Postneonatal Mortality
S ur vey P er iod, NDHS Infant Mortality

Child Mortality Under-five Mortality

4
 Causes of Deaths among Children
Under Five Years Old

Top Ten Leading C ause of Underfive M ortality

2000 Philippine Health Statistics

pneumonia 51.6
accidents 31.7
septicemia 30.4
measles 24.2
nutritional disorders 22.7
diarrhea 16.8
meningitis 11.5
congeninital anomalies 10.6
malignant neoplasm 8.3
perinatal causes 7.6

0 10 20 30 40 50 60
no. of Underive Deaths P er 1000LB
Source: 2000 Philippine Health Statistics
5
 Situation in First-Level Health
Facilities

 overlap of conditions
 irregular flow of patients
 diagnostic tools are minimal or non-existent
 drugs and equipment are scarce
 health workers have few opportunities to
practice complicated clinical procedures
 relies on history and signs and symptoms

6
 Features of IMCI…
 notnecessarily dependent on the use of
sophisticated and expensive technologies

a more integrated approach to managing sick

children

 move beyond addressing single diseases to

addressing the overall health and well-being
7 of the child
 Features of IMCI…
 careful and systematic assessment of common
symptoms and specific clinical signs to guide rational
and effective actions

 integrates management of most common childhood

problems (pneumonia, diarrhea, measles, malaria,
dengue hemorrhagic fever, malnutrition and anemia,
ear problems)

 includes preventive interventions

8
 Features of IMCI…

 adjustscurative interventions to the capacity

and functions of the health system
(evidence-based syndromic approach)

 involves family members and the community

in the health care process

9
 Objectives of IMCI

(1) reduce deaths and the frequency and

severity of illness and disability; and

(2) contribute to improved growth and

development

10
 IMCI Components

1. Improving case management skills of

health workers
– standard guidelines
– training (pre-service/in-service)
– follow-up after training
– role of private providers

11
 IMCI Components

2. Improving the health system to deliver IMCI

– essential drug supply and management

– organization of work in health facilities
– management and supervision
– referral system

12
 IMCI Components

3. Improving family and community practices

– for physical growth and mental development

– for disease prevention
– for appropriate home care
– for seeking care

13
 IMCI Components

3. Improving family and community practices

-For physical growth and mental development

 Breastfeeding
 Complementary feeding
 Micronutrient supplementation
 Psychosocial stimulation

14
 IMCI Components

3. Improving family and community practices

- For disease prevention

immunization
handwashing
sanitary disposal of feces
use of insecticide-treated bednets
dengue prevention and control

15
 IMCI Components

3. Improving family and community practices

- For appropriate home care

 continue feeding
 increase fluid intake
 appropriate home treatment

16
 IMCI Components

3. Improving family and community practices

- For seeking care

Follow health workers advice
When to seek care
Prenatal consultation
Postnatal (postpartum) consultation

17
 The Integrated Case Management Process
Outpatient Health Facility
•check for danger signs
•assess main symptoms
•assess nutrition and Immunization status
and potential feeding problems
•Check for other problems
•classify conditions and
• identify treatment actions

Outpatient Health Facility

Urgent referral
•pre-referral treatment Outpatient Health Home
•advise parents Facility
•refer child Caretaker is
Treatment counselled on:
•treat local infection •home treatment
•give oral drugs •feeding &fluids
Referral facility •advise and teach •when to return
•emergency triage & caretaker •immediately
treatment •follow up •follow-up
•Diagnosis & treatment
18 •monitoring & ff-up
  Sick young infant
– 1 week up to 2 months

 Sick young children

– 2 months up to 5 years

19
 Assessing the Sick Child

• lethargy or
unconsciousness
General • inability to drink or
Danger breastfeed

Signs • vomiting
• convulsions

20
 Checking the Main Symptoms

- cough and difficult breathing

- diarrhea
- fever
- ear problem

21
 Checking the Main Symptoms

1. Cough or difficult breathing

3 clinical signs
– Respiratory rate
– Lower chest wall indrawing
– Stridor

22
 Checking the Main Symptoms

2. Diarrhea
 Dehydration
– General condition
– Sunken eyes
– Thirst
– Skin elasticity
 Persistent diarrhea
 Dysentery
23
 Checking the Main Symptoms

3. Fever
 Stiff neck
 Risk of malaria and other endemic
infections, e.g. dengue hemorrhagic
fever
 Runny nose
 Measles
 Duration of fever (e.g. typhoid fever)
24
 Checking the Main Symptoms

4. Ear problems
 Tender swelling behind the ear
 Ear pain
 Ear discharge or pus (acute or
chronic)

25
 Checking Nutritional Status,
Feeding, Immunization Status

 Malnutrition
– visible severe wasting
– edema of both feet
– weight for age
 Anemia
– palmar pallor
 Feeding and breastfeeding
 Immunization status
26
 Assessing Other Problems

 Meningitis
 Sepsis
 Tuberculosis
 Conjunctivitis
 Others: also mother’s (caretaker’s) own health

27
 IMCI Essential Drugs and Supply
 Appropriate antibiotics
 Quinine
 Vitamin A
 Paracetamol
 Oral antimalarial
 Tetracycline eye ointment
 ORS
 Mebendazole or albendazole
 Iron
 Vaccines
 Gentian violet
28
 Benefits of IMCI

29
 Changes in Weight-for-Age
(Z-score) of children after consultation
by health worker
0.2

0.15

0.1

0.05

by IMCI-trained health workers

-0.05
by untrained health workers
-0.1

-0.15

-0.2
8 days 45 days 180 days

Changed
Z-score* * The 0 point represents the initial weight-for-age value, 8 days after the consultation.
30 Positive Z-score values indicate improvement in nutritional status, and negative Z-score
values
 Current Best Estimates
of Efficacy for Interventions in the
IMCI Strategy

Decline
Intervention in U5M Source
ARI case
35% Sazawal & Black, 1992
management

Oberle et al, 1990; Chen et al,

ORT 4-14%
1983

Measles The Kasengo Project Team,

20%
immunization 1981; Koenig, 1992

31
 Quality of Care Improves With
Introduction of IMCI
100 Proportion of children receiving

80
88 95
60
93

40

50
20 28
0
0
Comprehensive Nutritional evaluation Review of vaccination
assessment status
32
Before (1997) After (1999)
 IMCI Reduces Antibiotic Abuse
Rate in Morocco
%
Proportion of sick children who received unneeded prescription of
antibiotics:
50

40 34
Health worker NOT
30 using IMCI (n=132)
Health worker using
20 IMCI (n=147)
12
10

33 33
 Comparison of Drug Use
and Costs Based on Assessment of
1226 Sick Children
Number of different 50
drugs prescribed 11

% of cases prescribed:
77
- antibiotic 56
28
- injection 11
95
- >1 drug 53
5
- one drug 39
0.4
- no drug 8

82
Drug costs (US cents) 17

Doctors: current practice

34 Medical assistants using IMCI guidelines * Conditions not covered by IMCI were excluded
(Unpublished data from Black, et al; not for
citation)
 Mothers Leave the Facility
Better Able to Care for their Child.
Proportion of mothers leaving health facility who reported correctly:
100 (56/80)

80 (17/35) 70

60 49

40 (4/33) (4/57)

20 12
7

0
How to give oral medicines At least two danger signs
35 Before (1997) After (1999)
 Experience with IMCI in “Well Baby”
Clinic, Bolivia 1999

36
 Cost-effective Packages
of Public Health Interventions and
Essential Clinical Services
Proportion of total global disease burden averted
Annual cost Annual cost
per DALY per capita
US$ US$
Management of the sick child 14% 40.0 1.6

EPI Plus 6% 14.5 0.5

Prenatal and delivery care 4% 40.0 3.8

Family planning 3% 25.0 0.9

4.0 1.7
AIDS prevention programme 2%

2.0 0.2
Treatment of STD's 1%

4.0 0.6
Short-course chemotherapy for TB 1%

37
Source: World Bank Development Report, Investing in Health, 1993 DALY = Disability-adjusted life year