Integrated management of childhood illness (IMCI) was introduced in Iraq in 1998 as a strategy to address the most important causes of under-five mortality and morbidity using an integrated approach in line with the primary health care policy. It has since expanded to cover 33 health centers (21 in Baghdad, 6 in Thi-qar, 4 in Babel, and 2 in Ninawa). This study was planned to measure outcome indicators on quality of care at IMCI health facilities and compare them with non IMCI health facilities. The management was observed of 2267 sick children aged 1 day to 5 years old seen at 12 health facilities (clusters), 6 health centers providing IMCI activity in Baghdad City (at the time of beginning the study) and other 6 were randomly assigned from nearby health centers not providing IMCI activities. The data collection lasted from 1st of March 2007 till 28th of February 2008. The time sequence of data collection was by spending about one month (four weeks) in every health center, five days a week, 4 hours a day (9 AM-1 PM). Data was collected by exit interview of caretaker of children through a well structured questionnaire covering all activities provided by IMCI to care for sick children followed by re-examination of the children. The total number of children 2 months age up to 5 years were 1059 (92.3%) of children attending IMCI providing health centers compared to 1077 (96.2%) of health centers not providing IMCI activities. Their complaints were as follows; have danger sign (0.4%), cough or respiratory complaints (64.1%), diarrhea (25.9%), throat problems (82%), ear problem (30.4%), fever suspected as measles (32.8%), malnourishement (42.6%), aneamia (73.8%), other nutritional problems (73.4%), compared to the following percentages in the health centers not providing IMCI activities (0.1%, 53.1%, 29.9%, 43.8%, 9.1%, 47.6%, 11.5%, 54.7%, and 3.4% respectively). The median consultation length for children 2 months up to 5 years, in IMCI centers, was 14 minutes while it was much shorter in non IMCI centers with a median 6 minutes. The total number of children 1 day to 2 months age were 88 (7.7%) of young infants attending IMCI providing HCs compared to 43 (3.8%) of those HCs not providing IMCI activities. The median consultation length, in IMCI centers, was 19 minutes compared to shorter time in non IMCI centers (median 7 minutes). Their checking criteria regarding possible bacterial infection was 100% enquired in IMCI centers, but for non IMCI centers they were interested in few points (checking fever, umbilicus for pus and redness, and checking the consciousness or lethargy in child) with other tasks were not that checked (less than 20%). When comparing tasks performed for checking young infants, it showed that the amount of care was tremendously low in the centers not trained for IMCI toward this age group category. According to IMCI criteria there is an important issue of assessing breast feeding practice by mother a task that was ignored and not in the attention of non IMCI health care providers, although it include simple items. The same for immunization of young infant, this simple task, although very important, was performed for less than half of young infant in non IMCI centers compared to all young infants checked and insisted on in the IMCI centers. The problems in taking the history accurately led to misclassification of some of the cases. The tasks for assessment were highly enquired in IMCI trained health care provider than those not trained regarding, child was weighed and the weight was taken correctly and checked against the growth chart, the temperature was taken correctly, the respiratory rate was counted in children with cough or breathing problems, duration of the diarrhoea episode was asked and presence of blood to identify dysentery was considered, among the tasks to assess the hydration status children with diarrhoea had their skin pinched and high proportion of them were offered something to drink to check thirst, ear and throat problems were looked for properly, a history of measles was checked in children with fever or history of fever, signs to detect clinical anaemia were looked for, oedema on both feet with visible wasting to detect clinical severe malnutrition were checked, the vaccination status was asked about, and finally caretakers were enquired about the presence of any other problems than those listed in the IMCI algorithm, to complete the assessment of the child. There was high agreement in classification of IMCI trained care providers in conditions requiring urgent referral, treatment, or specific nutrition advice. Large proportions of conditions incorrectly classified by the provider were under-classified as milder cases in non IMCI centers, the reasons included inaccurate history, incomplete or incorrect assessment, not taking assessment findings into account, or giving no classification at all. The key case management and advising tasks were much more likely to be performed, and performed correctly, in children managed by providers trained in IMCI than by those untrained. Performance by providers not trained in IMCI was often rather poor, raising the issue about pre-service training and in-service supervision: for example, high percentage of children were prescribed antibiotics unnecessarily, few of the caretakers of diarrhoea cases given ORS were advised on its preparation and administration, and often low advice on home care were given by providers not trained in IMCI. The weak areas in providers’ instructions were the dose, followed by the duration of treatment. Furthermore, low proportion of checking for caretaker understanding of the instructions received for antibiotics, not describe correctly how to administer the antibiotic. Concerning other main treatment aspects, advice on definite follow-up would have been required raising some issues about the feasibility of such a recommendation, few caretakers instructions on treatment and feeding of children were clear before leaving the facility about key home care rules, showing substantial lack of knowledge especially about the danger signs that should prompt them to seek immediate care, encouraging was the main finding caretakers mentioned they would continue feeding their child during illness, feeding advice, however, was largely inadequate, effective communication techniques were used rarely by providers. The results on case management clearly show a better performance for tasks carried out by providers trained in IMCI than those untrained, evidence that IMCI training can improve quality of care. The poor performance of many tasks for cases seen by providers not trained in IMCI raises the issue about the quality of pre-service training and in-service supervision. Weak health system elements add to the challenges. To provide equitable access to care to the most vulnerable group: consideration should be given to protecting children, MoH should commit to making key drugs regularly available, to make the most of the substantial financial investment placed in IMCI training; to reinforce skills, by strengthening follow-up visits after IMCI training; to improve health providers’ basic skills; setting and promoting the policy that all children caretakers have good knowledge not only for immunization but also for sick child visits; to improve care-seeking practices, high priority should be given to targeting the community through health communication activities to improve family knowledge about the early signs that should prompt care-seeking for sick.