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Is India ready for the integrated management if childhood illness strategy?^__Anthony Costello

India is traditionally wary about importing foreign-made products. It comes as no surprise that Indian Pediatrics has been slow to enthuse about the integrated management of childhood illness (IMCI) strategy, currently heavily promoted by the World Health Organization (WHO) and UNICEF. Old hands might observe that India has been down this route before with a litany of programs (acronyms like GOBI, CDD and ARI come to mind) brought in from outside, and others, like ICDS, devised from within. Now there is the broadly constructed Reproductive and Child Health (RCH) program in place. Why should the country's health planners be distracted by another grand scheme from the international agencies?

In this context, it is worth remembering why IMCI was developed. The strategy arose through dissatisfaction with disease-specific control programs like those targeted at diarrhea and acute respiratory infections. Primary care workers usually deal with children whose symptoms have overlapping causes or for whom a single diagnosis may not be appropriate. For example, cough and tachypnea may be caused by pneumonia, but also by severe anemia or malaria. A "very sick" young infant may have pneumonia, septicemia or meningitis, or more than one diagnosis. Analysis of health worker performance showed that misclassification of illness was extremely common(1).

The strategy requires three interdependent components for success: to improve the case management skills of health workers through the provision of locally adapted guidelines and training activities to promote their use; to provide essential drug supplies required for effective case management of childhood illness; and to optimize family and community practices in relation to child health, particularly care-seeking behavior.

On reflection, there are several reasons why IMCI has much to attract pediatricians and child health professionals in India. Firstly, the IMCI strategy is as succinct a mission statement for child health as one could find. It is important to emphasize the three components of the IMCI strategy (training in case management skills, ensuring a functioning health service and adequate drug supply, and developing community awareness about prevention and treatment of common illnesses), and not to confuse this simply with component one, a guidelines-driven program of training developed by WHO for primary care workers. Certainly many details about guidelines need widespread discussion by national experts, and indeed, adaptation of the WHO training guidelines by Indian pediatricians is a key first step in the process, but we should not become obsessed by detail and lose sight of the broader picture. IMCI is the first integrated strategy for child health to be debated on the international stage for twenty years, and it is a far better approach than its predecessor GOBI, a piecemeal mix of vertical interventions pushed by UNICEF in the early 1980s. Child health has returned to the spotlight having for too long been relegated from the premier league of the international health agenda. Indian pediatricians could use IMCI as a strategy to attract national and international investment into many initiatives to improve child health.

Secondly, there is good evidence that an IMCI approach is diagnostically superior to conventional routine practice or vertical disease `algorithms'. The first evaluation in India of the IMCI algorithm for childhood illness between the age of two months to five years has been reported in this issue(2). Two hundred and three children presenting to the outpatient department or emergency room of a medical college were assessed and classified by a resident undergoing pediatric post- graduate training using the IMCI algorithm. The results were compared with a gold standard diagnosis based on more complete investigations, and a vertical disease algorithm. A major rationale for propagating the IMCI approach is that a single diagnosis for a sick child is often inappropriate. The study confirmed that an integrated, rather than a vertical approach to diagnosis makes sense given that two thirds of the children had two or more co-existent morbidities from gold standard diagnoses. The IMCI algorithm was also comprehensive in that it covered almost all (92%) the recorded illnesses. When the IMCI recommendation for referral was compared with the judgement of a pediatrician on the need for hospitalization (and a combination of hospitalization and observation) a reasonably good sensitivity (81% and 69%, respectively) and specificity (74% and 85%) was found. Overall only 15% of subjects had total disagreement with the gold standard. IMCI algorithms were also markedly superior to the "vertical" ones: a total agreement with gold standard was seen in 64% of cases for IMCI but only 46% using vertical algorithms. Caution is needed because this study evaluated the IMCI algorithm used by junior doctors, and the efficacy may be reduced when used by trained para-medical personnel. Further studies are clearly needed, but co-existence of illnesses is the rule rather than exception for sick under five children in India, and the proposed IMCI algorithm seems to have distinct advantages.

The evidence from Africa(3-5) is not dissimilar from the Indian study(2) in terms of the efficacy of the algorithm. Experience from countries which have implemented the IMCI training program for primary care workers suggests additional benefits such as more rational drug use, increased attendances, improved provider morale, improved perceptions of quality of care and better health outcomes. An agency report of an evaluation of the WHO Africa Region IMCI program (in which the author was involved) showed that in Tanzania a "20% increase in service utilization" was found after IMCI training(6). In November 1998 an IMCI program evaluation in Uganda showed that IMCI-trained health workers shared their training skills with other staff, that immunization services had improved, weighing of children had increased, the availability and use of first line drugs had increased, and referral patterns were better. IMCI skills and classification of disease had improved, and the health workers felt more confident. Mothers particularly liked being given the first dose of treatment on site, and felt that their children were now examined thoroughly.

A third reason why the IMCI strategy is valuable for India is that it specifically challenges planners to grapple with harsh realities at community level. Most children who die do not reach a health facility. In Africa 80% of deaths happen at home. Recent work by Dr. Abhay Bang in Maharashtra (soon to be published) suggests that early community-based treatment of neonatal infection from village health workers using injectable anti-biotics in the home, can have astonishing effects on neonatal mortality: a 62% reduction in a poor, rural community! Indian child health professionals need to face the challenge to understand more about how to improve maternal or family recognition of illness, appropriate care seeking behavior, and timely referral of sick children from a lower to a higher level of care.

But what of the problems with IMCI? In February 1999, in his address to the Indian Academy of Pediatrics in Jaipur, Dr. Jim Tulloch, Director of the WHO Child and Adolescent Health Unit responsible for IMCI, clearly pointed out some challenges for IMCI. Five issues are commonly raised:

1. The diagnosis guidelines for pneumonia rest heavily on an increased respiratory rate, but with rising rates of asthma, especially in urban areas, should wheezing and its detection be incorporated into the IMCI algorithm? Sachdev and colleague in their analysis(2) found underdiagnosis of bronchial asthma and bronchiolitis, and an overdiagnosis of pneumonia. In settings where asthma is common and drugs are available to manage it, the guidelines developed for India could be adapted to improve efficiency. The Indian Academy of Pediatrics has an important role to play in adapting and updating the generic WHO guidelines to make them suitable for different Indian populations, including versions in different languages.

2. What about the newborn infant? As infant mortality has fallen in India the proportion of neonatal mortality rate (NMR) to IMR has risen, NMR now accounting for 65% or more of infant deaths. Until now IMCI has concentrated on illness in infants aged one week or more, on the rational grounds that early newborn care is the prerogative of the safe motherhood professionals, and is part of the Mother Baby package promoted by another Division within WHO. Nonetheless there needs to be integration and overlap between IMCI and Safer Motherhood. The lesson from Bang's work is that both midwives and IMCI-trained primary care workers should be trained in the case management of neo-natal sepsis.

3. Another criticism of the IMCI algorithm is that its case definition for malaria in endemic areas is too crude, leading to gross overtreatment with antimalarials of children with unexplained fever. Sachdev and colleague's study(2) certainly confirms that the use of fever alone as a diagnostic criterion led to an overdiagnosis of malaria. Overdiagnosis has serious consequences for antimicrobial resistance. A recent review by a group of the world's leading malaria experts suggests that widespread resistance to chloroquine, and increasing resistance to pyrimethamine/sulphadoxine (PSD), means a health calamity looms in the next few years in sub-Saharan Africa(7). To avert disaster they recommend that single drug treatment be replaced by combination therapy in the same way as has happened for tuberculosis and AIDS. Artemisinin should be combined with chloroquine and PSD for treatment to reduce the development of resistance. IMCI strategists might counter by saying that additional diagnostic criteria (ideally a blood film result) and alternative combination drug treatment strategies can be incorporated into the national IMCI adaptation process, once national governments have got to grips with their malaria policy, and invested in better malaria diagnostic facilities at primary level.

4. HIV is devastating child health programs in sub-Saharan Africa, and is  inexorably rising in India. This raises problems for IMCI training: how to build prevention of maternal to child transmission
of HIV into guidelines, and how to incorporate guidelines for when to test, and how to treat positive children. Work is ongoing in southern Africa to  address these issues. 5. Finally, there are neglected  but important areas for child  health which IMCI has not yet addressed such as air pollution,  injury prevention, epilepsy,  mental health, child abuse and neglect. To do so will take time, and it makes sense not to  overload a program before it  starts. A final cautionary note relates  to cost and sustainability. Field experience in Africa suggests  that in-service training of  primary care workers to use the IMCI algorithm effectively,  it  takes at least ten days and   requires follow-up supervision. This poses an enormous financial and organizational  challenge for government  primary care program planners  in India. It might make sense to start immediately by incorporating the IMCI approach into government  pre-service training institutions, and to share the burden of  in-service training with partners such as international agencies  and national non-government organizations, through plans of action worked out by district level public health planners in  association with IMCI-trained consultant pediatricians.

Anthony Costello,
Reader in International Child Health,
Center for International Child Health,
Institute of Child Health,
30 Guilford Street, London
WC1N 1EH, United Kingdom
e-mail: a.costello@ich.ucl.ac.uk

 References

1. Integrated Management of Childhood Illness Information  Pack. 1998. World Health Organization Child and  Adolescent Health and  Development Division, Geneva,1998. (contact chd@who.ch).

 2. Shah D, Sachdev HPS. Evaluation of the WHO/UNICEF Algorithm for Integrated Management of childhood Illness between the age of two months to five years.Indian Pediatr 1999; 36: 767-777.

3. Weber MW, Mulholland EK, Jaffar S, Troedsson H, Gove S, Greenwood BM. Evaluation of an algorithm for the integrated management of childhood illness in an area with seasonal malaria in the Gambia. Bull WHO 1997; 75(Suppl 1):25-32.

4. Perkins BA, Zucker JR,Otieno J, Jafari HS, Paxton L,ReddSC, et al. Evaluation of an algorithm for integrated  management of childhood illness in an area of Kenya with high malaria transmission. Bull WHO 1997; 75(Suppl.1): 33-42.

 5. Simoes EAF, Desta T, Tessema T, Gerbresellasie T, Dagnew M, Gove S.                        Performance of health workers after training in integrated  management of childhood                    illness in Gondar, Ethiopia. Bull WHO 1997; 75(Suppl 1): 43-53.

6. Output To Purpose Review of the WHO Africa Regional  Office Integrated Management
Of Childhood Illness (IMCI) Project, February 1999, British Government Department for
International Development.

7. White NJ, Nosten F, Looareesuwan S, Watkins WM, Marsh K, Snow RW, et al. Averting a    malaria disaster. Lancet 1999; 353: 1965-1967.