Cathy Wolfheim

The World Health Report 2005 – Make Every Mother and Child Count, says that this year almost 11 million children under five years of age will die from causes that are largely preventable. Among them are 4 million babies who will not survive the first month of life. At the same time, more than half a million women will die in pregnancy, childbirth or soon after. The report says that reducing this toll in line with the Millennium Development Goals depends largely on every mother and every child having the right to access to health care from pregnancy through childbirth, the neonatal period and childhood.

This statement presents the latest evidence for integrated community case management of childhood illness, describes the necessary program elements and support tools for effective implementation, and lays out actions that countries and partners can take to support the implementation of integrated community case management at scale.

A systematic review was conducted to categorize and describe Intervention Models involving community health workers (CHWs) that aim to improve case management of sick children at the household and community levels. The review focused on management of children with signs of malaria or pneumonia. Seven Intervention Models were identified, and classified according to: (1) the role of CHWs and families in assessment and treatment of children, (2) system of referral to the nearest health facility (verbal or facilitated), and (3) the location in the community of the drug stock. Standardization of terminology for Intervention Models using this or a similar classification could facilitate comparison and selection of models, including deciding how to modify programmes when policies change concerning first-line drugs, and setting priorities for further research. Of the seven models, that of CHW pneumonia case management (Model 6) has the strongest evidence for an impact on mortality. Pneumonia case management by CHWs is a child health intervention that warrants considerably more attention, particularly in Africa and South Asia.

There is ample evidence from research and implementation to show that community health workers, when appropriately trained, supplied, supported and supervised, can identify and correctly treat most children for pneumonia, diarrhoea and malaria. Community management of childhood illness is an important contribution to the remarkable progress in reducing child mortality. Globally, the rate of under–five mortality has decreased by nearly half, from 90 deaths per 1000 live births in 1990 to 46 in 2013.

Integrated management of childhood illness (IMCI) was developed by the WHO and UNICEF in the mid-1990s as a strategy to reduce under-five mortality. Aimed at countries with mortalities >40/1000 live births, it has been adopted by more than 100 countries. Repeated evaluations have demonstrated that IMCI can improve the quality of clinical care for sick children, but coverage has rarely reached high enough levels to achieve the expected reductions in mortality. In this paper, we discuss the reasons why IMCI has fallen short of its full potential, what has already been done to address some of these issues, and how it could be repositioned to achieve its original goals.