The WHO/UNICEF Integrated Management of Childhood Illness (IMCI) strategy is paying dividends for most health indicators in Bangladesh. But over the seven years since the plan was enacted, there has been no significant effect on mortality of children under 5 years—although the strategy does seem to have reduced mortality at a greater rate than non-strategy areas in the last two years. These are the conclusions of an Article published in this week's edition of The Lancet, written by Dr Shams E Arifeen, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh, and colleagues.
IMCI was launched in the mid-1990s to reduce deaths from diarrhoea, pneumonia, malaria, measles, and malnutrition in children younger than 5 years. In this cluster randomised trial implemented from 1999 to 2007, 20 first-level government health facilities in the Matlab subdistrict of Bangladesh and their catchment areas (total population about 350,000) were paired and randomly assigned to either IMCI (intervention; ten clusters) or usual services (comparison; ten clusters). All three components of IMCI—healthworker training, health-systems improvements, and family and community activities—were implemented, beginning in February, 2002. Primary outcome was mortality in children aged between 7 days and 5 years. Nutrition status and other health indicators were also tracked.
The researchers found that the yearly rate of mortality reduction in children younger than 5 years (excluding deaths in first week of life) was similar in IMCI and comparison areas (8•6% vs 7•8%). In the last 2 years of the study, the mortality rate was 13•4% lower in IMCI than in comparison areas , corresponding to 4•2 fewer deaths per 1000 livebirths, although this finding was not statistically significant. Implementation of IMCI led to improved health-worker skills, health-system support, and family and community practices, translating into increased care-seeking and community treatment for illnesses. In IMCI areas, more children younger than 6 months were exclusively breastfed (76% vs 65%). The prevalence of stunting in children aged 2 to 5 years also decreased by 20%.
The authors suggest several possible explanations for what they view as a surprising lack of mortality differences between the two groups. Several interventions effective in reducing child mortality were delivered independently of IMCI to both intervention and comparison areas. These examples include vitamin A supplementation, childhood immunisations, family planning, and a national nutrition programme including community-based growth monitoring and promotion, food supplementation of undernourished pregnant women and children, and nutrition education and counselling. Associated with this, mortality in children younger than 5 years decreased much faster than expected in comparison areas, and was very similar to national trends. These reductions could be attributed to both high coverage of the interventions and improvements in other factors such as rapid economic growth, increased maternal education, electricity, water, sanitation, communications and mobile phones. Though use of oral hydration solution and exclusive breast feeding (both effective in decreasing diarrhoeal deaths) increased more in IMCI than control areas, overall numbers of diarrhoeal deaths may have been too small to detect an effect. For pneumonia deaths, despite increased use of government providers, village practitioners remained the leading source of health care, and antibiotics were used in about half of all children with suspected pneumonia in both areas. Co-trimoxazole (provided by the government for suspected pneumonia) was used by 20% of children with suspected pneumonia in IMCI areas, and by only 5% in the comparison area where potentially more effective antibiotics were often used. In view of the high levels of microbial resistance to cotrimoxazole in Bangladesh pneumonia treatment failures might have been more prevalent in IMCI than in comparison areas.
The authors say: "The Lancet Series on maternal and child undernutrition (January 2008) suggested that strong implementation of several interventions, particularly nutritional counselling for complementary feeding and zinc supplementation, is likely to reduce stunting at 36 months by about a third. Our results show a 20% reduction in stunting in the study area, which is somewhat below the predicted decrease; however, one of the key interventions to prevent stunting—zinc supplementation— was not implemented in this trial."
They conclude: "IMCI was associated with positive changes in all input, output, and outcome indicators, including increased exclusive breastfeeding and decreased stunting. However, IMCI implementation had no effect on mortality within the timeframe of the assessment."
In an accompanying Comment, Dr Trevor Duke Centre for International Child Health, Department of Paediatrics, Royal Children's Hospital, Melbourne, Australia; and University of Papua New Guinea, Port Moresby, Papua New Guinea, says that 'for IMCI to evolve into a sustainable part of the health culture, programme simplification and increased support for local health-training colleges and existing systems for maternal and child health must occur'.
He concludes: "An estimated US$5 billion in additional development aid for maternal, newborn, and child health per year would enable the scale-up of the child survival interventions in more than 40 of the poorest countries in the world. This additional aid is a tiny proportion of the trillions of dollars being spent to bail out failed banks in countries of the Organisation for Economic Co-operation and Development. Renewing of support for maternal and child health and education in developing countries would go much further to rebalancing the world's economies than would resuscitating decaying banks and paying bonuses to their executives. We need a global recovery that includes human resources for maternal and child health and education in the world's poorest countries. Without this, for most people, there will be no glimmer of hope."
Dr Shams E Arifeen, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh T) +880 2 881 0115 E) shams@icddrb.org
Dr Trevor Duke, Centre for International Child Health, Department of Paediatrics, Royal Children's Hospital, Melbourne, Australia; and University of Papua New Guinea, Port Moresby, Papua New Guinea T) +61 3 9 345 5968 E) trevor.duke@rch.org.au
For full Article and Comment, see: http://press.thelancet.com/imci.pdf
Journal
The Lancet