Abstract
Background: Community health worker (CHW) interventions to manage childhood illness is a strategy promoted by the global health community which involves training and supporting CHW to assess, classify and treat sick children at home, using an algorithm adapted from the Integrated Management of Childhood Illness (IMCI). To inform CHW policy, the Government of Tanzania launched a program in 2011 to determine if community case management (CCM) of malaria, pneumonia and diarrhea could be implemented by CHW in that country. Methods: This paper reports the results of an observational study on the CCM service delivery quality of a trial cohort of CHW in Tanzania, called WAJA. In 2014, teams of data collectors, employees of the Ministry of Health and Social Welfare trained in IMCI, assessed the IMCI skills rendered by a sample of WAJA on sick children who presented to WAJA with illness signs and symptoms in their communities. The assessment included direct observations of WAJA IMCI episodes and expert re-assessment of the same children seen by WAJA to assess the congruence between the assessment, classification and treatment outcomes of WAJA cases and those from cases conducted by expert re-assessors. Results: In the majority of cases, WAJA correctly assess sick children for CCM-treatable illnesses (malaria, pneumonia, and diarrhea) and general danger signs (90% and 89%, respectively), but too few correctly assess for physical danger signs (39%); on classification in the majority of cases (73%) WAJA correctly classified illness, though more for CCM-treatable illnesses (83%). In majority of cases (78%) WAJA treated children correctly (84% of malaria, 74% pneumonia, and 71% diarrhea cases). Errors were often associated with lapses in health systems support, mainly supervision and logistics. Conclusion: CCM is a feasible strategy for CHW in Tanzania, who, in the majority of cases, implemented the approach as well as IMCI expert re-assessors. Nevertheless, for CCM to be effective, in Tanzania, a strategy to implement it must be coordinated with efforts to strengthen local health systems
Highlights
Despite significant declines in the past decade, child mortality in Tanzania remains unacceptably high
Community case management (CCM) involves training and supporting Community health worker (CHW) to assess, classify and treat sick children in the home, using an algorithm adapted from the Integrated Management of Childhood Illness (IMCI) approach that focuses on a holistic assessment of the child presenting signs and symptoms using syndromic management, rather than targeting a single disease category
As per the sampling methodology, the Wawezashaji wa Afya ya Jamii (WAJA) representatively reflect the relative size of their respective training cohorts, with 40% coming from cohort 1 and 2, trained in 2010-2011 and 2011-2012, respectively, and 20% coming from the third cohort, trained in 2012-2013
Summary
Despite significant declines in the past decade, child mortality in Tanzania remains unacceptably high. As a strategy for accelerating achievement of goals to reduce childhood mortality, CCM can only succeed if it is delivered at scale and adequately in terms of quality and the strength of the systems that support it It follows that for countries, such as Tanzania, to adopt and implement CCM effectively, there is a need for knowledge on the degree to which community-based health workers can implement it according to existing clinical standards, the common errors they make in their application of CCM, and the functionality of necessary supervision and logistics systems.[4] There is evidence on the quality of care delivered through CCM set in limited pilot settings[5,6] and other studies have examined quality of care of CCM programs being implemented at scale.[7,8,9] Some studies have assessed the skills of providers by reviewing service delivery records,[10] knowledge tests,[11] role plays and case scenarios,[12] while others have directly observed CHW services rendered.[13,14,15] Research on CCM has compared the effectiveness of CCM programs for a single disease with programs that use CCM for multiple sicknesses, and those which integrate CCM into a broader package of primary healthcare interventions (iCCM).[16] This study uses rigorous, community-based observation methods with clinical, ‘gold-standard’ re-assessments to evaluate the quality of care for sick children in the context of a pilot program that was implemented from 2010-2015 in three districts of rural Tanzania. How WAJA performed vis-à-vis national standards, their specific clinical errors, and the systems factors that shape the quality of care, as well as the implications of these for CHW policy in Tanzania, are reviewed and discussed
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