? The Author 2005. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved.
Programmatic pathways to child survival: results
of a multi-country evaluation of Integrated Management
of Childhood Illness
JENNIFER BRYCE,1CESAR G VICTORA,2JEAN-PIERRE HABICHT,3ROBERT E BLACK4AND
ROBERT W SCHERPBIER ON BEHALF OF THE MCE-IMCI TECHNICAL ADVISORS5
1WHO Consultant, 2081 Danby Road, Ithaca, NY, USA,
3Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA,4The Johns Hopkins Bloomberg School
of Public Health, Baltimore, MD, USA and5Department of Child and Adolescent Health and Development,
Family and Child Health Cluster, World Health Organization, Geneva, Switzerland
2Universidade Federal de Pelotas, Pelotas, Brazil,
Objective: To summarize the expectations held by World Health Organization programme personnel
about how the introduction of the Integrated Management of Childhood Illness (IMCI) strategy would
lead to improvements in child health and nutrition, to compare these expectations with what was
learned from the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE-IMCI), and
to discuss the implications of these findings for child survival policies and programmes.
Design: The MCE-IMCI study designs were based on an impact model developed in 1999–2000 to
define how IMCI would be implemented at country level and below, and the outcomes and impact it
would have on child health and survival. MCE-IMCI studies included: feasibility assessments
documenting IMCI implementation in 12 countries (1999–2001); in-depth studies using compatible
designs in Bangladesh, Brazil, Peru, Tanzania and Uganda; and cross-site analyses addressing the
effectiveness of specific subsets of IMCI activities.
Results: The IMCI strategy was successfully introduced in the great majority of countries with
moderate to high levels of child mortality in the period from 1996 to 2001. Seven years of country-
based evaluation, however, indicates that some of the basic expectations underlying the development
of IMCI were not met. Four of the five countries (the exception is Tanzania) had difficulties in
expanding the strategy at national level while maintaining adequate intervention quality. Technical
guidelines on delivering interventions at family and community levels were slow to appear, and in
their absence countries stalled in their efforts to increase population coverage with essential
interventions related to careseeking, nutrition, and correct care of the sick child at home. The full
weight of health system limitations on IMCI implementation was not appreciated at the outset, and
only now is it clear that solutions to larger problems in political commitment, human resources,
financing, integrated or at least coordinated programme management, and effective decentralization
are essential underpinnings of successful efforts to reduce child mortality.
Conclusions: This analysis highlights the need for a shift if child survival efforts are to be successful.
Delivery systems that rely solely on government health facilities must be expanded to include the
full range of potential channels in a setting and strong community-based approaches. The focus
on process within child health programmes must change to include greater accountability for
intervention coverage at population level. Global strategies that expect countries to make massive
adaptations must be complemented by country-level implementation guidelines that begin with local
epidemiology and rely on tools developed for specific epidemiological profiles.
Key words: child survival, IMCI, public health programme evaluation, child health
The Integrated Management of Childhood Illness
Integrated Management of Childhood Illness (IMCI) is
a strategy for reducing mortality among children under
the age of 5 years (Tulloch 1999). UNICEF, the World
Health Organization (WHO) and their technical partners
developed the strategy in a stepwise fashion, seeking to
address limitations identified through experience with
disease-specific child health programmes, and especially
those addressing diarrhoeal disease and acute respiratory
infections (Claeson andWaldman
of the strategy were developed in a rough sequence
from: (1) evidence-based guidelines for health workers
serving high-mortality populations that defined clinical
case management actions to respond to common infec-
tious diseases in childhood and the delivery of key
prevention services including immunization and nutrition
interventions; (2) health worker training in the guidelines
based on paedological principles of supervised practice in
clinical settings and follow-up of trainees to assist with the
establishment of new practices; (3) attention to needed
health system supports for child health and development,
based on the recognition that health workers are not
isolated, but work in systems that, if not strengthened,
would limit their abilities to perform good work; and
(4) strengthening of family practices needed to prevent
disease, to stimulate appropriate utilization of health
services, and to improve home care for sick children.
Figure 1 presents the components of the IMCI strategy
and the interventions WHO and UNICEF initially
proposed for inclusion within each component (WHO
The IMCI case management guidelines for the integrated
management of sick children in a first-level health
facility were designed to address the major causes of
child mortality in countries with infant mortality rates of
40 per 1000 live births or greater (Gove 1997; WHO
1998a). Undernutrition, an underlying cause contributing
to over 50% of deaths in children between the ages of
1 month and 5 years (Pelletier et al. 1995; Caulfield et al.
2004), was also a major target. Interventions in the generic
IMCI guidelines therefore included the provision of
antibiotics for pneumonia and dysentery, antimalarials
for fever in settings where malaria was endemic, oral
rehydration therapy for the prevention and treatment of
dehydration due to diarrhoea, and the use of Vitamin A
as a treatment for measles (Gove 1997). Undernutrition
was addressed by having health workers counsel care-
takers about appropriate feeding, including breastfeeding.
The guidelines were adapted in each country (WHO
1998b), resulting in a set of tasks to be performed by the
health worker(s) including a full assessment and classifi-
cation of the child’s condition leading to a determination
of treatment, and counselling of the caretaker on
administration of medicines, appropriate home care, and
the conditions under which the child should be brought
back to the facility. The guidelines also recommend
the use of the illness episode as an opportunity for the
delivery of preventive interventions, including vaccines
and nutritional counselling.
The generic IMCI training course was developed based
on these guidelines, and emphasized supervised clinical
practice (Gove 1997). In addition, the IMCI training
approach recommends that each participant receive a
follow-up visit from their trainer within 4 to 6 weeks
after the initial training in order to help them implement
their new skills (WHO 1999a).
IMCI programme developers incorporated the need
for specific health system supports into the strategy
itself (see Figure 1), an important step forward from
the disease-oriented programmes of the past. The
expectation was that introducing IMCI would contribute
to these needed health systems changes, strengthening
existing systems for supervision, drug supply and health
The vision for the strategy also included the need to
deliver interventions at the community level aimed
at improving family practices – such as appropriate
Improve family &
health care providers
IMCI roles for private
involvement in health
services planning &
District planning and
Availability of IMCI drugs
Quality improvement and
supervision at health
Referral pathways and
Source: WHO (1999a).
Figure 1. The three components of IMCI as presented by WHO in 1998
i6Jennifer Bryce et al.
careseeking and home management of illnesses – that
would act synergistically with improving health worker
skills at the facility level. WHO and UNICEF defined
a set of 12 key family and community practices and
their importance relative to child health and survival
(Hill et al. 2004).
of evidence supporting
Implementation of the IMCI strategy
IMCI was first introduced at country level in 1996 by
Tanzania and Uganda. In the 9 years since then, over 100
additional countries across all geographic regions have
adopted the strategy and gained significant experience in
its implementation (WHO 2005a).
The global planning guidelines for use by countries in
implementing IMCI recommended three stages (WHO
1999b). In the introductory phase, countries conducted
orientation meetings, trained key decision makers in
IMCI, defined a management structure for preparing for
IMCI, planning and early implementation, and built
government commitment to move forward with the IMCI
strategy. In the early implementation phase, countries
gained experience while implementing IMCI in limited
geographic areas. They developed their national strategy
and plan, adapted the IMCI guidelines to their national
context, developed management and training capacity in
a limited number of districts, and started implementing
and monitoring IMCI. The end of this phase was marked
by a review meeting with the objective of synthesizing
expansion. In the expansion phase, countries increased
both the range of IMCI interventions and IMCI coverage.
An important challenge emphasized in planning for the
expansion phase was maintaining quality while expanding
and planning for
The Multi-Country Evaluation of IMCI Effectiveness,
Cost and Impact (MCE-IMCI)
The MCE-IMCI includes studies of the effectiveness,
cost, and impact of the IMCI strategy in Bangladesh,
Brazil, Peru, Tanzania and Uganda (Bryce et al. 2004).
In-depth studies assessing the feasibility of conducting a
large-scale impact evaluation like the MCE-IMCI were
conducted in seven additional countries. Planning for the
MCE-IMCI began in 1997, just as the first countries were
adapting the IMCI strategy and moving into the early
implementation phase. The evaluation objectives were to
assess the behavioural, nutritional and mortality impact
of IMCI, as well as to document the effect of IMCI
interventions on health worker performance, health
systems and family behaviour. The MCE-IMCI was
planned as one part of a larger research agenda that
included efficacy evaluations of the individual interven-
tions within IMCI, as well as qualitative and operations
research. Details about the development, design and
implementation of the MCE-IMCI are available elsewhere
(Bryce et al. 2004). A key focus of the MCE-IMCI was
the implementation of the IMCI strategy in the hands of
governments, and the results therefore have relevance to
efforts to improve the delivery and utilization of a broad
range of public health interventions (Bryce et al. 2003;
Victora et al. 2004).
The IMCI impact model
The MCE-IMCI Technical Advisory Group was created
in 1998, and included experienced researchers and
evaluators in the fields of child survival, economics and
health policy. Advisors worked closely with IMCI
developers from WHO and UNICEF to develop an
impact model for IMCI. This model was needed as a basis
for defining the specific types and magnitude of changes
expected from the introduction of IMCI, for choosing
indicators and for calculating sample sizes. Parts of this
model were then computerized using an approach that
was similar to that of Becker and Black (1996) and used to
estimate the magnitude of mortality reduction that could
be expected from introducing IMCI in different settings.
Figure 2 presents a greatly simplified version of the
model; the full model is available for review at [http://
www.who.int/imci-mce/]. Each of the arrows in Figure 2
reflects an expectation among WHO programme staff
in the late 1990s about the pathways through which
the introduction of IMCI at country level would lead to
improvements in child survival and nutrition. Important
exceptions are the boxes on coverage, which were added
only in 2004 based on the MCE-IMCI findings.
The temporal dimension of the model moves from level 1
to level 4. The first level defines the planning steps and
inputs needed to initiate IMCI-related activities. The
second level outlines how these activities were expected
to lead to implementation of the IMCI interventions.
The third and fourth levels specify the pathways through
which these IMCI interventions were expected to lead
to intermediate behavioural outcomes and to impact on
health status, respectively.
The objective of this paper is to compare the findings of
the MCE-IMCI relative to the programme expectations
reflected in the IMCI impact model. We review five of the
most important programme expectations from the impact
model and describe the extent to which each was realized
in IMCI implementation among countries participating
in the MCE-IMCI. These expectations are: (1) The generic
IMCI guidelines could and should be adapted and
implemented in developing countries with an infant
mortality of more than 40/1000 live births (WHO
1998a); (2) IMCI case management training would lead
to improved quality of care at first-level health facilities;
(3) The introduction and implementation of IMCI would
contribute to strengthening health system supports;
(4) Families would respond to improved quality of care
in government health facilities, leading to increases in
utilization and reductions in child mortality; and (5) All
three components of the IMCI strategy could be imple-
mented in a coordinated fashion at country level within
a time frame of 3 to 5 years. In our conclusions we
Pathways to child survivali7
summarize what has been learned from the MCE-IMCI
about effective child survival programmes and highlight
implications for other public health initiatives.
The MCE-IMCI consisted of a series of independent
studies with compatible designs, each tailored to the
stage and characteristics of IMCI implementation in the
participating country (Bryce et al. 2004). The set of
site-specific studies included prospective, retrospective
and mixed designs. They reflected a continuum from
efficacy to effectiveness, with variable degrees of influence
from the evaluation team on programme implementation.
Each study addressed the need to document the plausi-
bility of an effect of IMCI on intermediate steps defined
in the impact model. All studies measured an identical
set of indicators and, with few exceptions, used identical
data collection tools. Observation-based surveys were
used to assess the quality of child health care provided
in health facilities. Cost data were collected at the
household, health facility, district and national levels.
Household surveys assessed preventive practices and
family responses to illness. All tools were adapted to
respond to local characteristics and questions, and in
some sites the variables necessary to assess equity were
The MCE-IMCI includes three different types of studies,
each of which provides important findings relative to the
(1) The 12-country assessment of IMCI implementation.
The country selection process for the MCE-IMCI
included visits by teams of MCE-IMCI Advisors and
WHO staff to countries selected by WHO as
representing the best examples of IMCI implementa-
tion at that time. All countries in each of the six
WHO regions were evaluated against a set of criteria
that included the probability that the government
would be successful in implementing all three
components of the IMCI strategy over the subse-
quent 5 years. Further information on eligibility
criteria are presented elsewhere (Bryce et al. 2004).
Based on this review, in each region one or two
countries judged most likely to meet the criteria were
selected for assessment visits. The assessment proto-
col included in-depth reviews of country-level plans
and progress in child health activities, including but
not limited to IMCI. More than one assessment visit
was made to several countries in which small studies
were commissioned to evaluate the potential for
successful IMCI implementation. Although the
countries visited had been implementing IMCI for
varying periods of time, the search was restricted
to those likely to implement IMCI fully, in large
geographical areas, within the 2 years after the
health / nutrition
quality of care in
Increased coverage for curative & preventive interventions*
Increased training coverage*
*added later as a result of MCE-IMCI findings.
Figure 2. A simplified version of the IMCI impact model developed in 1999–2000
i8 Jennifer Bryce et al.
assessment visit, allowing an impact evaluation
period of 2 to 3 years within the time frame of the
MCE-IMCI. Bangladesh was included as a site even
though IMCI implementation had not yet begun, to
serve as an efficacy study in which the investigators
could collaborate with the Government in imple-
menting the strategy under relatively ideal condi-
tions. Findings from the 12-country assessment
provide important information on the validity of
those parts of the IMCI impact model related to
planning and implementing activities across the
three model components (WHO 1999b); some of
their implications have been reviewed and discussed
elsewhere (Victora et al., in press).
In-depth studies in five sites. Based on the findings
of the 12 country assessments described above,
Bangladesh, Brazil, Peru, Tanzania and Uganda
were selected as in-depth study sites. In Peru, IMCI
had already been taken to scale and implemented
nationwide, so the evaluation used a fully retro-
spective design and relied heavily on routine data
sources. IMCI implementation was in the expansion
phase in Brazil, Tanzania and Uganda, and each
design represented a mixture of retrospective and
prospective elements. In Bangladesh, as explained
above, a fully prospective design was possible
because IMCI implementation had not yet begun
at national level. In both Bangladesh and Tanzania,
MCE-IMCI investigators are participating actively
in the Government’s plans for IMCI implementa-
tion. Table 1 presents a summary of characteristics
and MCE-IMCI data collection activities in the five
in-depth sites. Full descriptions of the methods and
results for each study site are available at [http://
Cross-site analyses. The use of standard indicators
and analysis plans permitted comparisons across
the five MCE-IMCI study sites. Topics addressed to
date include the effect of IMCI in improving care
quality in first-level health facilities (Gouws et al.
2004), health system barriers to scaling-up (Victora
et al. 2004), and the importance of context-specific
delivery mechanisms (Bryce et al. 2003), as well as
methodological issues (Bryce et al. 2004; Bryce and
Victora 2005; Gouws et al. 2005).
In addition, other documentation and research efforts
related to IMCI were reviewed carefully and the findings
were taken into account in interpreting MCE-IMCI
The analytic approach used in the MCE-IMCI varied
among countries. As shown in Table 1, all evaluations
entailed a comparison, either between areas with and
without IMCI (Bangladesh, Brazil and Tanzania) or
among areas with variable degrees of implementation
(Peru and Uganda). Details of the analytical approaches
are available in the country-specific publications from
Bangladesh (Arifeen et al. 2005), Brazil (Amaral et al.
Table 1. Characteristics of in-depth study sites in the Multi-Country Evaluation of IMCI, 2000
Total population (1000)
Baseline under-5 mortality
GNP per capita (2000 US$)
Total adult literacy rate
Randomized trial of 10
health facilities with IMCI
and 10 without IMCI
Comparison of 32 IMCI
and 64 non-IMCI
Comparison of 25 departments
with different levels of IMCI
Pre–post comparison of
2 IMCI and 2 non-
Comparison of 10 districts
with different levels of
Household coverage surveys 2000 (baseline);
2001 & 2002 in catchment
areas of 10 study districts
Health facility assessments
1999 (pilot study in
Ongoing rolling sample
Included in survey tools
Included in survey tools
Included in survey tools
Included in survey tools
Type of inference
*Source of demographic estimates: UNICEF (2000).
Pathways to child survivali9
2004), Peru (Huicho et al. 2005), Tanzania (Armstrong
Schellenberg et al. 2004a) and Uganda (Pariyo et al. 2005).
Expectation 1: The generic IMCI guidelines could and
should be adapted and implemented in developing countries
where infant mortality is higher than 40 per 1000 live births
Although the original target for the IMCI case manage-
ment guidelines was countries with infant mortality rates
of at least 40 per 1000 (WHO 1998a), other countries
or specific geographic areas within countries found the
concept of integration attractive and moved to adapt
and adopt them as well. For example, the Pan American
Health Organization ‘...urges all countries to incorporate
IMCI as a basic standard for child care’ (PAHO,
undated). There was an expectation in the early years of
IMCI introduction that the generic guidelines could and
would be adapted by any country or area to reflect their
specific epidemiological profile and health system char-
acteristics. WHO therefore worked in the late 1990s to
develop guidelines for the country adaptation process,
including evidence for intervention choices, models for
how to incorporate additional diseases and conditions
into the training materials, and how to conduct local
studies to identify terminology and local foods (WHO
1998b). Cadres of ‘IMCI adaptation consultants’ were
trained at regional and global levels.
The resource-intensive efforts at country level required to
adapt the generic IMCI guidelines were necessary because
the specific pneumonia-diarrhoea-malaria profile under-
lying the generic IMCI algorithm represents countries
that accounted for only about 35% of under-five deaths
in 2000 (Black et al. 2003). The remaining 65% of deaths
occurred in epidemiological contexts without endemic
malaria, dominated by neonatal disorders or in a few
countries with generalized epidemics of HIV/AIDS.
The widespread uptake of the IMCI concept resulted in
overextension of the guidelines to settings with disease
profiles that varied widely from those for which they were
The IMCI strategy as defined in 1996 applied only to
children from the ages of 1 week to 5 years (Gove 1997),
and did not include interventions addressing deaths in the
early neonatal period. The cause structure of infant deaths
was not well understood at that time, and few interven-
tions had been fully developed and evaluated for efficacy.
The eventual expectation that a set of generic algorithms
based on the global distribution of causes of death,
combined with support for adaptation at country level,
would be an efficient way to improve case management
in all countries proved over-ambitious. With benefit of
hindsight, greater technical efficiency might have been
gained if lower mortality countries had been encouraged
to develop, or wait for, epidemiologically driven algo-
rithms more consistent with their cause-of-death profiles
for children under 5 years of age, and the incorporation
of interventions designed to reduce deaths from causes
in the neonatal period.
Another part of the expectation was that IMCI could
and should be implemented fully regardless of the strength
of the health service system. Again this was an implicit
expectation, but was supported by the fact that virtually
every developing country was approached by WHO
to introduce IMCI. IMCI implementation guidelines
suggested that countries with weak health systems
should begin slowly with IMCI implementation, and
build toward stronger health system strength and inte-
grated programmes simultaneously and synergistically
(Lambrechts et al. 1999; WHO 1999b).
Expectation 2: IMCI case management training would lead
to improved quality of care at first-level health facilities
One part of this assumption, that IMCI case management
training would improve health worker performance and
thus contribute to improved care quality, has been
repeatedly borne out through MCE-IMCI findings
(Amaral et al. 2004; Armstrong Schellenberg et al. 2004b;
El Arifeen et al. 2004; Gouws et al. 2004). In all settings
where case management training was implemented at
minimum standards of quality, and where sufficient
coverage of trained workers was able to be maintained
at health facility level, the quality of care improved.
Ill children managed by health workers trained in IMCI
receive a more thorough assessment than children cared
for by workers without IMCI training, and are more likely
to receive correct treatment. Caretakers are more likely
to receive key messages about how to continue care at
home and when to return to the facility.
Expectation 3: The introduction and implementation
of IMCI would contribute to strengthening health
Early experiences with IMCI implementation suggested
that the inter-programme working groups at national
level that were recommended as a mechanism to plan for
IMCI, and specific planning steps such as the review and
updating of child health policies and essential drug lists,
would lead to activities designed to improve health system
supports for child health activities (WHO 1999b). In most
countries this assumption, at this level, was borne out.
The introduction of IMCI led to the rationalization of
child health policies and the updating of essential drug
lists in most countries in Africa, for example (Lambrechts
et al. 1999; WHO 2000).
In three of the 12 countries assessed, IMCI benefited
from activities designed to strengthen the health system.
In Tanzania, the Tanzania Essential Health Intervention
Project (TEHIP) introduced basic management tools at
district level (De Savigny et al. 2004) which permitted an
effective use of decentralized health resources and resulted
in the adoption of IMCI. Other districts with the same
resources but without the TEHIP tools did not adopt
i10 Jennifer Bryce et al.
IMCI until later when MCE-IMCI results had demon-
strated its efficiency. In Bangladesh, as a part of the
MCE-IMCI efficacy study, record keeping and super-
vision were strengthened. In Brazil, routine supervision
was strengthened in MCE-IMCI sites in collaboration
with district health teams.
It is striking that the quality of trained IMCI workers
was much better than that of the untrained workers,
even if they received no supervision. Supervision systems,
including a decentralized approach implemented in
Tanzania designed explicitly to overcome barriers due to
distance and the expense of transportation, were unable to
be sustained in any of the countries. Even integrated
approaches in Tanzania and Uganda that combined child
health/IMCI supervision within broader training and
administrative activities proved too ambitious, particu-
larly with respect to the need to include clinical observa-
tion and feedback as a part of all supervision visits.
A second part of this expectation reflected assumptions
about the structure of health systems, as opposed to their
strength or level of functioning. For instance, the impact
of facility-level IMCI depends on the coverage of facilities
with an adequate proportion of IMCI-trained staff,
which depends on staff deployment and retention policies
and practice. In three of the in-depth study sites, staff
turnover was a serious impediment to sustained imple-
mentation of IMCI case management in health facilities
because it prevented sufficient coverage of IMCI-trained
workers within the health facilities. In Brazil, 42% of
health workers who participated in IMCI case manage-
ment training were transferred within 1 year, in part due to
competition between municipalities to meet public expec-
tations that health workers would provide care based
on IMCI guidelines. This lack of stability in coverage
was seriously compounded when Brazil forbade nurses
from delivering IMCI, so that only physicians could be
deployed. Coverage was not explicitly included in the
original impact model (Figure 1). Its addition, and more
important, efforts to focus renewed child survival efforts
on the need to achieve and sustain equitable coverage,
represent a major step forward in thinking about how
to reduce child mortality.
In assessment visits to Kyrgystan and Kazakhstan, the
MCE-IMCI discovered that the health system challenges
facing IMCI implementation were different from those
faced in other countries, and related to changing rather
than strengthening the health system.
In conclusion, the expectation of improved health system
support was only partially fulfilled in the areas of policy
development and drug supply. IMCI drew attention
to the improvement of health worker skills, but was
unable to address larger human resource issues, including
which cadres of staff are permitted to provide which
services, policies on deployment and transfer and issues
of retention, all of which are inextricably tied to the
provision of health services and therefore to the imple-
mentation of a child survival strategy. Some important
aspects influencing the delivery of high impact interven-
tions contained within IMCI, such as financing, were
ignored in the model. In retrospect, the IMCI model
reflected issues directly related to service delivery appro-
priately, but proved insufficient with respect to other
aspects of the health system such as transition path-
ways from policy and strategy to operations, human
resource issues including supportive supervision, financ-
ing and ensuring an equitable coverage of interventions.
This conclusion was supported by the findings of the
six-country analytic review of IMCI (DFID et al. 2003).
Expectation 4: Families would respond to improved quality
of care in government health facilities, leading to increases
in utilization and reductions in child mortality
The logic of this explanation is reflected in early IMCI
documents, most of which opened with a pie chart
showing the major causes of death among children under
five (WHO 1997), and introduced IMCI as a strategy
that could reduce mortality from these causes, and then
moved directly into how to plan for the training of health
workers in first-level government health facilities. Despite
the conceptual framework emphasizing the need for
concomitant efforts to strengthen health systems and
address key family practices, the de facto priority was
training government health workers.
Three factors contributed to the negative effect of this
expectation on IMCI outcomes and impact. First, a focus
on government health facilities meant that the eventual
impact of the strategy depended on the extent to which
such facilities were used by families for the care of their
sick children. The results of the computer simulation of
the IMCI impact model also indicated that measurable
reductions in child mortality and improvements in
nutrition would not be realized unless utilization of
government health facilities was increased sharply in
many countries (or alternatively, coverage rates for key
interventions were increased rapidly through community-
based delivery strategies). MCE-IMCI baseline studies
showed that with the exception of Tanzania, where about
40% of ill children were taken first to a government
health facility (Armstrong Schellenberg et al. 2004a),
utilization rates for government health facilities were very
low, ranging from about 8% in Uganda study districts
to 13% in Bangladesh. Utilization was even lower in
Niger, where a review of records by the MCE-IMCI
assessment team found fewer than one contact between
a child and the health care system per year.
Secondly, IMCI programme staff anticipated that low
rates of utilization for public health facilities at country
and district level could be increased through activities
designed to improve careseeking at community level.
As indicated above, these community-based activities
remained patchy and largely ineffectual. Within the
efficacy study in Bangladesh, where implementation of
IMCI under ideal conditions included both improvements
in the quality of care at health facilities and strong
delivery of careseeking messages at community level, the
Pathways to child survivali11
introduction of the strategy was associated with signifi-
cant increases in utilization (El Arifeen et al. 2004).
Thirdly, there have been few efforts within IMCI to
involve health care providers other than the government.
This is now being done in the MCE-IMCI efficacy study
in Bangladesh, where non-governmental providers deliver
most child health care.
In summary, MCE-IMCI findings indicate that improving
the quality of care in first-level government health
facilities was not sufficient, alone, to increase low
utilization levels. Where utilization was already relatively
high, as in Tanzania, improved care quality was asso-
ciated with reductions in under-five mortality. Early
findings from the study in Bangladesh suggest that if
appropriate careseeking messages can be disseminated at
high levels of population coverage, they can work together
with improved quality of care at facilities to increase
Expectation 5: All three components of the IMCI
strategy could be implemented in a coordinated fashion
at country level within a time frame of 3 to 5 years
Table 2 presents a qualitative summary of the MCE-IMCI
findings from the MCE-IMCI assessment visits conducted
between 1998 and 2002. Implementation strength is
characterized for each of the three IMCI components as
‘strong’ (in the expansion phase), ‘weak’ (in the introduc-
tion or early implementation phase), or ‘none’. With the
exception of Bangladesh, where IMCI had not yet been
introduced, all countries had begun implementation of
IMCI activities to improve health worker performance.
Fewer specific activities were under way to improve health
system support for IMCI, or to start or expand the
delivery of IMCI-compatible messages at community and
The design of the MCE permitted in-depth, long-term
documentation of IMCI implementation in the five study
sites. Figure 3 illustrates the wide variability in IMCI
implementation among the MCE-IMCI sites by mapping
onto the impact model the IMCI interventions being
delivered in two of these sites at the time of the final
MCE-IMCI mortality assessment: Tanzania (Figure 3a)
and Peru (Figure 3b).
Programme staff at WHO and their country counterparts
were confident at the outset that 3 to 5 years would allow
sufficient time for the establishment of IMCI implementa-
tion, including the move from pilot experiences in a few
districts as well as a good start on scaling-up the strategy.
In no MCE-IMCI country was this expectation realized,
and even full implementation of the training component
required longer periods than expected.
In most countries, the demands of implementing the
IMCI case management training course for health work-
ers in first-level facilities were far greater than expected,
and difficult to sustain after the initial pilot period.
Training facilitators, preparing materials and, in particu-
lar, conducting the follow-up visits that were included as
an essential part of the training course required massive
organizational skills and dedicated staff. Various short-
cuts were adopted by countries to make it possible to
scale-up the IMCI training – including reducing training
duration, abandoning follow-up visits or incorporating
IMCI content into preservice or national inservice
training courses for specific cadres of workers – with
potentially unfortunate effects on training quality and
subsequent performance by health workers. This requires
evaluation and development of feasible solutions that
result in good care.
In all 12 MCE-IMCI countries, the pace of implementa-
tion was also slower than expected in the health system
and community components. Some activities related to
improving health system support for IMCI or family
practices were implemented in some countries, but
with the exception of previous interventions designed to
strengthen district health management in the areas of
Table 2. Strength of implementation of IMCI components in ‘high-performing’ countries at the time of assessment for participation in the
Country Date of last assessment visit Component of the IMCI Strategy
i12Jennifer Bryce et al.
Tanzania taking part in the MCE (De Savigny et al. 2004),
these activities were not implemented at levels of coverage
sufficient to lead to measurable outcomes. Community
IMCI was weak, as shown in Figure 3 for Tanzania and
Peru. These findings were confirmed by the Analytical
Review of IMCI, a process that took place in 2002 and
consisted of a review of IMCI implementation through
short visits to six countries (Zambia, Indonesia, Egypt,
Mali, Kazakhstan and Peru) by a team of experts from
WHO, UNICEF, DFID and USAID (DFID et al. 2003).
The MCE-IMCI also showed that in Peru and Tanzania,
implementation of community activities was not coordi-
nated with facility-based IMCI case management training.
Health workers were being trained in some districts
while the community component was being implemented
in different districts, thus failing to achieve the intended
synergism between the two components. So-called ‘com-
munity IMCI programmes’ were often restricted to the
promotion of standard interventions (e.g. breastfeeding,
mosquito nets, vaccines) and failed to emphasize family
practices most likely to interact synergistically with
facility-based IMCI to achieve impact (i.e. careseeking,
compliance and home care).
Discussion: pathways to child survival
The achievement of population level health impact is
driven to a large extent by intervention efficacy, quality of
care, intervention utilization and coverage (Tugwell et al.
1985). Expectations about what IMCI would achieve in
terms of impact on child mortality and undernutrition
expanded incrementally as the strategy evolved, but
there was no concurrent evolution of resources, staff
support and other implementation prerequisites. The
initial guidelines for introducing and implementing IMCI
included efficacious interventions, and were designed to
support the rapid introduction of IMCI in high mortality
countries, and were successful in that regard. The findings
presented here, however, show that many countries
were unable to move beyond the introductory stage
to implement IMCI fully and at levels of population
coverage that would yield an impact. Although IMCI
increased quality of care where implemented, countries
struggled to scale-up IMCI rapidly to achieve higher levels
of coverage. The lack of strategic and operational plans
targeting different health system and epidemiological
contexts, and execution thereof, were probably important
barriers to achieving impact.
Strategically, the widespread adoption of IMCI by
countries with under-five mortality levels lower than
those for which the strategy was initially developed
meant that intervention and delivery strategies required
major adaptations at country level and below. Deaths in
the first week of life are a major part of under-five
mortality world wide (Bryce et al. 2005a), and were not
addressed by the strategy. This finding from the IMCI
evaluation has contributed to the establishment of a
special Steering Group and activities to address these gaps
(Darmstadt et al. 2005; Lawn et al. 2005).
Operationally, countries struggled to scale-up IMCI
rapidly to achieve higher levels of coverage. Specific
operational plans and tools to translate policies into
action, to prioritize high impact interventions addressing
major mortality causes, to identify the funds, human
resources and delivery channels to deliver these, and to
bring partners together around one implementation plan,
including mechanisms for monitoring, were not available.
This evolution led to a clear mismatch: countries that had
the mortality level and cause profile that most required
IMCI often lacked the basic health systems infrastructure
and support to deliver it; on the other hand, countries
with the required infrastructure and support often had
cause-of-death profiles that were inconsistent with an
impact of IMCI as it was defined at that time.
Some of the most basic MCE findings lend strength and
urgency to existing dilemmas in child survival and public
quality of care in
Increased training coverage*
Increased coverage for curative & preventive interventions*
dquality of care in
Increased training coverage*
Increased coverage for curative & preventive interventions*
*added later as a result of MCE-IMCI findings.
*added later as a result of MCE-IMCI findings.
Figure 3. Implementation of IMCI in two MCE-IMCI study
sites as of December 2003: (a) Tanzania; (b) Peru
Pathways to child survivali13
health programming, exacerbated by continuing shortages
of resources. For example, the development of the IMCI
case management guidelines was both innovative and
pragmatic in its time as a way to improve service quality
in high-mortality countries, but like other initiatives,
the strategy lacked relevance and therefore effectiveness
when implemented beyond its intended focus – in this
case, in countries with lower mortality rates and high
proportions of deaths in the neonatal period. One
implication for programmes would be to limit implemen-
tation to countries with a specific epidemiological
profile, but the consequence would be to do less for
large populations of children in ‘transitional’ countries
with high proportions of neonatal deaths. A similar
dilemma arises relative to the need for health system
support; the challenges here are enormous and continue
to be under-funded. Our results only begin to address
questions about which aspects of health systems are most
critical and mutable and how best they can be addressed.
Extension of intervention delivery beyond public facility-
based services as a way to increase intervention coverage
is a major step, and while arguably very important, the
methods for generating and implementing effective solu-
tions to the challenges revealed by the MCE need more
research and development.
There is a natural negative bias inherent in this type of
retrospective analysis. Our intention was to use the
findings of the MCE-IMCI to make the expectations
underlying the original IMCI strategy explicit, and to
assess their validity as a basis for strengthening child
survival efforts in the future. Integrated case management
in health facilities was visionary at the time it was
developed and has proven cost-effective in improving
the quality of care (Bryce et al. 2005c). Renewed efforts
to improve child survival must retain facility-based
IMCI, and move ahead to strengthen the delivery of
child survival interventions at the community level.
There are several factors that in combination make the
present an opportunity to mount renewed and more
effective child survival programmes. New attention to
child survival, new leadership in key organizations, and
a focus on achieving the Millennium Development Goal
of reducing child mortality by two-thirds all provide
the impetus to move quickly, forcefully and in new ways
to achieve universal coverage with proven child survival
interventions. What are the policy lessons from our
experience with IMCI that can make these renewed
efforts more effective?
First, child survival efforts must begin with local
epidemiology, targeting the major causes of death within
each region, country and even district (Bryce et al. 2005a).
Secondly, integrated guidelines for the case management
of ill children in health facilities, supported by high-
quality training and supportive supervision, are the gold
standard and should continue to be implemented widely.
New evidence that IMCI is efficient (Bryce et al. 2005c)
and costs less than routine care in some settings (Adam
et al. 2005) is encouraging, as are more global estimates of
the affordability of essential child survival interventions
(Bryce et al. 2005b).
Thirdly, we must move beyond health facilities, and
develop new and more effective ways of reaching
children with proven interventions to prevent mortality.
In most high-mortality settings, this means providing
case management services at community level, as well
as focusing on prevention and on reducing rates of
Fourthly, we must make coverage the driving force
behind district, national, regional and global child
survival programmes. Only by paying close attention to
whether mothers and children receive interventions can
we decipher whether the delivery methods are effective
and equitable, and whether mortality reductions are
likely. Public accountability at all levels can bring delivery
bottlenecks to the attention of all, and encourage rapid
action to address them.
Fifthly, we must help countries prioritize and put first
those interventions known to be cost-effective in reducing
under-five mortality (Jones et al. 2003; Darmstadt et al.
2005). Better tools to support policy and decision makers
in estimating the costs and impact of their choices are
essential. Developing management structures that increase
accountability at local level (e.g. de Savigny et al. 2004)
are a promising way forward. Ensuring that resources
are available, not only for time-limited projects but in
the longer term, is essential to allow sufficient time for
planning and implementation to mature and yield impact.
Finally, we must support policy-relevant research at
country level, especially studies that focus on the
effectiveness of policies and strategies implemented by
Ministries of Health and their partners.
It is time for a paradigm shift in child survival: from
delivery systems that rely solely on government health
facilities to those that include the full range of channels
and strong community-based approaches; from a focus on
process to greater accountability for coverage at popula-
tion level; from single approaches requiring massive
adaptation at country level to bottom-up approaches
that begin with local epidemiology and apply tools
developed for specific epidemiological profiles.
These lessons are certainly relevant beyond the field of
child survival. For example, the massive 3?5 programme
(WHO 2005b) for care and prevention of HIV, Stop TB
for global tuberculosis control (WHO 2003) and the Roll
Back Malaria initiative [http://www.rbm.who.int/] are
already struggling with many of the same health systems
barriers that have hindered IMCI implementation.
The remaining papers in this special issue of Health Policy
and Planning provide greater detail on MCE-IMCI
i14 Jennifer Bryce et al.
findings in specific areas. Together, they provide concrete
lessons that can help policy makers, researchers and
public health professionals at all levels do a better job
of delivering effective interventions to the children that
need them, and improving child survival.
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This work is part of the Multi-Country Evaluation of IMCI
Effectiveness, Cost and Impact (MCE-IMCI), coordinated by the
Department of Child and Adolescent Health and Development of
the World Health Organization (CAH/WHO), and supported by the
Bill and Melinda Gates Foundation and the US Agency for
International Development. We are grateful to the many MCE-
IMCI investigators who designed and carried out the MCE-IMCI
studies in the five MCE-IMCI sites, and specifically to principal
investigators Shams El Arifeen (Bangladesh), Joa ˜ o Amaral (Brazil),
Luis Huicho (Peru), Hassan Mshinda (Tanzania) and George Pariyo
(Uganda). Elizabeth Mason, first in her work in the Office of
the WHO Africa Region and more recently as the Director of
CAH/WHO, has collaborated closely with the MCE-IMCI and
been receptive throughout for its findings and their implications
for policy. Stan Becker worked tirelessly to develop the computer
simulation of the IMCI impact model and to ensure that the findings
were disseminated to and discussed with key decision makers
in child health. We also thank Alice Ryan and Cathy Kiener of
the World Health Organization for their managerial and adminis-
trative support to this work. Most important, we thank the many
health workers, mothers and children who participated in this
On behalf of all of the authors who contributed to the series,
we would like to thank the Editorial Staff of Health Policy and
Planning and the anonymous reviewers they selected to review our
work. Their suggestions were uniformly helpful and constructive,
and contributed to the overall quality of the papers.
Jennifer Bryce was working as a Scientist at the Department
of Child and Adolescent Health and Development, World Health
Organization, Geneva, Switzerland, at the time this work was
initiated. She developed and coordinated the Multi-Country
Evaluation of IMCI Effectiveness, Cost and Impact supported
by WHO and the Bill and Melinda Gates Foundation until 2004,
and provided technical support for child health epidemiology
and child health and poverty work within the Department. She
received her doctorate in education from Columbia University
(1980), and completed postdoctoral training in policy analysis
with the Vanderbilt University Institute for Public Policy Studies
(1982). She has worked in public health programme evaluation
for various institutions and agencies since 1983, including the
US Centers for Disease Control and Prevention, WHO, the
American University of Beirut and the Michigan State Health
Cesar G Victora is Professor of Epidemiology at the Federal
University of Pelotas in Brazil, which he joined in 1977 after obtain-
ing his MD from the Federal University of Rio Grande do Sul (1976).
In 1983, he obtained a Ph.D. in Health Care Epidemiology at the
London School of Hygiene and Tropical Medicine (LSHTM). He
has conducted extensive research in the fields of maternal and child
health and nutrition, equity issues and the evaluation of health
services. He has worked closely with UNICEF and with the World
Health Organization, where he is the Senior Technical Advisor
to the Multi-Country Evaluation of the Integrated Management
of Childhood Illness Strategy, and a member of the Advisory
Committee on Health Research. Since 1996, his unit was designated
as a WHO Collaborating Centre in Maternal Health and Nutrition.
He is also an Honorary Professor at the LSHTM.
Jean-Pierre Habicht has been the James Jamison Professor of
Nutritional Epidemiology at Cornell University, Ithaca, NY, USA,
since 1977. He obtained a Doktorat der Medezin (1964) from the
University of Zurich, Switzerland, an MPH from Harvard School of
Public Health (1968) and a Ph.D. in Nutritional Biochemistry from
MIT (1969). From 1969–74 he served as a WHO medical officer in
Guatemala where he developed, implemented and evaluated the
impact of a primary health care system. He has conducted research
in child and maternal health, including controlled field intervention
trials, and the evaluation of the contextual determinants of nutri-
tion and health. He is a member of the Technical Advisor for the
Multi-Country Evaluation of the IMCI Strategy.
Robert E Black is the Edgar Berman Professor and Chair of the
Department of International Health of the Johns Hopkins
University Bloomberg School of Public Health in Baltimore, USA.
He has worked closely with UNICEF and with the World Health
Organization (WHO), where he serves as a Technical Advisor to the
Department of Child and Adolescent Health and Development
(Multi-Country Evaluation of the IMCI Strategy), as an expert in
Maternal and Child Nutrition, and as a member of the Advisory
Committee on Health Research. He has served as a Trustee for the
International Centre for Diarrhoeal Diseases Research (ICDDR,B)
in Bangladesh, and as a Technical Advisor to the Tanzania Essential
Health Interventions Project, and he is currently a member of the
Expert Group on Health of the Global Governance Initiative of
the World Economic Forum. He was elected to membership in the
Institute of Medicine of the National Academy of Sciences, effective
1 October 2002.
Robert Scherpbier is a generalist physician with postgraduate
degrees in tropical medicine (Antwerp, 1992) and public health
(Baltimore, 1997). He has worked on outcome-oriented programmes
and health systems for the Ministry of Health, Ghana and many
other countries. He joined the StopTB Department of the World
Health Organization (WHO) in 1997. Since 2002, he has been a
medical officer in the Department of Child and Adolescent Health
and Development. He coordinates the Multi-Country Evaluation
i16Jennifer Bryce et al.
of the IMCI, and the development of a health systems approach to Download full-text
child health. He is WHO’s Regional Focal Point for child health in
the Western Pacific Region. He is a visiting lecturer at the Brescia
University and an Examination Board member of the Dutch Royal
The MCE-IMCI Technical Advisory Group includes four members
in addition to named authors CGV, J-PH, and REB: Don de
Savigny served as the Director of Research for the Tanzania Health
Interventions Project on behalf of the International Development
Research Center of Canada (IDRC) for the first 5 years of the MCE-
IMCI; David Evans, who is Director of the Department of Health
Systems Financing within the Evidence and Information for Policy
Cluster of the World Health Organization; Joanna Armstrong
Schellenberg, who is a Senior Lecturer in Epidemiology at the
London School of Hygiene and Tropical Medicine (LSHTM) and
served as the Co-principal Investigator for the MCE-IMCI-
Tanzania from 1999 to 2004; and J Patrick Vaughan, a health
systems specialist and Professor at LSHTM. The seven MCE-IMCI
Technical Advisors provided independent technical guidance for
the MCE-IMCI beginning in 1998. They met at least twice each
year, as well as providing review and recommendations on all site
proposals, reports and cross-site publications.
Correspondence: Robert Scherpbier, Department of Child and
Adolescent Health and Development, World Health Organization,
Via Appia, 1211 Geneva 27, Switzerland. Tel: þ41 22 791 2693;
Fax: þ41 22 791 4853; E-mail: email@example.com
Pathways to child survivali17