The Integrated Management of Childhood Illness Strategy (IMCI), developed by WHO and UNICEF, has been identified as a key strategy to meeting the fourth millennium development goal (MDG4). IMCI has three components, viz. case management training (ICMT), strengthening the health system and intensifying household and community behaviours to improve child health . ICMT is presented as an 11-day course (usually residential) and teaches health care providers to manage sick children up to the age of 5 years, presenting to primary health care facilities with illnesses that account for major childhood morbidity and mortality. The course comprises six key modules and clinical practice. WHO recommends that 44.2% of course time is spent on clinical practice 1.2% on Introduction, 20.9% on Assess and Classify, 4.9% on Identify Treatment, 11.6% on Treat the Child, 6.9% on Counsel the Mother, 6.9% on Sick Young Infant and 3.5% on Follow-up. The IMCI management algorithms or charts are colour coded and each trained health care provider is provided with a chart booklet to use during consultations. Each ICMT course is facilitated by trained facilitators and a 1:<4 facilitator: participant ratio is recommended.
Follow-up after training is an essential component of ICMT, as laid down in the IMCI information package . The package describes follow-up after ICMT as an opportunity to reinforce skills acquired during training and solve problems encountered during IMCI implementation. The approach to follow-up developed by the WHO Department of Child and Adolescent Health and Development (CAH), also serves as a bridge to ongoing district-level supervision.
ICMT has been shown to reduce under-five mortality  and to improve antimicrobial use in first level facilities .
Despite data on the effectiveness of IMCI in decreasing antimicrobial prescription by health workers, improving quality of care, child health indicators, quality of counselling provided to caregivers, and bed net use [3–10], current global coverage by IMCI-case management-trained health workers is low . Furthermore recent data from South Africa showed that although health workers in South Africa were implementing IMCI, clinical assessments using IMCI were frequently incomplete - only 18% checked for all main symptoms . Focus group discussions amongst health workers in South Africa also showed that although they found the training interesting, informative and empowering the training time was short and follow-up visits, though helpful, were often delayed resulting in no ongoing clinical supervision .
In view of the potential contribution that IMCI scale-up could have on childhood morbidity and mortality, and the dearth of documented information on how IMCI was actually being implemented globally we conducted a survey in 2006 to review the training approaches and methods used for IMCI case management, document challenges to rapid scale-up of ICMT, document how countries are addressing these barriers and explore country experiences with follow-up after ICMT. It was intended that this information be used to guide future approaches to ICMT.
The first two questions (reviewing training approaches and methods) have been addressed in a separate paper . This paper reports the challenges to rapid ICMT scale-up, how countries have tried to address these, and country experiences with follow-up of IMCI trainees after ICMT.