Quality improvement and the integrated management of childhood illness: lessons from developed countries.
BACKGROUND: The World Health Organization (WHO) and the United Nations Children's Fund have launched a global initiative to reform the health care received by sick children in developing countries. The core of this initiative, known as Integrated Management of Childhood Illness (IMCI), is a clinical practice guideline. The guideline addresses the case management of clinically ill children under the conditions typical of peripheral facilities, focusing on the most common serious conditions, such as pneumonia and malaria. WHO estimates that up to 70% of childhood deaths in developing countries are attributable to conditions addressed by IMCI. About 40 developing countries have made commitments to implementing IMCI in public-sector programs. QI STRATEGIES AND GUIDELINES IN DEVELOPING COUNTRIES: Like other clinical guidelines, which are increasingly accepted in developing countries' health programs, IMCI raises difficult quality issues. High levels of guideline compliance are needed for IMCI to be effective. However, many developing countries have achieved relatively low levels of compliance with far simpler guidelines, such as those for diarrhea case management. Despite obvious differences, the experience of developed countries in quality improvement (QI) offers a wide range of promising strategies for IMCI, including (1) developing standards, (2) communicating those standards to providers, (3) monitoring quality and providing feedback, (4) team-based QI problem solving, (5) designing processes conducive to high levels of quality, and (6) regulating providers and institutions. MORE LESSONS FROM DEVELOPED COUNTRIES FOR IMCI: Only recently have QI strategies been adapted for use in developing countries, and virtually none of the early experience has dealt with IMCI. Indirect evidence suggests that a wide range of QI approaches will prove suitable for IMCI. However, it will be important to carefully evaluate the cost-effectiveness of early applications. The experience of developed countries also provides useful models for important issues that have not yet been addressed by the IMCI initiative. These issues include (1) the review and possible modification of the current guideline, (2) extending IMCI into the private sector through regulatory strategies, and (3) institutionalizing QI.