Matlab thana, a rural sub-district (population ~500,000) in Eastern Bangladesh, has an under-five mortality rate of about 71 per 1000 live births. About 40% of the deaths can be attributed to pneumonia, diarrhoea, measles and malnutrition, conditions that are directly addressed by IMCI. About one-fifth of the sub-district’s population is in the catchment area of high-quality medical services provided by ICDDR,B (population about 107,000). The IMCI evaluation is taking place in the remaining four-fifths of the sub-district, where health services are run by the Government of Bangladesh (population about 365, 000).

IMCI implementation in Bangladesh was at an early phase when the evaluation was initiated in late 1999; national guidelines had been developed but training had not yet begun. Matlab thana thus provided an excellent opportunity for a probability-design assessment of IMCI impact. At the same time, Matlab is serving as a pilot area for IMCI in the country and is being carried out in close collaboration with the Government.

The project aims to assess the impact and cost of IMCI implemented in first-level health facilities, in association with a community-based intervention. The primary impact measures include all-cause under-five mortality and nutritional status. The project is also documenting the implementation of IMCI and monitoring the quality and coverage of child survival services as well as key family and community practices related to child health. 

A two-cell randomized design was adopted for implementing and evaluating IMCI over a five-year period. The 20 eligible first-level government health facilities in the thana were matched in pairs according to selected characteristics, and one facility in each pair was randomly selected for IMCI intervention. This sample permits the detection of a 20% difference in under-five mortality between the two sets of facilities; health-facility catchment areas are the units of statistical analysis. Two-year rates are used, as annual rates fluctuate considerably, and verbal autopsies are being used to ascertain cause of death.

In the 10 facilities receiving IMCI, a supervision and support system is in place to ensure best-possible implementation of IMCI and the improvement of drug supplies and referral pathways. Community-level activities have been implemented in the catchment areas of these facilities, including improved home management of common illnesses and appropriate care-seeking practices. IMCI will be introduced in the control facilities at the end of the project.

Interim results on the implementation of IMCI in the study area and its effects on health care quality and utilization have been disseminated within Bangladesh and internationally (see publications).  Final assessments of impact are scheduled for 2007.

The Bangladesh site is the only MCE study with a probability design aimed at assessing IMCI implementation under the best possible circumstances. Its results will therefore be crucial to assessing IMCI impact. It is also a model partnership where ICDDR,B is responsible for overall design, evaluation and technical oversight, the Government of Bangladesh is implementing IMCI and BRAC is assisting in the community component.