From 1960 to 1999, there was already signifcant success in global child health—a 50% reduction in child mortality attributable to a variety of public health approaches.8 Mass immunization campaigns conducted in the 1950s through 1970s resulted in smallpox eradication and reductions in other vaccine-preventable diseases. The Expanded Program on Immunization (EPI), established in 1974, allowed for continued strides in improving worldwide vaccination status among children, from a baseline of 5% (3 doses of diphtheria, pertussis, tetanus [DPT3] vaccine) in 1974 to a current rate of 83% (2012). The UNICEF growth monitoring for undernutrition, oral rehydration, breastfeeding, and immunization program, instituted in 1982, expanded the focus of public health programs from solely immunizations to include other important interventions. There began a growing awareness and interest in improving primary care infrastructure to better disseminate a greater number of interventions that positively affect child health.
The Integrated Management of Childhood Illness (IMCI) program was created in the mid-1990s.In this program, local-level caseworkers were identifed in rural and urban communities and trained to provide health education and support to families for a variety of maternal and childhood diseases and conditions. The IMCI program was initially created as a facility-based program using case management with a defned set of evidence-based guidelines for sick children. It was eventually expanded to include interventions that could be performed in the household, in the community, or by referral. Such a change required improving case management and health systems, as well as family and community services, including health education in growth promotion and development, disease prevention, care, and compliance with the advice of health workers.
Adoption of all IMCI program aspects (ie, facility-based services, case management, and family and community health services) is not complete, even in countries with the most effective implementation. While these countries have well-trained community health workers, changes in their health systems and family health practices have been slow. Evaluators note that one of the signifcant problems associated with IMCI implementation is high staff turnover, which makes it diffcult to achieve a sustained effect. The staffng problem is a greater issue among facility-based staff (who could be moved from the area) than with staff who are local community women, demonstrating that it may be preferential to increase participation of local workers. Future success of the IMCI program requires that regions work from the top down (strengthening the health service system) and also from the bottom up (mobilizing the community to use those services)