Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial

doi:10.1016/S0140-6736(09)60828-X

The Lancet

Volume 374, Issue 9687, 1–7 August 2009, Pages 393-403

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https://doi.org/10.1016/S0140-6736(09)60828-X Get rights and content

Summary

Background

WHO and UNICEF launched the Integrated Management of Childhood Illness (IMCI) strategy in the mid-1990s to reduce deaths from diarrhoea, pneumonia, malaria, measles, and malnutrition in children younger than 5 years. We assessed the effect of IMCI on health and nutrition of children younger than 5 years in Bangladesh.

Methods

In this cluster randomised trial, 20 first-level government health facilities in the Matlab subdistrict of Bangladesh and their catchment areas (total population about 350 000) were paired and randomly assigned to either IMCI (intervention; ten clusters) or usual services (comparison; ten clusters). All three components of IMCI—health-worker training, health-systems improvements, and family and community activities—were implemented beginning in February, 2002. Assessment included household and health facility surveys tracking intermediate outputs and outcomes, and nutrition and mortality changes in intervention and comparison areas. Primary endpoint was mortality in children aged between 7 days and 59 months. Analysis was by intention to treat. This study is registered, number ISRCTN52793850.

Findings

The yearly rate of mortality reduction in children younger than 5 years (excluding deaths in first week of life) was similar in IMCI and comparison areas (8·6% vs 7·8%). In the last 2 years of the study, the mortality rate was 13·4% lower in IMCI than in comparison areas (95% CI −14·2 to 34·3), corresponding to 4·2 fewer deaths per 1000 livebirths (95% CI −4·1 to 12·4; p=0·30). Implementation of IMCI led to improved health-worker skills, health-system support, and family and community practices, translating into increased care-seeking for illnesses. In IMCI areas, more children younger than 6 months were exclusively breastfed (76% vs 65%, difference of differences 10·1%, 95% CI 2·65–17·62), and prevalence of stunting in children aged 24–59 months decreased more rapidly (difference of differences −7·33, 95% CI −13·83 to −0·83) than in comparison areas.

Interpretation

IMCI was associated with positive changes in all input, output, and outcome indicators, including increased exclusive breastfeeding and decreased stunting. However, IMCI implementation had no effect on mortality within the timeframe of the assessment.

Funding

Bill & Melinda Gates Foundation, WHO's Department of Child and Adolescent Health and Development, and US Agency for International Development.

Introduction

The Integrated Management of Childhood Illness (IMCI) strategy was launched in the mid-1990s by WHO and UNICEF to reduce deaths due to diarrhoea, pneumonia, malaria, measles, and malnutrition, which accounted for an estimated 70% of all global deaths of children younger than 5 years at that time.¹ A multicountry evaluation of IMCI began in 1997 to measure its effect on health and its cost-effectiveness.²

Five countries were included in the assessment, of which four have published final results: Brazil,³ Peru,⁴ Uganda,⁵ and Tanzania.⁶ In these countries, IMCI was already implemented under routine conditions when the assessment began, and investigators used observational designs to measure changes in process and effect indicators. Because IMCI had not yet been implemented in Bangladesh, government approval was obtained for a cluster randomised trial in which the study units were health facilities and their catchment areas. The objective was to assess the effect of IMCI on mortality and nutritional status in children younger than 5 years, and the cost-effectiveness of the strategy. This study was an efficacy trial of public health delivery⁷ in which efforts were made to achieve optimum delivery of IMCI, including active promotion of care seeking. Early findings showed improvements in the quality of care in health facilities, increases in use of health facilities, and gains in the proportion of sick children taken to an appropriate health-care provider.⁸ The trial lasted nearly 6 years to allow for both the achievement and measurement of a possible effect on health and nutrition. In this Article we present the final results.

Section snippets

Study setting and sample

The study was undertaken in Matlab upazilla (subdistrict). The sampling frame included 20 of the 24 first-level outpatient facilities in the study area and their catchment areas defined by reported care-seeking patterns for ill children in the baseline household census in 2000. Four units were excluded because substantial portions of their catchment populations received child and reproductive health services from the International Centre for Diarrhoeal Disease Research, Bangladesh. The

Results

Figure 2 shows the trial profile. IMCI and comparison areas were similar at baseline apart from the use of sanitary latrines, which was significantly higher in IMCI areas (table 1). The total population of the comparison area was about 43% larger than that of the IMCI area. We noted improvements in maternal education, type of housing, water supply, availability of latrines, and electricity in both areas over the duration of the study (table 1). Routine government programmes that were not part

Discussion

Unlike the other four studies in the multicountry evaluation of IMCI, the Bangladesh study used a randomised design, and the team collaborated with the government to lend support to strong implementation of all three components of IMCI on the basis of formative research.⁷ To mimic real-life programme management, we incorporated lessons learned in the initial implementation stages to enhance the programme—eg, by improving referral guidelines and incorporating community case management. With the

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ArticlesEffect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Study setting and sample

Results

Discussion

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Articles
Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial