Tools for Integrated Management of Childhood Illness

Related program: Market dynamics

Improving access to tools that detect severe illness

When sick children arrive at primary health care (PHC) facilities, it is critical that they are appropriately screened, diagnosed, and managed, and if needed, referred to urgent care without delay.

Clinical signs alone do not detect all indicators of severe illness in children. In order for health care workers to make the right diagnosis, they must be equipped with the right tools and training, including access to and training for pulse oximeters and clinical decision support systems.

In many countries, these critical tools are not available, not functioning properly, not suited for infants who need them most, or providers lack appropriate training.

There is also no clear global guidance to help countries in choosing the best devices, nor is information available on their cost-effectiveness or their suitability in primary care.

Lacking these important devices, frontline health workers face difficulty in identifying children who require immediate medical attention. When danger signs are overlooked or not adequately addressed, children’s lives are at risk. Patients may receive medicines that they don’t need. Misuse of antibiotics, in turn, gives rise to drug-resistant superbugs.

< 5 child deaths globally due to preventable causes in 2018
reduction in child deaths after provision of pulse oximetry & oxygen
severely sick children diagnosed with hypoxemia using pulse oximetry

TIMCI value proposition

  • Pneumonia remains the leading infectious cause of mortality among children under five, claiming more than 800,000 lives every year globally, with children living in poor rural communities and urban slums being especially vulnerable. Too many cases of pneumonia go untreated or are misdiagnosed because health systems do not provide access to effective and affordable care.
  • Detection and management of children at high risk of morbidity and mortality is crucial. Clinical signs alone do not detect all children with severe disease.
  • Low oxygen in the blood (hypoxemia) is one of the main signs of severe illness like pneumonia. Children with hypoxemia are 5.5 times more likely to die than those without hypoxemia.
  • Tools for measuring blood oxygen levels, such as pulse oximetry, are essential for alerting health workers to signs of severe disease and the need for urgent treatment.
    • Pulse oximetry identified hypoxemia in 30% of very sick children who were not identified by clinical signs alone.
    • After pulse oximetry and oxygen were provided in pediatric wards of hospitals, child deaths fell by 50%.
  • Clinical decision support systems (such as clinical decision support algorithms or CDSAs) that help process patient information and symptoms through digital applications are another key piece in improving care.
    • Research studies have linked clinical decision support systems to improved quality of care, such as reduced unnecessary use of antibiotics, better communication with the child’s caregiver, higher rates of referral to hospital when needed and, most tellingly, improved recovery of children.
  • Integration of pulse oximetry and CDSA use into national Integrated Management of Childhood Illness (IMCI) guidelines is an important step to ensure consistent and correct use.



TIMCI aims to improve access to affordable and appropriate tools to help health workers identify critically ill children and refer them for treatment without delay.

Between 2019 and 2024, TIMCI is working in collaboration with the governments of India, Kenya, Senegal, and Tanzania and global partners to:

  • Introduce pulse oximeters and CDSAs in nearly 300 PHC facilities across the four project countries, including health care worker training and supportive supervision.
  • Generate data on health impact, cost-effectiveness, and feasibility of utilization of these tools in PHC settings, helping to address evidence gaps, inform national and global guidance, increase donor engagement, and incentivize manufacturers to innovate and governments to pursue adoption and scale-up.
  • Strengthen the market for next generation pulse oximeters (POs with additional features to measure respiratory rate, temperature, and/or hemoglobin), including developing a target product profile, collecting and sharing market intelligence, and conducting field evaluations.
  • Collaborate with national and global stakeholders to ensure pulse oximetry is included in IMCI/IMNCI guidelines and relevant child health policies, and develop scale-up plans for sustainable and long-term use.
  • Advance access to pulse oximeters that work on all skin tones.

By making PHC service delivery more accessible, accountable, affordable, and reliable, this initiative can help establish progress toward universal health coverage targets mandated by the UN Sustainable Development Goal 3.8 by 2030.

Pulse oximeters that work on ALL skin tones

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TIMCI tools and evidence generation

Cross-country quasi-experimental pre-post study

We are implementing a cross-country quasi-experimental pre-post study, with embedded mixed methods studies, cost, and modelled cost-effectiveness in Kenya and Senegal.

  • Population: children 0-59 months of age
  • Intervention: pulse oximetry, incorporated into a CDSA, into primary care facilities, supported by targeted training and embedded into monitoring, supportive supervision, and maintenance systems.
  • Study setting:
    • Kenya (Kakamega, Kitui, Uasin Gishu counties) - 12 referral and 60 implementation Level 2 (dispensaries) and Level 3 (health centers and sub-county hospitals) facilities
    • Senegal (Thies region) – 5 referral and 60 implementation facilities (health posts)
  • Identifier: NCT05065320
Randomized controlled trial

We are implementing a pragmatic cluster randomized controlled trial, with embedded mixed methods, cost, and cost-effectiveness studies in India and Tanzania.

  • Population: children 0-59 months of age
  • Intervention: pulse oximetry, incorporated into a CDSA, into primary care facilities, supported by targeted training and embedded into monitoring, supportive supervision, and maintenance systems.
  • Study setting:
    • India (State of Uttar Pradesh) – 6 referral and 102 implementation facilities (primary health care centers and community health centers)
    • Tanzania (Mwanza, Tanga, Tabora regions) – 15 referral and 66 implementation facilities (dispensaries and health centers)
  • Identifier: NCT04910750
Hybrid study

We are implementing a hybrid type 2 study of next generation pulse oximeters to support the integrated managment of childhood illnesses in primary care settings.

Population: children 0-59 months of age

Intervention: a mixed methods type 2 effectiveness-implementation study measuring the performance and feasibility of multimodal pulse oximeter devices by primary care providers.

Study setting: 2 facilities each in India, Kenya, Senegal, and Tanzania.


Core TIMCI partnership

  1. ALIMA

    PATH has partnered with the Amélioration de l’Identification des détresses Respiratoires de l’Enfant (AIRE) project led by ALIMA to improve diagnostic techniques to identify severe cases in children under five years of age, using pulse oximetry integrated into IMCI guidelines at PHC level in West Africa.

  2. International Advisory Group

    Independent consultative body of global experts, advocates, and stakeholders from the child health community serving in an advisory capacity to provide guidance to help ensure that the TIMCI project interventions adhere to rigorous international and national research standards.

  3. Observer countries network

    PATH and ALIMA have engaged a network of observer countries to share evidence and learnings and build additional support for scale-up of project interventions across additional geographies. Our observer countries partners include: Cote d'Ivoire, Malawi, Nigeria, Uganda, Zambia, and the Indian states of Assam, Chhattisgarh, Odisha, and Rajasthan.

  4. Open Oximetry initiative

    We are working with the University of California San Francisco Open Oximetry Project to improve access to pulse oximeters that work on all skin tones. Learn more here.


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