Strengthening of primary-care delivery in the developing world: IMAI and the need for integrated models of care.

September, 2013, marked the 35th Anniversary of the 1978 Declaration of Alma-Ata, an agreement in which WHO member states outlined a comprehensive vision for primary health care that addressed provision of medical services and wider structural and community needs. More than three decades later, eff ective, highquality primary care is still an elusive goal for most countries. This status partly shows a failure to develop practical, operational models of primary-care delivery in the developing world in the wake of Alma-Ata. Instead, the global health community turned to programmes smaller in scope and thus deemed more feasible, rapid, and measurable. This choice is partly why primary care and its attendant metrics often refer to targeted initiatives—eg, immunisation campaigns or childhood interventions for children younger than 5 years—rather than more generalised, systems-based interventions. When The Lancet revisited Alma-Ata on its 30th anniversary in 2008, editors and contributors recommended a recommitment to primary care, broader global-health targets, and better integration. Similarly to primary care, integration has several layers, including the integration of multiple social and economic sectors that aff ect primary care, integration of structures and programmes on the health-systems level, and, clinically, integration of services for multiple diseases into essential packages of care. Published studies suggest that concise integrated management guidelines can help to improve quality of comprehensive primary-care delivery, much as standardised protocols have improved quality within disease-specifi c programmes. Several examples exist of successful integration of services for one disease programme (eg, tuberculosis, sexually transmitted infections, non-communicable diseases, and family planning) with a second programme (commonly HIV), whereas other groups have proposed so-called diagonal approaches to service integration around, for example, women’s health. Perhaps most notably, the WHO/UNICEF Integrated Management of Childhood Illness (IMCI) framework has been widely implemented and has proven successful in integrating treatment for multiple specifi c diseases (eg, acute respiratory infections, anaemia, diarrhoea or dehydration, and malaria) to improve overall quality of care for children younger than 5 years, when delivered by well-trained and well-supported multipurpose health workers. Despite equivocal fi ndings from long-term eff ectiveness studies, IMCI leads to reductions in childhood mortality and overall cost-savings to health systems. Also developed by WHO, the Integrated Management of Adult and Adolescent Illness (IMAI) is an analogous guideline that integrates discrete vertical interventions into a single operational model at the point of care. Although IMAI has received little attention or examination, we propose that, with adequate support, research, and iterative improvement, it could have an important role in improvement of primary-care delivery in low-income settings. Apart from specifi c programmes for maternal health, HIV, tuberculosis, malaria, and other (mainly infectious) diseases, adult and adolescent ambulatory care in the developing world is neither standardised nor well Copyright © Vasan et al. Open Access article distributed under the terms of CC BY