Implementation of the integrated management of childhood illnesses strategy in Peru and its association with health indicators: an ecological analysis

Abstract

Objectives: (1) To document trends in integrated management of childhood illnesses (IMCI) implementation in the 24 departments of Peru from 1996 to 2000. (2) To documenttrends in indicators of health services coverage and impact(mortality and nutritional status) for the same period. (3) To correlate changes in these two sets of indicators. And (4)to attempt to rule out contextual factors that may affect the observed trends and correlations. Materials and Methods: An ecological analysis was performed in which the units of study were the 24 departments.Results: By 2000, 10,2% of clinical health workers were trained in IMCI,but some districts showed considerably higher rates. There were no significant associations between clinical IMCI training coverageand indicators of outpatient utilization, vaccine coverage, mortality or malnutrition. The lack of association persisted after adjustment for several contextual factors including socioeconomic and environmental indicators and the presence of other childhealth projects. Community health workers were also trainedin IMCI, and training coverage was not associated with any of the process or impact indicators, except for a significant positivecorrelation with mean height for age. According to the MCE impactmodel, IMCI implementation must be sufficiently strong to leadto an impact on health and nutrition. Conclusions: Health systems supportfor IMCI implementation in Peru was far from adequate. Thisfinding along with low training coverage level and a relativelylow child mortality rate may explain why the expected impactwas not documented. Nevertheless, even districts with high levels of training coverage failed to show an impact. Further national effectiveness studies of IMCI and other child interventions are warranted as these interventions are scaled up.