Armstrong Schellenberg Joanna R M, Adam Taghreed, Mshinda Hassan, Masanja Honorati, Kabadi Gregory, Mukasa Oscar, John Theopista, Charles Sosthenes, Nathan Rose, Wilczynska Katarzyna, Mgalula Leslie, Mbuya Conrad, Mswia Robert, Manzi Fatuma, de Savigny Don, Schellenberg David, Victora Cesar
Ifakara Health Research and Development Centre, Ifakara, Tanzania.
Lancet. 2004;364(9445):1583-94. doi: 10.1016/S0140-6736(04)17311-X.
The Integrated Management of Childhood Illness (IMCI) strategy is designed to address major causes of child mortality at the levels of community, health facility, and health system. We assessed the effectiveness of facility-based IMCI in rural Tanzania.
We compared two districts with facility-based IMCI and two neighbouring comparison districts without IMCI, from 1997 to 2002, in a non-randomised study. We assessed quality of case-management for children's illness, drug and vaccine availability, and supervision involving case-management, through a health-facility survey in 2000. Household surveys were used to assess child-health indicators in 1999 and 2002. Survival of children was tracked through demographic surveillance over a predefined 2-year period from mid 2000. Further information on contextual factors was gathered through interviews and record review. The economic cost of health care for children in IMCI and comparison districts was estimated through interviews and record review at national, district, facility, and household levels.
During the IMCI phase-in period, mortality rates in children under 5 years old were almost identical in IMCI and comparison districts. Over the next 2 years, the mortality rate was 13% lower in IMCI than in comparison districts (95% CI -7 to 30 or 5 to 21, depending on how adjustment is made for district-level clustering), with a rate difference of 3.8 fewer deaths per 1000 child-years. Contextual factors, such as use of mosquito nets, all favoured the comparison districts. Costs of children's health care with IMCI were similar to or lower than those for case-management without IMCI.
Our findings indicate that facility-based IMCI is good value for money, and support widespread implementation in the context of health-sector reform, basket funding, good facility access, and high utilisation of health facilities.
儿童疾病综合管理（IMCI）策略旨在解决社区、医疗机构和卫生系统层面儿童死亡的主要原因。我们评估了坦桑尼亚农村地区基于医疗机构的IMCI的有效性。
在一项非随机研究中，我们比较了1997年至2002年期间两个实施基于医疗机构IMCI的地区和两个相邻的未实施IMCI的对照地区。通过2000年的医疗机构调查，我们评估了儿童疾病的病例管理质量、药品和疫苗供应情况以及涉及病例管理的监督情况。1999年和2002年使用家庭调查来评估儿童健康指标。从2000年年中开始，通过人口监测在预定的2年期间跟踪儿童的生存情况。通过访谈和记录审查收集了有关背景因素的进一步信息。通过在国家、地区、医疗机构和家庭层面的访谈和记录审查，估计了IMCI地区和对照地区儿童医疗保健的经济成本。
在IMCI逐步实施阶段，IMCI地区和对照地区5岁以下儿童的死亡率几乎相同。在接下来的2年中，IMCI地区的死亡率比对照地区低13%（95%置信区间为-7至30或5至21，具体取决于对地区层面聚类的调整方式），每1000儿童年的死亡率差异为少3.8例死亡。诸如使用蚊帐等背景因素都有利于对照地区。IMCI下儿童医疗保健的成本与未实施IMCI的病例管理成本相似或更低。
我们的研究结果表明，基于医疗机构的IMCI性价比高，并支持在卫生部门改革、整笔资金、良好的医疗机构可及性和高医疗机构利用率的背景下广泛实施。
