Open Access Opinion

Integrated care as a means to improve primary care delivery for adults and adolescents in the developing world: a critical analysis of Integrated Management of Adolescent and Adult Illness (IMAI)

Ashwin Vasan12345*, Andrew Ellner16, Stephen D Lawn4, Sandy Gove7, Manzi Anatole23, Neil Gupta236, Peter Drobac236, Tom Nicholson23, Kwonjune Seung236, David C Mabey4 and Paul E Farmer1236

Author Affiliations

1 Program in Global Primary Care and Social Change, Department of Global Health & Social Medicine, Harvard Medical School, Boston, MA, USA

2 Partners In Health, Boston, MA, USA

3 Partners In Health, Kigali, Rwanda

4 Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK

5 Department of Medicine, Weill Cornell Medical College/New York-Presbyterian Hospital, New York, NY, USA

6 Division of Global Health Equity, Brigham & Women’s Hospital, Boston, MA, USA

7 IMAI-IMCI Alliance, San Francisco, CA, USA

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BMC Medicine 2014, 12:6  doi:10.1186/1741-7015-12-6

Published: 14 January 2014



More than three decades after the 1978 Declaration of Alma-Ata enshrined the goal of ‘health for all’, high-quality primary care services remain undelivered to the great majority of the world’s poor. This failure to effectively reach the most vulnerable populations has been, in part, a failure to develop and implement appropriate and effective primary care delivery models. This paper examines a root cause of these failures, namely that the inability to achieve clear and practical consensus around the scope and aims of primary care may be contributing to ongoing operational inertia. The present work also examines integrated models of care as a strategy to move beyond conceptual dissonance in primary care and toward implementation. Finally, this paper examines the strengths and weaknesses of a particular model, the World Health Organization’s Integrated Management of Adolescent and Adult Illness (IMAI), and its potential as a guidepost toward improving the quality of primary care delivery in poor settings.


Integration and integrated care may be an important approach in establishing a new paradigm of primary care delivery, though overall, current evidence is mixed. However, a number of successful specific examples illustrate the potential for clinical and service integration to positively impact patient care in primary care settings. One example deserving of further examination is the IMAI, developed by the World Health Organization as an operational model that integrates discrete vertical interventions into a comprehensive delivery system encompassing triage and screening, basic acute and chronic disease care, basic prevention and treatment services, and follow-up and referral guidelines. IMAI is an integrated model delivered at a single point-of-care using a standard approach to each patient based on the universal patient history and physical examination. The evidence base on IMAI is currently weak, but whether or not IMAI itself ultimately proves useful in advancing primary care delivery, it is these principles that should serve as the basis for developing a standard of integrated primary care delivery for adults and adolescents that can serve as the foundation for ongoing quality improvement.


As integrated primary care is the standard of care in the developed world, so too must we move toward implementing integrated models of primary care delivery in poorer settings. Models such as IMAI are an important first step in this evolution. A robust and sustained commitment to innovation, research and quality improvement will be required if integrated primary care delivery is to become a reality in developing world.

Primary care; Integrated management; Integration; Quality improvement; Health care delivery; Health systems; IMAI