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continue their ongoing assessmmment of the Integrated Management of Childhood Illness (IMCI) strategy, by looking at how well it reached poor areas within three countries. Their findings are sobering: overall, the stratm megy seemed to be implemented least energetically in the areas where it was most needed.This illustrates one of the many cruel ironies of efforts to help the poor: the tendency of service programmes to be much weaker in deprived areas than elsewhere. As a result, the promoters of new initiatives tend to adopt the IMCI strategy of beginning in easier, bettermoff districts, to achieve the early successes needed to establish credibility. The intent is to expand into more difficult areas as soon as possible. Whether such expansion ever takes place is usually unreported; but the wellmdocumented difficulties encountered by IMCI are consistent with anecdotal evidence about other programmes, and they will sound familiar to anyone who has tried to introduce new approaches.This suggests that the issue is not unique to IMCI. If it applies to public health interventions in general, what are the implications for the design of initiamtives to reach disadvantaged groups? Three stand out.First, the IMCI experience illusmtrates the distinction that needs to be made between developing intervenmtions that address the needs of the poor, and reaching the poor with those interventions. The relevance of IMCI interventions is beyond doubt: study after study has demonstrated a much higher prevalence of childhood illness among the poor.

IMCI what can we learn from an innovation that didn't reach the poor?