Conclusions: Promises and Pitfalls
IMCI was introduced in the mid 1990s as an ambitious global strategy that held many promises. Cost-effective vertical interventions against the main causes of under-five mortality in the world were integrated into a single, facility-based health worker training program. The program was accompanied by efforts to improve health systems support for child health care and to promote key family practices at the community level. Integration was expected to further improve coverage levels and the cost-effectiveness of child survival interventions relative to their delivery through separate vertical programs.
IMCI case-management training was repeatedly shown to improve the quality of care delivered in first-level health facilities, and the costing data reviewed above suggest that it can do so at similar or lower costs than those of existing health services. IMCI, therefore, is able to deliver better child health care at no increase in costs.
Nevertheless, community IMCI interventions only reached meager population coverage in the countries studied, and even health worker training was never effectively scaled up in most countries as a result of health system constraints. The major effect on child survival that was initially expected as a result of IMCI implementation has not yet materialized, and country reports of the barriers to achieving and maintaining high coverage levels suggest that effects will not be seen unless IMCI in first-level facilities is buttressed by equally strong or stronger efforts to develop health system capacity and reach families and communities. In fact, progress in child survival in the late 1990s and early 21st century has been slower than in earlier decades (Bellagio Study Group on Child Survival 2003), and current trends suggest that the Millennium Development Goals are unlikely to be achieved for most countries unless major new investments are made very soon.
The Tanzania results suggest that, in a setting where IMCI was implemented in conjunction with health system strengthening and where utilization of health facilities is high, an effect on mortality and nutritional status is likely. However, experience from other countries showed that reaching high and sustained implementation was difficult.
Although IMCI has only partially lived up to initial expectations, it has many positive aspects that must be fostered. A return to isolated vertical programs for child survival will not solve the difficulties faced by scaling up IMCI effectively, and integration should continue to be a key goal of child survival strategies in the future. In fact, much of the frustration associated with reported underperformance of IMCI arises from the fact that sufficient resources—financial, human, and organizational—were not planned for or available to support its full implementation, either at national or at international levels. The meager training coverage levels observed in most of the MCE countries are clear evidence of insufficient implementation, and it is thus not surprising that coverage and effect were also less than expected.
Renewed and expanded efforts to reduce child mortality should build on the proven effectiveness of IMCI case management in first-level facilities, but they also should incorporate new knowledge. Country-specific planning is needed to reach families and communities and to build on the existing health system to achieve and sustain population-level coverage. Countries with weak health systems will require creative approaches to intervention delivery in the short term at the same time that health systems are strengthened as a long-term strategy. The poorest strata of the population are also the neediest in terms of health care and the hardest to reach. The challenge of improving equity is not unique to IMCI or to child survival; it affects virtually every intervention and delivery strategy. Unless equity considerations become a key part of policy making and of monitoring outcomes, interventions may widen instead of narrow inequity gaps (Victora and others 2003).
A continuing challenge is how to raise and sustain the standing of child survival in the international agenda. The more than 10 million annual deaths of children under age five—more than 20 deaths per minute—represent twice the number of deaths attributable to AIDS, malaria, and tuberculosis combined (Black, Morris, and Bryce 2003). Putting child survival back on the public health and development agenda is an essential developmental step in the process of refining country-level and global child health strategies. Only through taking stock of the lessons learned in early IMCI implementation can a flexible, integrated program be developed that will improve child survival in particular and child health in general.
