This document discusses the evolution of approaches to improving child health and survival over time, from early colonial public health efforts focused on single diseases, to integrated primary health care and selective primary care strategies in the late 20th century. It describes campaigns targeting specific diseases from the 1950s-1970s and the "child survival revolution" of the 1980s based on low-cost GOBI interventions of growth monitoring, oral rehydration, breastfeeding, and immunization. More integrated, health system-wide approaches emerged in the 1990s to strengthen struggling systems.

1. IMCI

3. • Altogether more than 10 million children
die each year in developing countries
before they reach their fifth birthday.
• Seven in ten of these deaths are due to
acute respiratory infections (mostly
pneumonia), diarrhoea, measles, malaria,
or malnutrition—and often to a
combination of these conditions.

5. • These conditions will continue to be major
contributors to child deaths in the year
2020 unless significantly greater efforts
are made to control them.

6. WHAT THE LOCAL FIGURES SAY
• In relation to child health, with
– the Under-5 Mortality Rate of 107,
– Infant Mortality Rate of 74.6,and
– Neonatal Mortality Rate (NMR) of 43.1,
• Pakistan ranks high in terms of child mortality with respect
to regional comparisons.
• A wide provincial variation is seen in Infant Mortality Rates
with IMRs of
– 71 for Sindh
– 104 Balochistan
– 77 Punjab and
– 79 per 1,000 live births NWFP

11. Child survival: where we stand
• Although the annual number of deaths among children
less than 5 years old has decreased by almost a third
since the 1970s, this reduction has not been evenly
distributed throughout the world.
• Every day, on average more than 26,000 children under
the age of five die around the world, mostly from
preventable causes.
• Nearly all of them live in the developing world or, more
precisely, in 60 developing countries.
• More than one third of these children die during the first
month of life, usually at home and without access to
essential health services and basic commodities that
might save their lives

12. • Some children succumb to pneumonia, diarrhoea or
malaria that are no longer threats in industrialized
countries or to early childhood diseases that are easily
prevented through vaccines, such as measles.
• In up to half of under-five deaths an underlying cause is
undernutrition, which deprives a young child’s body and
mind of the nutrients needed for growth and development.
• Unsafe water, poor sanitation and inadequate hygiene
also contribute to child mortality and morbidity.
Child survival: where we stand

13. Why child survival matters?
• A greater chance of becoming creative
and productive members of society.
• Investing in children is also wise from an
economic perspective
• Improvements in child health and survival
can also foster more balanced population
dynamics.

14. The inequities of child health
• Infant and childhood mortality sensitive indicators of
inequity and poverty.
• Children who are most commonly and severely ill, who are
malnourished and who are most likely to die of their illness
are those of the most vulnerable and underprivileged
populations of low-income countries.
• Millions of children are often caught in the vicious cycle of
poverty and ill health—poverty leads to ill health and ill
health breeds poverty.
• Quality of care another important indicator of inequities in
child health.

15. Background
• Every day, millions of parents seek health care
for their sick children, taking them to hospitals,
health centers, pharmacists, doctors and
traditional healers.
• Many sick children are not properly assessed
and treated by health care providers, and their
parents are poorly advised.
• At first-level health facilities in low-income
countries, diagnostic supports are minimal or
non-existent, and drugs and equipment are often
scarce.

16. • Limited supplies and equipment, combined with an
irregular flow of patients, leave doctors to rely on history
and signs and symptoms to determine a course of
management that makes the best use of the available
resources.
• These factors make providing quality care to sick
children a serious challenge.
• Improvements in child health are not necessarily
dependent on the use of sophisticated and expensive
technologies.

17. • Improvements in child health rather
depend on effective strategies
– that are based on a holistic approach,
– that are available to the majority of those in
need, and
– which take into account the capacity and
structure of health systems, as well as
traditions and beliefs in the community

18. WHO and UNICEF have addressed this
challenge by developing a strategy called
the
Integrated Management of Childhood
Illness (IMCI)

19. • Diverse approaches are currently employed to
deliver essential health services for children and
mothers.
• These range from initiatives targeted towards a
single disease or condition, such as measles or
undernutrition, to the ideal of providing a
continuum of comprehensive primary health
services that integrate hospital and clinical
facilities, outpatient and outreach services, and
household and community-based care.
Evolution of health-care systems
and practices

20. Evolution of health-care systems
and practices
• The colonial period: 1900–1949
• Mass disease control campaigns: 1950–
1977
• Primary health care: 1978–1989
• Selective primary care and the child
survival revolution: 1980s
• Focusing on integrated, sector-wide
approaches and health systems: 1990s

21. The colonial period: 1900–1949
• High mortality and disability from such causes as diarrhoea, malaria,
measles, pneumonia, smallpox, tuberculosis and various forms of
undernutrition affected a large population.
• In the first half of the century, a few key malaria programmes were
developed.
• Efforts were however fragmented, undertaken by colonial governments
• Despite their narrow focus, some of the initiatives – for example,
Malaria control from 1930–1950 in and around copper mines in Zambia
was quite successful.
• A national public health system began in the 1920s with efforts to
control the rapidly spreading pneumonic plague in the province of
Manchuria.

22. • Facility-based care vs. mass care by mobile
units focused on a single disease such as
sleeping sickness, elephantiasis, leprosy and
other high-prevalence conditions affecting the
capacity to work.
• Early in the century, such countries as Denmark,
the Netherlands, Norway and Sweden managed
to reduce maternal mortality very quickly.
• Efforts focused on providing professional care
close to where women lived, mainly by
enhancing the skills of community midwives.
The colonial period: 1900–1949

23. Mass disease control campaigns:
1950–1977
• The 1950s, 1960s and 1970s witnessed a
number of disease control efforts, often termed
‘mass campaigns’ or ‘disease focused
responses’.
• The smallpox eradication initiative, which
reported its last case of human-to-human
transmission in 1977 most successful.
• Expanded Programme on Immunization (EPI),
launched in 1974

24. Primary health care: 1978–1989
• The International Conference on Primary Health
Care held in Alma-Ata in 1978 came about as a
result of successful innovations in community
health care developed after World War II in
resource-poor settings.
• The district health system concept, also known
as ‘catchment area focus’ or the ‘small area’ or
‘intermediate group’ approach in Europe and
other countries, was subsequently developed.

25. • The primary-health-care approach encompasses
– the tenets of equity,
– community involvement,
– Intersectoral collaboration,
– use of appropriate technology,
– Affordability and health promotion.
• These have become guiding principles in the
development of health systems that
– take into account broader population health issues, reflecting
and reinforcing public health functions;
– that emphasize the integration of care across time and place;
– that link prevention, acute care and chronic care across all
components of the system;
– that evaluate and try to improve performance
Primary health care approach

26. Selective primary care : Late 1970
• In the late 1970s, two scientists, Julia
Walsh and Kenneth Warren, published
‘Selective Primary HealthCare: An interim
strategy for disease control in developing
countries’ – a milestone paper that
proposed an alternative strategy for
rapidly reducing infant and child mortality
at a reasonable cost.

27. • Concluded that
– a small number of causes (diarrhoea, malaria,
respiratory diseases and measles, among others) were
responsible for the vast majority of under-five deaths
and
– that these deaths could be easily prevented by
• immunization (only 15 per cent of the world’s children were
immunized at the time),
• oral rehydration therapy,
• breastfeeding and
• antimalarial drugs.
• The result was a new strategy known as ‘selective
primary health care
Selective primary care

28. Integrating key elements of vertical
approaches by targeting the diseases
identified as the most important
contributors to high infant and child
mortality rates, it was intended to be
more focused and more feasible
than primary health care.
Selective primary care

29. Child survival revolution:1980s
• The ‘child survival revolution’,
spearheaded by UNICEF and launched in
1982, was based on the framework of
‘selective primary care’
• Focused on four low-cost interventions
collectively referred to as GOBI

30. GOBI
• Growth monitoring for undernutrition,
• Oral rehydration therapy to treat childhood
diarrhoea,
• Breastfeeding to ensure the health of
young children and
• Immunization against six deadly childhood
diseases

31. GOBI-FFF
• Subsequently, GOBI added three more
components:
• Food supplementation,
• Family spacing and
• Female education

32. • Selective primary care initiatives
contributed to the sharp fall in the global
under-five mortality rate, from 115 per
1,000 live births in 1980 to 93 in 1990 – a
reduction of 19 per cent over the course of
the decade.

33. • By the late 1980s, health systems in many
developing countries were under severe
stress.
• The contributing factors were
– population growth,
– the debt crisis in many Latin American and
sub-Saharan African countries, and
– political and economic transition in the former
Soviet Union and Central and Eastern Europe
Integrated, sector-wide approaches
and health systems: 1990s

34. Integrated, sector-wide
approaches:1990s
• In response, a number of countries
stressed on efforts
– to reform deteriorating, under-resourced health
systems,
– raise their effectiveness, efficiency and
financial viability, and
– increase their equity.
• One such approach used by many
countries was the Bamako Initiative

35. Integrated, sector-wide approaches and
health systems: 1990s
• The Bamako Initiative:
– launched in 1987 at the World Health Organization
meeting of African health ministers in Bamako, Mali.
– focused on delivering an integrated minimum health-
care package through health centres.
– emphasis was placed on
• access to drugs and
• regular contact between health-care providers and
communities.

36. • Integration:
– ‘Bamako Initiative’ became the driving force of
integrating the essential services approach in
the 1990s
– Integrated approach sought to combine the
merits of selective primary care and primary
health care.
Integrated, sector-wide approaches
and health systems: 1990s

37. Integrated, sector-wide approaches
• Like selective approaches, they placed a strong
emphasis on providing
– a core group of cost-effective solutions in a timely way
to address specific health challenges
• Like primary health care, they also focused
attention on
– community participation,
– intersectoral collaboration and
– integration in the general health-delivery system.

38. • A long-standing example of the greater
emphasis on integration during the 1990s
is IMCI, the
Integrated Management of Childhood
Illness

39. • Developed in 1992 by UNICEF and WHO,
• Employed in more than 100 countries since
then.
• IMCI adopts a broad, cross-cutting
approach to case management of
childhood illness, acknowledging that there
is usually more than one contributing cause
IMCI

40. IMCI
• IMCI is an integrated approach to child health
that focuses on the well-being of the whole child.
• IMCI aims to reduce death, illness and disability,
and to promote improved growth and
development among children under five years of
age.
• IMCI includes both preventive and curative
elements that are implemented by families and
communities as well as by health facilities.

41. • The strategy includes three main
components:
– Improving case management skills of health-
care staff
– Improving overall health systems
– Improving family and community health
practices.
IMCI

42. Improving health worker
performance
• This involves
– training health workers to assess symptoms of diseases,
– correct mapping of illness to treatment, and
– provision of appropriate treatment to children and
– information to the caregivers.
• Through provision of locally adapted guidelines, health
staff are taught case management skills for five major
causes of childhood mortality:
– acute respiratory infections, especially pneumonia;
– diarrhoeal diseases;
– measles;
– malaria; and
– undernutrition

43. Improving health systems
• Seeks to strengthen health systems for effective
management of childhood illnesses.
• Measures employed include
– supporting drug availability,
– enhancing supervision,
– strengthening referral and
– deepening health information systems.
• Planning guides are provided for managers at the
district and national levels.

44. Improving community and family
practices
• Often referred to as Community Integrated
Management of Childhood Illness (C-IMCI).
• Based on the basic household practices for
families and communities

45. • The clinical guidelines, which are based on
expert clinical opinion and research results, are
designed for the management of sick children
aged 1 week up to 5 years.
• They promote evidence-based assessment and
management, using a syndromic approach that
supports the rational, effective and affordable
use of drugs.
IMCI Guidelines

46. IMCI Guidelines
• They include
– methods for assessing signs that indicate severe
disease;
– assessing a child’s nutrition, immunization and feeding;
– teaching parents how to care for a child at home;
– counselling parents to solve feeding problems; and
– advising parents about when to return to a health
facility
– recommendations for checking the parents’
understanding
– of the advice given and for showing them how to
administer the first dose of treatment

47. The principles of integrated care
• All sick children must be examined for “general danger signs” which
indicate the need for immediate referral or admission to a hospital.
• All sick children must be routinely assessed for major symptoms
– (for children age 2 months up to 5 years:
• cough or difficult breathing,
• diarrhoea,
• fever,
• ear problems;
– for young infants age 1 week up to 2 months:
• Bacterial infection and
• Diarrhoea
They must also be routinely assessed for nutritional and
immunization status, feeding problems, and other potential
problems.

48. • Only a limited number of carefully-selected clinical signs are
used
• A combination of individual signs leads to a child’s classification(s)
rather than a diagnosis.
Classification(s) indicate the severity of condition(s). They call for
specific actions based on whether the child
– should be urgently referred to another level of care,
– requires specific treatments (such as antibiotics or antimalarial
treatment), or
– may be safely managed at home.
The classifications are colour coded:
– “pink” suggests hospital referral or admission,
– “yellow” indicates initiation of treatment, and
– “green” calls for home treatment.
The principles of integrated care

49. • Address most, but not all, of the major reasons a sick
child is brought to a clinic.
The guidelines do not describe the management of
trauma or other acute emergencies due to accidents or
injuries
• IMCI management procedures use a limited number of
essential drugs and encourage active participation of
caretakers in the treatment.
• counselling of caretakers about home management,
including counselling about feeding, fluids and when to
return to a health facility.
The principles of integrated care

50. The IMCI case management process
Outpatient health facility
• Assessment;
• Classification and identification of
treatment;
• Referral, treatment or counselling of the
child’s caretaker (depending on the
classification(s) identified);
• Follow-up care.

51. Referral health facility
• Emergency triage assessment and treatment (ETAT);
• Diagnosis, treatment and monitoring of patient progress.
Appropriate home management
• Teaching the mother or other caretaker how to give oral
drugs and treat local infections at home;
• Counselling the mother or other caretaker about food
(feeding recommendations, feeding problems); fluids;
when to return to the health facility; and her own health.
The IMCI case management process

52. The IMCI guidelines recommend case
management procedures based on two
age categories:
• Children age 2 months up to 5 years
• Young infants age 1 week up to 2 months

55. • In health facilities, the IMCI strategy
– promotes the accurate identification of childhood
illnesses in outpatient settings,
– ensures appropriate combined treatment of all major
illnesses,
– strengthens the counseling of caretakers, and
– speeds up the referral of severely ill children.
• In the home setting, it
– promotes appropriate care seeking behaviors,
– improved nutrition and preventative care, and
– the correct implementation of prescribed care.
IMCI

56. Why is IMCI better than single-
condition approaches?
• Children brought for medical treatment often
suffering from more than one condition, making a
single diagnosis impossible.
• IMCI an integrated strategy,
– takes into account the variety of factors that put
children at serious risk.
– Ensures the combined treatment of the major
childhood illnesses,
– emphasizes prevention of disease through
immunization and improved nutrition.

57. How is IMCI implemented?
• Introducing and implementing the IMCI strategy
in a country is a phased process that requires a
great deal of coordination among existing health
programmes and services.
• It involves working closely with local
governments and ministries of health to plan and
adapt the principles of the approach to local
circumstances.

58. Steps for implementing IMCI
• The main steps are:
– Adopting an integrated approach to child health and
development in the national health policy.
– Adapting the standard IMCI clinical guidelines to the
country’s needs, available drugs, policies, and to the
local foods and language used by the population.
– Upgrading care in local clinics by training health
workers in new methods to examine and treat children,
and to effectively counsel parents.

59. • Making upgraded care possible by ensuring that
enough of the right low-cost medicines and
simple equipment are available.
• Strengthening care in hospitals for those children
too sick to be treated in an outpatient clinic.
• Developing support mechanisms within
communities for preventing disease, for helping
families to care for sick children, and for getting
children to clinics or hospitals when needed.
Steps for implementing IMCI…
contd

60. What has been done to evaluate the
IMCI strategy?
• A Multi-Country Evaluation (MCE) has been
undertaken to evaluate the impact, cost and
effectiveness of the IMCI strategy.
• The results of the MCE support planning and
advocacy for child health interventions by
ministries of health in developing countries, and
by national and international partners in
development.
• To date, MCE has been conducted in Brazil,
Bangladesh, Peru, Uganda and Tanzania.

61. • The results of the MCE indicate that:
– IMCI improves health worker performance and their
quality of care;
– IMCI can reduce under-five mortality and improve
nutritional status, if implemented well;
– IMCI is worth the investment, as it costs up to six times
less per child correctly managed than current care;
– child survival programmes require more attention to
activities that improve family and community behaviour;
– the implementation of child survival interventions needs
to be complemented by activities that strengthen system
support;
– a significant reduction in under-five mortality will not be
attained unless large-scale intervention coverage is
achieved.

62. IMNCI
• Stimulated by a series of studies on
maternal, newborn and child survival
integrated models of health care have been
developed within the context of the
maternal, newborn and child health
continuum of care
• In effect, the continuum of care concept
expands IMCI to include integrated
management of neonatal illness

63. • Successful preliminary experience with the
new approach, called the
Integrated Management of Neonatal and
Childhood Illnesses (IMNCI)
has been pioneered and fully implemented
in India.

64. Integrated Management of Neonatal and
Childhood Illnesses (IMNCI)
• Modifies IMCI with specific actions taken to
promote neonatal health and survival.
• Like IMCI, IMNCI supports three pillars for the
effective delivery of essential services to
neonates, infants and young children:
– Strengthening health-system infrastructure,
– enhancing the skills of health workers and
– promoting community participation
• All with additional emphasis on
– neonatal health and survival.

65. IMNCI
• In practice, IMNCI consists of
– three home visits in the first 10 days after birth to
promote best practices for the young child;
– a special provision at the village level for follow-up of
infants with low birth weights;
– reinforcement of messages through meetings of
women’s groups and
– establishing a linkage between the village and the
home; and
– Assessment of the child at local health facilities based
on referral.