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Integrated Management of Neonatal and Childhood Illness:
An Overview
GK Ingle, Chetna Malhotra
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Annually, over 10 million children in low- and middle-
income countries die before they reach their Þfth birthday.
Seven in ten under-Þve deaths in such countries are from
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illnesses such as diarrheal dehydration, acute respiratory
infections, measles, malaria, and malnutrition. All these
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Þve conditions can either be treated or prevented.(1)
Despite this, more than 25,000 under-Þve children die
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from these illnesses each day. Factors that contribute
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to illness are poor living conditions like lack of safe
water supply, poor hygiene, overcrowding; inability of
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parents to recognize danger signs; and delay in seeking
appropriate treatment. The problem is compounded by
the poor quality of care provided at the health facilities.(2) kn kno ee
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Projections based on 1996 analysis in the Global Burden
of Disease indicate that these conditions will continue to
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make major contributions to childhood mortality through
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the year 2020 unless signiÞcant greater efforts are made
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to control them.(3)
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Children brought for medical treatment are often found
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suffering from more than one morbid condition, making
a single diagnosis impossible. These children require
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a combined therapy for successful treatment. Thus,
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the need of the hour is an integrated strategy that
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combines the treatment of major childhood illnesses, with
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involvement of parents in provision of home-based care,
prevention of disease through immunization, improved
nutrition, and breast feeding. This integrated strategy
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led to the formation of “The Integrated Management
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of Childhood Illness (IMCI)” in 1992 by UNICEF and
WHO. It was based on the rationale that decline in child
mortality rates is not necessarily dependent on the use of
sophisticated and expensive technologies but rather on
a holistic approach that combines the use of strategies
that are cheap and can be made universally available and
accessible to all.(2) According to the World Bank Report
1993, for situations where laboratory support and clinical
resources are limited, such an approach is more realistic
Department of Community Medicine, Maulana Azad Medical
College, New Delhi, India
Correspondence to:
Dr. G. K. Ingle,
Department of Community Medicine, Maulana Azad Medical
College, New Delhi - 110 002, India. E-mail: gkingle-2@hotmail.com
Guarantor of paper:
Dr G. K. Ingle, Professor and Head, Department of Community
Medicine, Maulana Azad Medical College, New Delhi, India.
Received: 22.07.06
108
and cost-effective, and therefore, has the potential to make
the greatest impact on the global burden of disease.(4)
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An evaluation of IMCI strategy in 12 countries over the
world revealed that the training of healthcare workers
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improved the quality of care signiÞcantly. For example, in
Tanzania, IMCI was associated with a 13% reduction in
under-Þve mortality over a two-year period and stunting
was reduced signiÞcantly. In Bangladesh, the utilization
of government facilities improved substantially due to its
availability. This strategy has now been implemented in
more than 100 countries.(5)
In India, there are nearly 17 lakh child deaths each
year, and child mortality rates are one of the highest
in the world. The Government of India recognized
the need to strengthen child-health activities in the
country and decided to launch IMCI. A core group was
constituted comprising representatives from Indian
Academy of Paediatric (IAP), National Neonatology
Forum of India (NNF), National Anti-Malaria Program
(NAMP), Department of Women and Child Development
(DWCD), Child-in Need Institute (CINI), WHO, UNICEF,
eminent Pediatricians and Neonatologists and the
representatives from the Ministry of Health and Family
Welfare (MOHFW), and the Government of India. The
generic IMCI guidelines were adapted and the Indian
version was named Integrated Management of Neonatal
and Childhood Illness (IMNCI). The major adaptations
were as follows:
i) The entire age group of 0 to 59 months (as against 2
weeks to 59 months in IMCI) was included to address
the neonatal mortality challenge.
ii) The order of training was reversed, starting from
the young infant (0-2 months) to the older child (2
months-5 years).
iii) The total duration of training was reduced from 11
days to 8 days out of which, half of the training time
was earmarked for the management of the young
infants, 0 to 2 months, which contributes to a lot to
the mortality rate.
iv) Home-based care of newborns and young infants
was included.
The management guidelines were made consistent with
the current policies of MOHFW, DWCD, and NAMP.(6)
Separate training material, e.g., training module, chart
booklet, photo booklet, and video was developed for
the health and nutrition workers and for the physicians.
Indian Journal of Community Medicine, Vol. 32, Issue 2, April 2007

The training material for the health workers was also
translated in Hindi, Marathi, Gujarati, and Tamil.(7)
The major objectives of IMNCI strategy are to reduce
mortality and the frequency and severity of illness
and disability and contribute to improve growth and
development during the Þrst Þve years of a child’s life.
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The guidelines represent an evidence-based, syndromic
approach of case management that includes rational,
effective, and affordable use of drugs and diagnostic
tools. The syndromic approach is used to determine the
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health problem(s) of the child, severity of child’s condition,
and the actions taken. It also promotes the adjustment of
interventions to the capacity of the health system and the
active involvement of family members and the community
in the health care process.(1)
IMNCI includes both preventive and curative interventions.
The strategy has the following three components:(1)
1. Health-worker component: Improvements in the
case-management skills of health staff through the
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provision of locally adapted guidelines
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2. Health-service component: Improvements in
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the overall health system required for effective
management of neonatal and childhood illness
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3. Community component: Improvements in family
and community health care practices.
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IMNCI does not imply that the health workers will not
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treat individual diseases. Rather, it implies that the
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workers will broaden their approach to consider and
respond to the child and manage the different factors
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that could be contributing to child’s sickness. These
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guidelines recommend standardized case management
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procedures based on two age categories: (i) upto 2
months and (ii) 2 months to 5 years. In IMNCI, only a
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limited number of carefully-selected clinical signs are
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considered, based on their sensitivity and speciÞcity, to
detect the disease. A combination of these signs helps
in arriving at the child’s classiÞcation, rather than a
diagnosis. ClassiÞcation(s) also indicates the severity
of the condition. The classiÞcations are color coded:
“pink” suggests hospital referral or admission, “yellow”
indicates initiation of treatment, and “green” calls for
home treatment. A sick young infant up to 2 months of
age is assessed for possible bacterial infection, jaundice,
and diarrhea. A sick child aged 2 months to 5 years is
assessed for general danger signs and major symptoms
like cough or difÞcult breathing, diarrhea, fever, and ear
problems. All the children are also routinely assessed for
nutritional and immunization status, feeding problems,
and other potential problems.(1)
The management procedures in IMNCI involve the use
of only a limited number of essential drugs in order to
promote their rational use. The mother is given clear
instructions on how to give oral drugs and to treat the
Indian Journal of Community Medicine, Vol. 32, Issue 2, April 2007
Ingle GK, et al.: IMNCI: An overview
child at home when hospital admission is either not
required or is not possible. She is also directed to return
for follow-up visits as per the IMNCI protocol.(1)
The IMNCI strategy provides for home-based care for
newborns and young infants. The home care component
for newborns aims to promote exclusive breast feeding,
prevent hypothermia, improve recognition of illnesses
by parents, and reduce delays in seeking care. As per
the IMNCI protocol, a health worker has to make at least
three home visits for all newborns, the Þrst visit should be
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within 24 hrs of birth, second on day 3-4 and third at day
7-10. Three additional visits are scheduled for newborns
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with low birth weight at day 14, 21, and 28.(1)
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IMNCI strategy promotes the accurate identiÞcation of
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childhood illnesses in outpatient setting and ensures
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appropriate combined treatment of all major illnesses,
strengthens counseling of caretakers, and speeds up
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the strategy aims to improve the quality of care provided
to sick children. In the home setting, it promotes
appropriate care-seeking behaviors, improved nutrition
and preventive care, and the correct implementation of
recommended care.(1)
In India, IMNCI is a component of the World Bank-
supported Reproductive and Child Health (RCH) II
program. It is being implemented through a joint effort
of UNICEF, National Rural Health Mission (NRHM),
Government and other child survival partners. IMNCI was
Þrst piloted in six districts from end of 2002 to 2004. For
training the physicians, the Þrst training of trainers (TOT)
was carried out for three batches at Kalawati Saran Child
Hospital, Delhi and for two batches in Vellore district. For
conducting the training of workers, TOT was conducted
in Jhalawar, Valsad, and Vellore districts. The health and
nutrition workers of one primary health center (PHC) of
Osmanabad and two sub-centers of Shivpuri were also
trained. Implementation of IMNCI has been initiated
in the states and union territories of Delhi, Gujarat,
Haryana, Jharkahand, Madhya Pradesh, Maharashatra,
Nicobar Islands, Orissa, Rajasthan, Tamil Nadu, and
Uttaranchal. IMNCI training for undergraduate medical
students has been introduced in Þve medical schools.
The National Institute of Public Cooperation and Child
Development (NIPCCD), India, has also introduced
IMNCI in the pre-service curriculum of Integrated Child
Development Services (ICDS) workers. The faculty
of the Council for Technical Education and Vocational
Training-the apex national institution responsible for
training paramedical staff-were trained in IMNCI.
The Indira Gandhi National Open University has also
included IMNCI in distance learning courses for doctors
and paramedics. Collaboration with Emergency and
Humanitarian Action Unit has resulted in the production
of an orientation package on IMCI for health workers who
109
 Ingle GK, et al.: IMNCI: An Overview
provide health care to children in disaster situations.(7) IAP
has now formed the IAP National Task Force in HIV/AIDS
to look into the feasibility of adaptation of pediatric HIV
care in IMNCI.(8)
The major strength of IMNCI strategy is that it makes
use of evidence-based management decisions like oral
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rehydration therapy for diarrhea, childhood vaccinations
to reduce deaths due to diphtheria, pertussis, and
measles and antibiotic treatment for pneumonia. Other
strong points of IMNCI are the hands-on clinical training
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for 50% of training time, feasibility of its incorporation
into pre-service education and in service training, focus
on communication and counseling skills, and locally
adapted recommendation for infant and young child
feeding. By improving the coordination and quality of
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services provided by existing child health and other
programmes, the IMNCI strategy will increase the
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effectiveness of care and simultaneously reduce the
cost. IMNCI has the potential of lowering the burden on
hospitals, particularly, in urban areas where access to kn kno ee
care is not a limiting factor. It offers a model for improving
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one aspect of service delivery that could be applied
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to other aspects of health care. On the other hand, a
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critical appraisal of IMNCI revealed that it has failed to
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address the key issues of safe home delivery, training of
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traditional birth attendants, creating facilities for a triage
system at primary, secondary, and tertiary care levels, a
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referral system with linkages between these levels, care
of newborn at birth and childhood injuries.(9) There is also
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a need to evaluate the content, duration, and period of
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training of IMNCI.
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The major challenges before IMNCI are the feasibility
of provision of health care using IMNCI at sub-center
and village level by ANMs and Anganwadi workers
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(AWWs) considering the irregular supply of drugs and
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logistics, lack of proper supervision, sustaining what is
initiated through indicator-based monitoring, making
home-based care of young infants operational by ANMs
and AWWs and a high staff turnover. An assessment
of the effectiveness of IMNCI was initiated in 2005 by
Government of India and WHO.(10)
The program aims to reach out to 1 million people
and provide a comprehensive newborn and child care
package at all levels of care in 250 of the country’s 602
110
districts by 2010.(11) At the sub-center level, it shall be
implemented through ANMs; at PHCs, through medical
doctors, nurses, and Lady Health Visitors; at First
Referral Units, through medical ofÞcers and nurses; and
at the village/household level through the AWWs.(11)
Thus, IMNCI offers a strategy for improving the state of
health of children in India. This approach could help the
country in achieving the Millennium Development Goals
of reducing the under-Þve mortality.
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References
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1. WHO Department of Child and Adolescent Health and
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Development (CAH), MOHFW. Student’s handbook for
Integrated management of neonatal and childhood illness.
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2003.
2. WHO. Improving Child health, the integrated approach.
Division of Child Health and Development; WHO/CHD/97.12
Rev.2. WHO: 1997. p. 2-7.
3. Murray CJ, Lopez AD. The global burden of disease: A
comprehensive assessment of mortality and disability from
diseases injures and risk factors in 1990 and projected to
2020. WHO: Geneva; 1996.
4. World Bank. World development report 1993: Investing in
Health. Oxford University Press: New York; 1993.
5. Available from: http://www.unmillenniumproject.org/
documents/maternalchild-chapters3-4.pdf. [Last accessed
on 2006 Jun 3].
6. Child Health Programme in India - Major milestones in Child
Health. Available from: http://mohfw.nic.in/dofwwebsite/
childhealthrti.pdf. [Last accessed on 2006 Jun 3].
7. Chaturvedi SK, Chaturvedi K. Adaptation of the Integrated
Management of Newborn and Childhood Illness
(IMNCI) Strategy for India. Available from: http://www.
publichealth.pitt.edu/supercourse/SupercoursePPT/20011-
21001/20421.ppt. [Last accessed on 2006 Jun 3].
8. Bhargava SK. The challenge of neonatal mortality in India.
Indian Pediatr 2004;41:657-62.
9. IAP Action Plan 2006. Available from: http://www.iapindia.
org/president.cfm. [Last accessed on 2006 Jun 3].
10. Aggarwal SP. Towards achieving millennium development
goals in the health sector in India. J Indian Acad Clin Med
2005;6:268-74.
11. WHO. Child and adolescent health and development
Progress report 2002-2003. WHO: Geneva; 2004.
Source of Support: Nil, Conßict of Interest: None declared.
Indian Journal of Community Medicine, Vol. 32, Issue 2, April 2007