摘要：Objectives. To estimate the impact of the Integrated Management of Childhood Illness (IMCI) strategy on early-childhood mortality, we evaluated a malaria-control project in Benin that implemented IMCI and promoted insecticide-treated nets (ITNs). Methods. We conducted a before-and-after intervention study that included a nonrandomized comparison group. We used the preceding birth technique to measure early-childhood mortality (risk of dying before age 30 months), and we used health facility surveys and household surveys to measure process indicators. Results. Most process indicators improved in the area covered by the intervention. Notably, because ITNs were also promoted in the comparison area children's ITN use increased by about 20 percentage points in both areas. Regarding early-childhood mortality, the trend from baseline (1999–2001) to follow-up (2002–2004) for the intervention area (13.0% decrease; P < .001) was 14.1% ( P < .001) lower than was the trend for the comparison area (1.3% increase; P = .46). Conclusions. Mortality decreased in the intervention area after IMCI and ITN promotion. ITN use increased similarly in both study areas, so the mortality impact of ITNs in the 2 areas might have canceled each other out. Thus, the mortality reduction could have been primarily attributable to IMCI's effect on health care quality and care-seeking. In sub-Saharan Africa, malaria is a leading cause of child mortality. 1 , 2 These deaths can be prevented with insecticide-treated nets (ITNs), indoor insecticide spraying, prompt and effective treatment of malaria cases, and intermittent preventive treatment of malaria in pregnant women. 2 To improve children's malaria treatment, the Roll Back Malaria partnership and the World Health Organization (WHO) recommend the Integrated Management of Childhood Illness (IMCI) strategy. 3 – 5 IMCI, which was developed by WHO and other partners, aims to prevent mortality from all leading causes of child deaths (e.g., pneumonia, diarrhea, and malaria). IMCI has 3 components: (1) improving case-management quality (especially in health facilities) by training health workers to use evidence-based clinical guidelines, (2) strengthening health systems, and (3) promoting community and family health practices. IMCI has been introduced in more than 100 developing countries, 6 and studies have demonstrated that it can improve health care quality at health facilities. 7 – 10 With regard to its effect on mortality, however, the evidence is mixed. IMCI seems to have lowered child mortality in Tanzania, 11 but studies in Brazil 12 and Bangladesh 8 did not find a statistically significant reduction. Thus, despite IMCI being one of the world's most widely implemented child health strategies, its impact on mortality remains unclear. In 1998, before today's billion-dollar malaria initiatives, the US Agency for International Development launched a subnational malaria demonstration project in Benin that included IMCI. Benin is a low-income country in West Africa with extreme poverty, 13 endemic malaria, and high mortality for children younger than 5 years (160 deaths per 1000 live births when the project began 14 ). We conducted this study to evaluate the project's impact on early-childhood mortality, with an emphasis on IMCI's impact.
