John: Hello, I'm John Hilton, editor of the Cochrane Editorial unit. Alongside the thousands of Cochrane Reviews of drugs and other individual treatments are some that investigate the effects of packages of care. One such review was published for the first time in June 2016, assessing strategies intended to integrate the management of childhood illness. We asked lead author, Tarun Gera, from SL Jain Hospital in New Delhi, India to tell us why the review is so important and what it found.

Tarun: Every year, more than 7.5 million children die before reaching the age of five, mostly in low- and middle-income countries. This is largely attributed to the interaction of common infections such as neonatal sepsis, measles, diarrhoea, malaria, and pneumonia with poor nutritional status, inadequate health infrastructure and poverty. Effective and affordable interventions have been known to reduce childhood morbidity and mortality for some time, but their availability, accessibility, and acceptability to the ultimate beneficiaries have been low. Part of the problem is that the presence of multiple and overlapping illnesses makes diagnosis and treatment difficult. To address these issues, the World Health Organisation, in collaboration with the UNICEF and other agencies developed a strategy known as integrated management of childhood illness, or IMCI. This has three main components: improving the case management skills of healthcare staff; improving the overall healthcare system; and improving family and community healthcare practices.
More than 75 countries are implementing the IMCI strategy on a large scale. Individual components have often been tested and shown to be effective in randomized trials and systematic reviews, but we also need evidence on the impact of the package on hard outcomes, like child mortality and quality of care. We have tackled this in our review, looking into the effects of IMCI implementation on mortality, nutritional status, quality of care, and coverage with IMCI deliverables.
We were able to include four trials, all testing different implementations of IMCI. Two were cluster trials from India and Bangladesh, and two were controlled before and after studies in Tanzania and India.
Combining the findings revealed low certainty evidence suggesting some reduction in child, infant and neonatal mortality. Three studies from Tanzania, India and Bangladesh evaluated nutritional status and their moderate to low quality showed little or no effect on both stunting and wasting. Quality of care was studied by observing prescribing for common illnesses in two studies. Effects were mixed and included both no effect and quite large effects. We were also unable to confirm a consistent effect on prescribing at health facilities or by lay health care workers, because the certainty of the evidence was very low. For coverage of IMCI deliverables, we examined vaccine coverage, appropriate care seeking, and exclusive breast feeding; finding little or no effect on vaccine or vitamin A coverage. All four studies investigated appropriate care seeking and IMCI areas had reported better care seeking behavior in some studies, but not in others. The four studies also found mixed results on exclusive breast feeding, with very low certainty: some studies indicated that exclusive breast feeding was higher in IMCI areas but it was not very different in others.
In summary, we have shown that IMCI may have a modest effect on mortality and may well be worth implementing. However, policymakers need to be careful about justifying the considerable investment in IMCI on the basis that it will result in large improvements in mortality. We found inconsistent effects of the various IMCI strategies that have been tested on quality of care, but those implementing IMCI programmes should consider including services directed at the newborn baby as an integral component.

John: If you would like to learn more about the effects of the IMCI strategies and their various components in the studies in Tarun’s review, it’s freely available in full to everyone in the Cochrane Library. If you go online to Cochrane Library dot com and type IMCI into the search box, you’ll be able to find and download it.