摘要：The Multi-Country Evaluation of the Integrated Management of Childhood Illness (IMCI) includes studies of the effectiveness, cost, and impact of the IMCI strategy in Bangladesh, Brazil, Peru, Tanzania, and Uganda. Seven questions were addressed when the evaluation was designed: who would be in charge, through what mechanisms IMCI could affect child health, whether the focus would be efficacy or effectiveness, what indicators would be measured, what types of inference would be made, how costs would be incorporated, and what elements would constitute the plan of analysis. We describe how these questions were answered, the challenges encountered in implementing the evaluation, and the 5 study designs. The methodological insights gained can improve future evaluations of public health programs. Integrated Management of Childhood Illness (IMCI) is a strategy for improving child health and development. The IMCI strategy was developed in a stepwise fashion. It began with a set of case-management guidelines for sick children seen in first-level health facilities. Over time, the strategy expanded to include a range of guidelines and interventions addressing child health needs at household, community, and referral levels. A detailed review of the development and evaluation of the case-management guidelines is available elsewhere. 1– 3 IMCI has 3 components, each of which is adapted in countries on the basis of local epidemiology, health system characteristics, and culture. One component focuses on improving the skills of health workers through training and reinforcement of correct performance. Training is based on a set of adapted algorithms that guide the health worker through a process of assessing signs and symptoms, classifying the illness on the basis of treatment needs, and providing appropriate treatment and education of the child’s caregiver. The IMCI guidelines include identifying malnutrition and anemia, checking vaccination status, providing nutritional counseling, and communicating effectively with mothers. A second component of IMCI aims to improve health system supports for child health service delivery, including the availability of drugs, effective supervision, and the use of monitoring and health information system data. The third component focuses on a set of family practices that are important for child health and development and encourages the development and implementation of community- and household-based interventions to increase the proportions of children exposed to these practices. The ministries of health in Tanzania and Uganda began implementing IMCI in 1996. In the 8 years since then, over 80 additional countries have adopted the strategy and gained significant experience in its implementation. 1, 4 Evaluation received special attention throughout the development and introduction of IMCI. The strategy includes numerous specific interventions, most of which have been rigorously tested in controlled trials. 3 Examples include antibiotic treatment for pneumonia, oral rehydration therapy for diarrhea, antimalarials, immunizations, breastfeeding counseling, anemia diagnosis and treatment, and vitamin A supplementation. Nevertheless, there was a need to evaluate the strategy as a whole as an approach to the delivery of these proven child health interventions. Planning for the Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (MCE) began in 1997. The objectives were to: evaluate the impact of the IMCI strategy as a whole on child health, including child mortality, child nutritional status, and family behaviors evaluate the cost-effectiveness of the IMCI strategy document the process and intermediate outcomes of IMCI implementation, as a basis for improved planning and implementation of child health programs The Department of Child and Adolescent Health and Development of the World Health Organization (WHO) coordinates the evaluation. This article has 3 aims. In the first part, we describe the early design decisions as well as their implications for study implementation. In the second part, we explain the challenges encountered in implementing the evaluation, how each was addressed, and the 5 study designs currently being implemented. The conclusions section summarizes the implications of this work for the design of large-scale evaluations of public health programs. We have used the simple past tense throughout to improve readability. In fact, many of the MCE activities described have already been completed, some are under way, and the remainder are planned for the future.
