Policy Shift to Integrated Management
Until the mid 1990s, actions aimed at improving child health were organized as vertical programs, each addressing a specific disease or providing a given intervention or set of interventions (Claeson and Waldman 2000). Typical examples of these programs are the Expanded Program on Immunizations (EPI), Control of Diarrhoeal Diseases (CDD), acute respiratory infection (ARI) programs, malaria control programs, and nutrition programs that include growth monitoring, breastfeeding promotion and support, and micronutrient supplementation.
The need for an integrated approach to improve child health became evident in the mid 1990s for a number of reasons. From the perspective of epidemiology, a small number of diseases accounted for a high proportion of deaths, and those diseases were often present in the same children and had overlapping clinical signs. Integrated management was expected to increase the probability that children would receive treatment for all major diseases and to decrease the possibility that children would receive correct treatment for one disease and die from another unrecognized illness. The important role played by nutrition across these major diseases also suggested that an integrated approach to case management was needed to ensure that health workers addressed children's nutritional needs throughout the clinical encounter.
A second set of reasons for the policy shift to an integrated approach was based on the need to promote managerial efficiency. The vertical approach required countries to appoint managers at national, provincial, and district levels to run each program. It also led to separate training activities; for example, health workers might be required to leave their posts on a number of occasions to be trained for the programs. Similar examples of duplication of effort were often found in supervision and provision of essential drugs. There was a strong logical basis for believing that integrating the management structure of child health programs would lead to improved efficiency.
A third group of reasons for the shift to integrated case management related to the need to improve the quality of case management provided by health workers. Vertical programs trained health workers to manage one disease at a time, and decisions about how best to assess and treat those diseases, as well as how to promote nutrition and educate caretakers, were often left to individual health workers. An integrated set of guidelines for managing sick children ensured that health workers, including those with low levels of training, applied the best available knowledge of case management systematically and in correct sequence.
The realization that a few diseases were responsible for most child deaths, that comorbidity was highly prevalent, that effective interventions were available, and that there were many missed opportunities for prevention led to the recognition that an integrated approach was needed. Thus, the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) launched the Integrated Management of Childhood Illness (IMCI) strategy in the mid 1990s (Tulloch 1999). Tanzania and Uganda began implementing IMCI in 1996. By 2003, more than 100 countries had adopted the strategy (http://www.who.int/child-adolescent-health).
