The Implementation of Integrated Management of Childhood Illness ...

Abstract
Introduction
The under-five (U5) mortality in the world today exceeds 10 million children per year. The majority of
these deaths are the result of preventable diseases, e.g. malaria, acute respiratory infections,
diarrhoea, measles, compounded with malnutrition. Most of these deaths occur in developing
countries, in particular sub-Saharan Africa. The Integrated Management of Childhood Illness (IMCI) was
developed for settings where child mortality is high and where simple and inexpensive solutions are
needed. IMCI enables, with the help of a flow-chart, health care workers in outpatient settings to
classify the health problems in U5s and provide them with appropriate care and treatment.
Objective
Describe and analyse the outpatient settings for children in a sub-Saharan country with focus on the
implementation of IMCI.
Methods
The study was conducted in the Monkey Bay health zone in Malawi. The Icelandic International
Development Agency (ICEIDA) has been supporting the health sector in the area since the year 2000. In
the area there are five health facilities. Two of them are run by the government and offer services free
of charge while three are run by the Christian Health Association of Malawi (CHAM) and charge user
fees. Data about all children’s attendances and illness classifications during March 2005 was collected
from Outpatient Registers in each of the health facilities. Drug inventories were taken at each health
centre. Health workers who consult children were interviewed about IMCI. Guardians of 11 children
were interviewed at the Monkey Bay Community Hospital (MBCH).
Results
State run facilities were more frequented than those run by CHAM. Based on population data in the
catchment areas of each the health facilities, the population of all ages was 1.45 times more likely (RR,
95% CI: 1.43-1.47) to visit a state-run facility than a CHAM-run facility. Children were 1,22 times more
likely (RR, 95% CI 1.18-1.26) to be brought to a state run health facility than a CHAM-run one. At the
government-run facilities, about ¼ of the attendees were U5s compared to about half in the private
and user-charging health facilities. Around 4/5 of all classifications for sick children less than five
years were dealt with in the IMCI. More than half of all the attending children were classified as
having malaria while pneumonia and other respiratory tract infections were used classifications for
about 1/3 of attending children. One case of malnutrition was reported and seven cases of anaemia.
Eight out of ten health workers who consult children in the Monkey Bay area are trained in IMCI;
seven use the IMCI guidelines in practice. The drug inventories revealed that most oral IMCIrecommended
drugs were in stock while intramuscular antibiotics were not.
Discussion
The relatively higher attendance to the government-run facilities may indicate that patients prefer
facilities that do not charge for services despite occasional drug shortages. The majority of attendees
less than five years of age presented with problems that are dealt with in the IMCI flow-chart which
supports the notion that IMCI is appropriate in the setting. The high number of malaria cases may
indicate mis-classifications. The low number of anaemia and malnutrition classifications calls for
improvement in assessment of children regarding these conditions. It is important that all health
workers receive IMCI training, appropriate supervision and are given necessary equipment and
support to adequately attend sick children.
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