Effectiveness Of Implementation Of Integrated Management Of Childhood Illness On Improving Quality Of Care For Minority Children Under Five Years Old In Rural Yunnan Province And Xinjiang Uygur Autonomous Region,China

Background IMCI was introduced in China in 1998 and the evaluation of early implementation and scaling-up in limited areas showed that it was effective in improving rural health worker's skills and supplies of basic equipment and drugs in primary health facilities.Therefore,IMCI strategy was adopted as national child health policy as indicated in the National Program of Action for Child Development 2001-2010 as well as the one 2011-2020.In 2014,WHO revised the IMCI general technical guidelines.According to the WHO's new guidelines and the actual situation of China,National Health and Family Planning Commission of the People's Republic of China organized relevant experts to revise the Chinese version of IMCI guideline in 2015,and held provincial facilitators' training course all over the country,which laid the foundation for IMCI scaleing-up across the country.However,the evidence on effectiveness of IMCI strategy in China was largely based on pre-and postcomparison rather than randomized controlled studies.Moreover,the cost-effectiveness and sustainability of IMCI implementation which are of great value for policy makers are still unknown.This study explore the impact factors and sustainability of IMCI implementation in two parts: systematice literature review and clustered randomized control trial.Part 1Objective Although IMCI strategy has been introduced to more than 100 countries worldwide,systematically collected knowledge on factors influencing the implementation of IMCI is still scare.Therefore,a qualitative systematic literature review was carried out to systematically identify and synthesize factors influencing the implementation of IMCI and suggested strategies.Using pre-defined criteria,a systematic search of both Chinese and English literatures from 16 databases published in 1990 to May 2016 revealed 5357 papers.After quality evaluation,220 studies were selected for analysis.MethodsResults 220 full texts were included.From these,influencing factors and related strategies were extracted and summarized using thematic analysis.The influencing factors and strategies were condensed into topics with respect to three main stakeholders involving the implementation of IMCI: health system,primary health workers(PHW)and caregivers.Factors and strategies at health system level were analyzed according to the four main critical health system functions(e.g.management and governance,financing and supply,service delivery,and monitoring & supervision).Factors and strategies regarding PHW were analyzed from two dimensions: willingness and capability which grouped PHW-related factors and strategies into three aspects(e.g.capable of IMCI but reluctant,capable of IMCI without necessary implementation conditions,incapable of IMCI).Factors and strategies referring to caregivers were presented into two groups: low compliance to doctors' recommendations and poor care-seeking behaviors.Conclusions Regardless of the IMCI guidelines update,knowledge on factors influencing the implementation and sustainability of IMCI is key to appropriately plan and implement such interventions,our review informed factors influencing the implementations and sustainability of IMCI and its related strategies with rigorous and systematical evidence.Therefore,future researchers and policy makers should take these factors and recommendations into account in implementing and scaling up IMC with highest efficiency.Part 2Objective This study aims to evaluate the effectiveness and cost-effectiveness of IMCI implementation on improving quality of care for under five children in rural China and acceptability by village doctors.Methods This study was designed as clustered randomized controlled trials(c RCT)with village clinics as randomization units.Villages in IMCI group implemented IMCI program,while villages in control group provided routine health care services for children.Data was collected through health factility survey to evaluate the quality of care for under five chidren,satisfaction by caregivers,supplies of basic equipment and drugs in primary health facilities and cost per case.Effective Matrixes have been deveploed to systematically evaluate the benefits brought by IMCI;Difference in Difference Estimation Regression has been applied to measure to net IMCI intervention benefits.Results 102 villages and 201 children and their caregivers participated in baseline survey: 49 villages and 97 children with their caregivers in IMCI group,53 villages and 104 children with their caregivers in control group;88 villages and 157 children and their caregivers participated in mid-term survey: 43 villages and 74 children with their caregivers in IMCI group,45 villages and 83 children with their caregivers in control group.The results showed that,IMCI brought in significant improvement on health worker's disease assessment skills,demonstration skills of drug administration,and treatment capability.The total intervention cost of IMCI is 1986,209.8RMB and the average intervention cost per child is 173.7RMB.IMCI strategy significantly improved quality of care for under five children,for example,there was 42.1% improvement in health workers' disease assessment skills,with ICER value 23425.4 RMB;there was 34.0% improvement in communication skills,with ICER value 29006.2RMB;there was a 10.0% improvement in classification and treatment accuracy,with ICER value 98620.9 RMB.However,the improvement of family's care-seeking pratices and satisfaction was not observed(5.5%),with ICER value ICER=179310.9RMB.Conclusion According to the results of randomized controlled study,IMCI can bring significant improvement of health workers' skills and supplies of basic equipment and drugs in primary health facilities.