Global strategies for improving child health under scrutiny

This week's issue of THE LANCET is largely devoted to research and comment on health-systems development for developing countries, ahead of a global summit being held in Mexico City next month. The lead editorial (p 1555) highlights the main challenges ahead: '…research for health must no longer be confined to the components--the drugs, the devices, the vaccines. The Mexico Ministerial Summit must boldly and publicly assert that the traditional biomedical model of health research is wholly inadequate to tackle disease alleviation in the less-developed world. A new health-systems research specialty must be founded, one that is supported technically and financially by the affluent nations and integrated within the policy and health systems of less-developed countries. This research specialty must focus on narrowing the gap between what is known and what is done, and should lead to a culture where policy and practice derives from evidence. The specialty should also draw on what useful research has already been done in other disciplines, such as the social, behavioural, and organisational sciences.'

Two studies in this week's issue give an insight into the effectiveness of a global strategy for improving child health in developing countries: the Integrated Management of Childhood Illness (IMCI) introduced by WHO in the mid 1990s.

More than ten million children worldwide die every year; 95% of these deaths occur in 42 less developed countries. Neonatal disorders, diarrhoea, pneumonia, and malaria are the main causes of child death, although HIV/AIDS accounts for at least 10% of deaths in some African countries. Undernutrition is a major underlying cause and has been estimated to contribute to more than half of all childhood deaths.

The main components of the IMCI strategy (the integrated management of childhood illness) are: the adoption of an integrated approach to child health and development in countries' national health policies; adaptation of the standard IMCI clinical guidelines to individual country's needs; upgrading care in local clinics by training health workers in integrated methods to examine and treat children, and to effectively counsel parents; 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; and 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.

In the first study, Joanna Armstrong Schellenberg (Ifakara Health Research and Development Centre, Tanzania) and colleagues compared two districts with facility-based IMCI and two neighbouring comparison districts without IMCI in Tanzania. Child mortality decreased by 13% after two years of IMCI implementation compared with the areas where IMCI was not available. Furthermore, IMCI implementation was no more expensive than the cost of conventional health care. The authors comment: 'Our data suggest that high coverage of facility-based IMCI leads to lower child mortality and that the reduction is achievable within existing health budgets. In our setting, simple, practical planning and management tools for strengthening the capacity of district health systems were the essential first step to achieving this impact.'

The effect of IMCI is also assessed in Bangladesh by Shams El Arifeen (ICDDR,B: Centre for Health and Population Research, Dhaka, Bangladesh) and colleagues. 20 first-level outpatient facilities around the Matlab region were randomised to either IMCI or standard care. Encouraging results from the areas where IMCI was implemented have emerged: on a scale (0 to 100) to assess the correct treatment of sick children, a score of 54 was obtained in IMCI facilities compared with 9 in comparison facilities. Use of the IMCI facilities increased from an average of 0.6 visits per child per year at the start of the study to around 2 visits per child per year around 2 years after the introduction of IMCI. 19% of sick children in the IMCI areas were taken to a health worker compared with 9% in non-IMCI areas.

IMCI is assessed in an accompanying commentary (p 1557) by Davidson R Gwatkin who states: "IMCI can work. Despite the methodological limitations that the authors note, their findings show that IMCI almost certainly is a significant improvement over what previously existed in Bangladesh and Tanzania… how well IMCI can work depends upon the strength of the health system responsible for its implementation. Despite the important steps toward reality in the field taken by the Bangladesh and Tanzania projects, information available in other IMCI documents suggests that implementing IMCI effectively in other countries will not be easy." He concludes: "So, constraints in health systems strike again. Such constraints have long been known to be a major barrier to the effective implementation of vertical health programmes. The IMCI experience suggests that they are also central in determining the amount of progress attainable by promising horizontal approaches."

Contact: (Tanzania study) Dr Joanna Armstrong Schellenberg, Ifakara Health Research & Development Centre, PO Box 78373, Dar es Salaam, Tanzania;
T)255-74-845-2214;
dajobelo@aol.com

(Bangladesh study) Dr Shams El Arifeen , ICDDR, B: Centre for Health and Population Research, GPO Box 128, Dhaka, Bangladesh;
T)880-2-881-0115;
shams@icddrb.org

Dr Davidson R Gwatkin, 6483 Wishbone Terrace, Cabin John, MD 20818, USA;
dgwatkin@comcast.net

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