Abstract
Program managers, investors, and evaluators need real-time information on how program strategies are being scaled up and implemented. Integrated Community Case Management (iCCM) of childhood illnesses is a strategy for increasing access to diagnosis and treatment of malaria, pneumonia, and diarrhea through community-based health workers. We collected real-time data on iCCM implementation strength through cell phone interviews with community-based health workers in Malawi and calculated indicators of implementation strength and utilization at district level using consensus definitions from the Ministry of Health (MOH) and iCCM partners. All of the iCCM implementation strength indicators varied widely within and across districts. Results show that Malawi has made substantial progress in the scale-up of iCCM since the 2008 program launch. However, there are wide differences in iCCM implementation strength by district. Districts that performed well according to the survey measures demonstrate that MOH implementation strength targets are achievable with the right combination of supportive structures. Using the survey results, specific districts can now be targeted with additional support.
Highlights
One challenge to program evaluation at scale is determining the strength of implementation, defined here as the quantity of a program delivered to a population
The program assumption is that deploying Integrated Community Case Management (iCCM)-trained community health workers (CHWs) who are appropriately trained, supplied, and supervised, and at sufficient density in populations without access to fixed health facilities will improve access to appropriate treatment, will be used by the population, and will reduce child mortality from childhood pneumonia, diarrhea, and malaria
In some districts (e.g., Salima and Mulanje), rates of facility-based mentorship were higher than field-based supervision, while in others (e.g., Chitipa and Kasungu), field-based supervision was more common than facility-based mentorship. This is the first report of a cross-sectional implementation strength snapshot for iCCM
Summary
One challenge to program evaluation at scale is determining the strength of implementation, defined here as the quantity of a program delivered to a population. Integrated Community Case Management (iCCM) is a community-based strategy that uses trained and supervised community health workers (CHWs) to assess, classify, and treat diarrhea, malaria, and pneumonia among children under 5 years of age.[4] iCCM holds promise as a strategy to improve access to correct case management for the major infectious causes of child deaths.[5] There is a growing body of implementation research addressing the challenges of scaling-up iCCM in lowincome countries, and the first full evaluations of the strategy are starting to appear. Malawi was the first country in sub-Saharan Africa to implement iCCM at national scale.[6] Beginning in 2008, the Ministry of Health (MOH), with support from the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), trained existing and newly recruited CHWs, who are called Health Surveillance Assistants (HSAs) in Malawi, and deployed them across 10 districts to areas that District Health Management Teams (DHMTs) defined as hard-to-reach, with limited access to fixed heath facilities. A report on the validation study and cost of the method was published previously.[3]
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