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Are health interventions being implemented where they are most needed? Lessons from the Integrated Management of Childhood Illness strategy and from the literature

Date: Tuesday 30 October 10.45–12.15
Source: Forum 11
Authors: L Huicho, Professor of Paediatrics, Universidad Nacional Mayor de San Marcos, Peru
with JJ Amaral, J Armstrong-Schellenberg, F Manzi, E Mason, R Scherpbier and CG Victora

Abstract

This paper describes geographical implementation patterns of the Integrated Management of Childhood Illness (IMCI) strategy in three countries and explores whether it was implemented in areas with the greatest child health needs. We complement this information with additional findings of the Multi-Country Evaluation of IMCI (MCE of IMCI) and with a literature review on innovative implementation strategies for reducing equity gaps in child health.

The district uptake of IMCI was assessed through a desk review of governmental documents and databases, complemented by interviews with key informants in Brazil, Peru, and the United Republic of Tanzania.

Early IMCI implementation districts were close to the capital and had suitable training sites, motivated health managers and a functioning health system. In the expansion phase, IMCI tended to be adopted by other districts with similar characteristics. In Brazil, uptake by poor and small municipalities and those further away from the state capital was significantly lower. In Peru, there was no association with distance from Lima, and there was a non-significant trend for IMCI adoption by poor departments. In Tanzania, the only significant finding was lower uptake by remote districts. Implementation was not associated with baseline mortality levels in any of the three countries.

Whereas clear and reasonable guidelines are provided for selection of `early use' districts, no guidance was provided to countries regarding IMCI expansion, and high- risk areas were not prioritized. Equity analyses based on the geographical deployment of new programmes and strategies can contribute to assessing whether they are reaching those who need them most.

These findings are not unique to IMCI. Innovative implementation strategies aimed at reducing equity gaps need to be promoted and evaluated. A recent systematic review shows that programmes relying on training of lay health workers at primary and community level are encouraging. The literature also shows that comprehensive plans for primary health care interventions with active community involvement, conditional cash transfer initiatives, and pre-payment mechanisms for avoiding catastrophic out- of pocket spending, seem promising for reducing child health inequities. However, further research is needed to conclude whether social health insurance systems offer better or worse protection than tax-based systems.