Why tackle child health?
The global equity gap in health is largest among children, and is concentrated in communicable diseases. - Children under fiive years of age account for more than 50% of the global gap in mortality between the poorest and richest quintiles of the world's population.
- Almost all (99%) of the 10.9 million children under five who died in 2000 were from developing countries. Of these children, 36% died in Asia, 33% in Africa.
More than 50% of all child deaths are due to just five communicable diseases, which are preventable and can be treated: pneumonia, diarrhea, measles, malaria and HIV/AIDS. Malnutrition is an underlying factor that increases the risk of dying from these diseases. Children are particularly vulnerable during early life. Perinatal mortality accounted for more than 20% of deaths in children under five years of age, in 2000 and includes birth asphyxia, trauma, and low birth weight. top
The Integrated Management of Childhood Illness (IMCI) IMCI is a broad strategy to improve child health outcomes developed by WHO and UNICEF. IMCI encompasses interventions at home, in the community and in the health system. The aims are to reduce childhood deaths, illnesses, and disability and toimprove children's growth and development, with a particular focus on the poorest and most disadvantaged children. IMCI has three main components: - Improve family and community practices related to child health and nutrition;
- Improve the health system for effective management of childhood illness;
- Improve health workers' skills.
IMCI is a flexible strategy that in each country addresses the major health problems of children under five years of age. It includes preventive and curative interventions, such as improved infant and child nutrition, breastfeeding promotion, immunization, and use of bednets in areas with malaria. It responds to the needs of caretakers and seeks to improve their satisfaction with child health services. In Brazil, after receiving IMCI nutrition counseling, mothers were able to recall feeding recommendations, modified their feeding practices and as a result their children had significantly better nutritional status than control groups. In Tanzania, in districts where IMCI is in place, health worker performance has improved and caretakers are more satisfied with the care their children receive. In rural Kenya, IMCI led to savings of at least 50% in the cost of drugs per child treated. The World Development Report 1993 identified IMCI as one of the most cost-effective services – it could avert 14% of the global burden of disease for only US$1.60 per capita per year. 
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What can be done to improve child health? Cost effective and feasible interventions and indicators are summarized in the table
| Core Interventions | Benefiiciaries/
target groups | Indicators |
Improve family and community practicies
| Counseling on child feeding including: - Early and exclusive breast feeding up to 6 months
- Breastfeeding with appropriate complementary feeding between 6 and 24 months
- Adequate amound of micronutrients (vitamin A and iron in particular) through dient and supplementation as necessary
 | Children under 2 years of age | | | Promote insecticide impregnated bednets in malaria endemic areas | Children under 5 years of age |  | | Promote safe disposal of faeces and hand washing after defacation and before preparing meals and feeding children | Caretakers and children under 5 years of age | Access to safe drinking water: % of popularion who use any of the following for drinking: piped water, public tap, borehole/pump, protected well or spring, rainwater Access to sanitary means of excreta disposal: % of population who use toilet or pit latrine
 | Complete full course of immunization for children before their first birthday (BCG, DPT, OPV, and measles)
(see Immunization at a Glance for recommended schedule and other details). | Children under 2 years of age | % of children under 12 months fully immunized for DPT; % of children under 12 months immunized for measles  | Promote mental and social development by responding to children's needs for care, and through talking, playing and providing a stimulating environment
| Children under 5 years of age | TBD | | Provide adequate care to sick children, including informaiton on appropriate home treatment for infectioins, offering increased fluids and food, and recognition of danger signs for seeking care at health facility | Children under 5 years of age Caretakers | - % children sick in last 2 weeks, who were offered increased fluids and same amount of more food
- %Â children with fever in last 2 weeks, who received appropriate antimalarial treatment (in malaria risk areas)
- Caretaker knows at least 2 signs for seeking care
| | Provide adequate prenatal care to every pregnant woman | Pregnant women | - % of pregnant women receiving antenatal care at least once
| | Improve the health system | Â | Â | | Ensure drugs and supplies for treating major childhood illnesses are available in health facilities | First level health facilities | - % of health facilities with all essential equipment, materials, and drugs for IMCIÂ
| Improve quality of care provided at health facilities and organization of work
| First level health facilities | - % of health facilities with at least 60% of oworkers who manage children trained in IMCI
| | Improve referral pathways | Children under 5 years of age with severe illness | - % of children who need referral, referred
| | Identify and develop methods for sustainable financing and equity of access | Children under 5 years of age | - % of children under 5 years of age who have access to a health facility able to provide IMCI
| | Link IMCI and the health information system | First level health facilities | - Disease notificatioin system compatible with IMCI classificatioins
| | Improve health workers skills | Â | Â | Develop and adapt case management guidelines and standards for major childhood illnesses in the country
| Children under 5 years of age | - Policy and case mangement guidelines for major childhood illness developedÂ
| Train health providers at first level health facilities and referral level in standard case management
 | Health workers in first level facilitiess and first referral level
 | - Correct assessment and treatment for sick children
| Improve and maintain health workers' performance through follow-up after training and periodic supervision
 | Health workers in first level facilitiess and first referral level
| - Correct assessment and treatment for sick children
| Define roles for non governmental/private providers
 | NGOs, private providers | - Involvement of NGOs and private providers in the IMCI strategy
|
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More on what to do… A combination of integrated curative and preventive interventions is required to address the immediate and underlying determinants of child health. Maternal determinants and risk factors associated with pregnancy and childbirth are especially important. Neonatal deaths account for about one-third of all deaths in children under five years of age. Simple, cost-effective interventions delivered at the community level can save most newborn lives in developing countries. The IMCI strategy is being expanded so that its facility-based and community components will cover the entire neonatal period in the near future.
In addition, maternal education is important for child health as educated mothers can better care for their children and recognize when they need health care. The life cycle approach recognizes the interrelations of different sector inputs needed to improve child health. IMCI is a key component of early childhood development projects, and part of health sector reform and community based projects. top
How much does it cost? An IMCI costing tool, which was field-tested in Nepal, was developed by the World Bank with several partners, including UNICEF, WHO, USAID, BASICS, and Abt Associates.
The data from the Nepal field test provide an estimated cost per child treated using the IMCI protocol, of US$0.09-US$0.14 for drugs alone, and US$0.24-US$0.35 for drugs and personnel costs. (These are recurrent costs only, they do not include IMCI investment costs for training, etc.) top
Do's and don'ts in introducing IMCI in a country: Create working groups with representation from government and non governmental stakeholders to develop plans for the three IMCI components. Don’t concentrate all efforts on only one component; a balanced effect on supply and demand for child health services is needed. To promote key family practices related to child health and nutrition, build on existing programs and community initiatives. Adapt the national guidelines and the IMCI training materials to include major causes of child deaths and conditions that the provider should be able to handle. Train a critical mass of health workers in first level health facilities to improve the quality of care provided to children. Follow-up health workers to reinforce their skills and help with the organization of work. Supervise health facilities regularly and ensure the health information system is compatible with IMCI classifications. Link the introduction of IMCI to health sector reform efforts in the country, as it can offer a cost effective package of health services for children. Target poor communities and disadvantaged children. Link health facilities with communities, and ensure appropriate and affordable referral arrangements. Don't forget to assess then engage the private sector to complement public sector efforts in the implementation of activities.
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For more information…
Useful Websites: top
Key references: - WHO/UNICEF, Integrated Management of Childhood Illnesses (IMCI), The Information Package, 1999.
- WHO/UNICEF, Integrated Management of Childhood Illnesses (IMCI) Planning Guide, Gaining experience with the IMCI strategy in a country. WHO/CHS/CAH/99.1
- WHO, Child Mortality, Consultation on Monitoring HNP Goals using the PRSP Framwork, Novemeber 2001, World Bank, Washington DC
- World Bank, Poverty Reduction Strategy Paper Toolkit, 2000. Life cycle annex, segment on childhood.
- World Bank, The Family Health Cycle: From Concept to Implementation, 2001.
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