iCCM Implementation Research Articles

Measuring Implementation Strength for Integrated Community Case Management in Malawi: Results from a National Cell Phone Census.

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.

Valuing and Sustaining (or Not) the Ability of Volunteer Community Health Workers to Deliver Integrated Community Case Management in Northern Ghana: A Qualitative Study.

BackgroundWithin the integrated community case management of childhood illnesses (iCCM) programme, the traditional health promotion and prevention role of community health workers (CHWs) has been expanded to treatment. Understanding both the impact and the implementation experience of this expanded role are important. In evaluating UNICEF’s implementation of iCCM, this qualitative case study explores the implementation experience in Ghana.Methods and FindingsData were collected through a rapid appraisal using focus groups and individual interviews during a field visit in May 2013 to Accra and the Northern Region of Ghana. We sought to understand the experience of iCCM from the perspective of locally based UNICEF staff, their partners, researchers, Ghana health services management staff, CHWs and their supervisors, nurses in health facilities and mothers receiving the service. Our analysis of the findings showed that there is an appreciation both by mothers and by facility level staff for the contribution of CHWs. Appreciation was expressed for the localisation of the treatment of childhood illness, thus saving mothers from the effort and expense of having to seek treatment outside of the village. Despite an overall expression of value for the expanded role of CHWs, we also found that there were problems in supporting and sustaining their efforts. The data showed concern around CHWs being unpaid, poorly supervised, regularly out of stock, lacking in essential equipment and remaining outside the formal health system.ConclusionsExpanding the roles of CHWs is important and can be valuable, but contextual and health system factors threaten the sustainability of iCCM in Ghana. In this and other implementation sites, policymakers and key donors need to take into account historical lessons from the CHW literature, while exploring innovative and sustainable mechanisms to secure the programme as part of a government owned and government led strategy.

Using the Lives Saved Tool as part of evaluations of community case management programs.

BackgroundIntegrated community case management (iCCM) has been recommended by the World Health Organization to reduce mortality among children in populations with limited access to facility–based health care providers. Although many countries have introduced iCCM, interpretation of the impact is difficult due to many other activities occurring in the community. This paper suggests a method for using the Lives Saved Tool to model the independent impact of iCCM on child mortality.ModelThe Lives Saved Tool (LiST) is a multi–cause model of mortality which allows users to look at the potential impacts of one or many interventions on one or many causes of death without double counting their impact. LiST uses changes in intervention coverage and cause–specific effectiveness estimates on mortality and risk factors to model overall changes in mortality as well as to attribute mortality reduction to specific interventions. Collecting data on the source of the care seeking behaviors is critical to being able to model and interpret the changes observed.DiscussionThe complexity of implementation of iCCM in the environment of broader health changes requires modeling to understand the program specific impacts. Using LiST results as additional data in combination with observed coverage change and mortality reduction can help explain the isolated impact of a given iCCM program when other changes are ongoing. LiST is unable to determine why the changes in health care seeking behaviors occur, but can be useful in helping to explain whether or not the changes were beneficial.

Integrated community case management of malaria, pneumonia and diarrhoea across three African countries: A qualitative study exploring lessons learnt and implications for further scale up.

Numerous studies highlight the effectiveness of an integrated approach for the management of malaria, pneumonia and diarrhoea at the community level. There has however been little study on lessons learnt from implementation in practice and stakeholder experiences which could inform future programmatic planning and evaluation frameworks. A participatory, qualitative evaluation was conducted in the three varied settings of South Sudan, Uganda and Zambia, which have seen the scale up of integrated community case management (iCCM) over the last five years. All key in–country stakeholders were consulted on study design, with a particular focus on scope and methodology. Data collection methods included stakeholder consultations (key informant interviews, focus group discussions), and a review of project and Ministry of Health documentation. Data analysis followed the Framework Approach. Results suggest that iCCM implementation generally followed national pre–agreed guidelines. Overarching key programmatic recommendations included: collaboration with implementing partners in planning stages to positively impact on community acceptance and ownership; adoption of participatory training methods adapted to low literacy populations; development of alternative support supervision methods such as peer support groups; full integration of community level data into the health management information system and emphasizing data analysis, use and feedback at all levels; strengthened supply chains through improved quantification and procurement of commodities in conjunction with the national distribution network; community engagement to establish a support system for community health workers to increase their motivation; enhanced sensitisation and behaviour change communication to raise awareness and usage of appropriate health services; and advocacy at the national level for funding and logistical support for the continuation and integration of iCCM. This qualitative study is a valuable contribution in understanding the ‘hows’ of iCCM implementation with key insights for improved feasibility and acceptability. Main findings show how community support to iCCM and community health workers is necessary for sustained health benefits coupled with a focus on strengthening and ‘enabling’ the public health system. The participatory study design and methodologies used enabled the scope of the research enquiry to effectively capture various stakeholder perspectives.

The way forward for integrated community case management programmes: A summary of lessons learned to date and future priorities.

Integrated community case management (iCCM) programming is an important and increasingly common strategy used to deliver essential health and nutrition interventions to families in sub–Saharan Africa [1–3]. Between 3 and 5 March 2014, over 400 individuals from 35 countries in sub–Saharan Africa and 59 international partner organisations gathered in Accra, Ghana for an iCCM Evidence Review Symposium. The objective of the Symposium was twofold: first, to review the current state of the art of iCCM implementation by bringing together researchers, donors, government, implementers and partners to review the map of the current landscape and status of evidence in key iCCM programme areas, in order to draw out priorities, lessons and gaps for improving child and maternal–newborn health and nutrition. Second, to assist African countries to integrate and take action on key frontline iCCM findings presented during the evidence Symposium around eight thematic areas: 1) Coordination, Policy Setting and Scale up; 2) Human Resources and Deployment; 3) Supervision & Performance Quality Assurance; 4) Supply Chain Management; 5) Costs, and cost-effectiveness and financing; 6) Monitoring, Evaluation and Health Information Systems; 7) Demand generation and social mobilisation; and 8) Impact and outcome evaluations. The eight thematic areas were based on the CCM benchmark framework, a tool for iCCM program planners and managers to systematically design and implement iCCM programs from the early phases through expansion and scale up. The framework specifies key steps that should be completed for each component and phase of implementation [4].

Current scientific evidence for integrated community case management (iCCM) in Africa: Findings from the iCCM Evidence Symposium.

In March 2014, over 400 individuals from 35 countries in sub-Saharan Africa and 59 international partner organizations gathered in Accra, Ghana for an integrated Community Case Management (iCCM) Evidence Review Symposium. The objective was 2-fold: first, to review the current state of the art of iCCM implementation and second, to assist African countries to integrate lessons learned and best practices presented during the symposium into their programmes. Based on the findings from the symposium this supplement includes a comprehensive set of articles that provide the latest evidence for improving iCCM programs and ways to better monitor and evaluate such programs.

Routine monitoring systems for integrated community case management programs: Lessons from 18 countries in sub-Saharan Africa.

Integrated community case management (iCCM) programs are expanding rapidly in many low– and middle–income countries, particularly in sub–Saharan Africa. Conclusions from the recent review of iCCM programs in Africa emphasized the critical importance of using routine data to assess program performance and to inform impact evaluations [1]. Yet monitoring systems often fail to deliver quality data (defined as relevant, complete, timely and accurate [2]) and program managers do not have the capacity or are not empowered to use data for decision–making and corrective action [3]. Monitoring systems for iCCM suffer from many of the same shortcomings of the broader routine health information systems (HIS), but extending these systems to the community level at scale presents unique challenges and constraints. While the literature highlighting results of iCCM programs has expanded, little has been published that explores the monitoring systems necessary to support successful implementation. This paper aims to synthesize lessons learned from recent experience developing and implementing systems for routine monitoring of large scale iCCM programs. These lessons were compiled from the primary partners supporting iCCM implementation across 18 countries in sub–Saharan Africa through interviews with monitoring focal persons and review of relevant documents and tools and informed by literature on strengthening routine health information systems more broadly [3–5]. We first outline the rationale for routine data and the challenges iCCM programs face to establish functional monitoring systems to generate such data. We then characterize the current state of routine monitoring systems for iCCM, summarize lessons learned and conclude with a way forward.

Nationwide implementation of integrated community case management of childhood illness in Rwanda.

Between 2008 and 2011, Rwanda introduced integrated community case management (iCCM) of childhood illness nationwide. Community health workers in each of Rwanda's nearly 15,000 villages were trained in iCCM and equipped for empirical diagnosis and treatment of pneumonia, diarrhea, and malaria; for malnutrition surveillance; and for comprehensive reporting and referral services. We used data from the Rwanda health management information system (HMIS) to calculate monthly all-cause under-5 mortality rates, health facility use rates, and community-based treatment rates for childhood illness in each district. We then compared a 3-month baseline period prior to iCCM implementation with a seasonally matched comparison period 1 year after iCCM implementation. Finally, we compared the actual changes in all-cause child mortality and health facility use over this time period with the changes that would have been expected based on baseline trends in Rwanda. The number of children receiving community-based treatment for diarrhea and pneumonia increased significantly in the 1-year period after iCCM implementation, from 0.83 cases/1,000 child-months to 3.80 cases/1,000 child-months (P = .01) and 0.25 cases/1,000 child-months to 5.28 cases/1,000 child-months (P<.001), respectively. On average, total under-5 mortality rates declined significantly by 38% (P<.001), and health facility use declined significantly by 15% (P = .006). These decreases were significantly greater than would have been expected based on baseline trends. This is the first study to demonstrate decreases in both child mortality and health facility use after implementing iCCM of childhood illness at a national level. While our study design does not allow for direct attribution of these changes to implementation of iCCM, these results are in line with those of prior studies conducted at the sub-national level in other low-income countries.

Plausible role for CHW peer support groups in increasing care-seeking in an integrated community case management project in Rwanda: a mixed methods evaluation.

The Kabeho Mwana project (2006-2011) supported the Rwanda Ministry of Health (MOH) in scaling up integrated community case management (iCCM) of childhood illness in 6 of Rwanda's 30 districts. The project trained and equipped community health workers (CHWs) according to national guidelines. In project districts, Kabeho Mwana staff also trained CHWs to conduct household-level health promotion and established supervision and reporting mechanisms through CHW peer support groups (PSGs) and quality improvement systems. The 2005 and 2010 Demographic and Health Surveys were re-analyzed to evaluate how project and non-project districts differed in terms of care-seeking for fever, diarrhea, and acute respiratory infection symptoms and related indicators. We developed a logit regression model, controlling for the timing of the first CHW training, with the district included as a fixed categorical effect. We also analyzed qualitative data from the final evaluation to examine factors that may have contributed to improved outcomes. While there was notable improvement in care-seeking across all districts, care-seeking from any provider for each of the 3 conditions, and for all 3 combined, increased significantly more in the project districts. CHWs contributed a larger percentage of consultations in project districts (27%) than in non-project districts (12%). Qualitative data suggested that the PSG model was a valuable sub-level of CHW organization associated with improved CHW performance, supervision, and social capital. The iCCM model implemented by Kabeho Mwana resulted in greater improvements in care-seeking than those seen in the rest of the country. Intensive monitoring, collaborative supervision, community mobilization, and CHW PSGs contributed to this success. The PSGs were a unique contribution of the project, playing a critical role in improving care-seeking in project districts. Effective implementation of iCCM should therefore include CHW management and social support mechanisms. Finally, re-analysis of national survey data improved evaluation findings by providing impact estimates.

Integrated community case management of childhood illness in Ethiopia: implementation strength and quality of care.

Ethiopia has scaled up integrated community case management of childhood illness (iCCM) in most regions. We assessed the strength of iCCM implementation and the quality of care provided by health extension workers (HEWs). Data collectors observed HEWs' consultations with sick children and carried out gold standard re-examinations. Nearly all HEWs received training and supervision, and essential commodities were available. HEWs provided correct case management for 64% of children. The proportions of children correctly managed for pneumonia, diarrhea, and malnutrition were 72%, 79%, and 59%, respectively. Only 34% of children with severe illness were correctly managed. Health posts saw an average of 16 sick children in the previous 1 month. These results show that iCCM can be implemented at scale and that community-based HEWs can correctly manage multiple illnesses. However, to increase the chances of impact on child mortality, management of severe illness and use of iCCM services must be improved.

Socioeconomic conditions in childhood and ischaemic heart disease during middle age.

To examine the association between socioeconomic conditions in childhood and ischaemic heart disease in middle aged men, including the role of physiological and behavioural risk factors. Prevalence study with extensive examination and testing and with recall of childhood conditions. Population based study in Kuopio, Finland. Representative sample of 2679 men aged 42, 48, 54, and 60. Ischaemic findings on progressive maximal exercise test. Low socioeconomic style in childhood was associated with significantly higher prevalence of findings indicating ischaemias. Compared with those in the highest tertile of childhood socioeconomic conditions, the age adjusted odds ratio for subjects in the lowest tertile was 1.44 and for those in the middle tertile 1.35. Adjustment for years of cigarette smoking times the average number of cigarettes smoked, ratio of high density lipoprotein to low density lipoprotein cholesterol, fibrinogen and serum selenium concentrations, and adult height did not appreciably weaken the association. Adjustment for adult socioeconomic state resulted in a 16% decline in the association. The association was reduced to non-significance by adjustment for measures of prevalent cardiovascular illness. Socioeconomic state in childhood was significantly associated with ischaemic heart disease in middle aged men. Levels of risk factors measured at middle age did not account for this association, nor did adult height. Because childhood socioeconomic conditions precede the development of ischaemic heart disease the substantial impact of prevalent illness on the observed association suggests that ischaemic heart disease develops earlier in those with lower socioeconomic state during childhood.

Uveitis and rheumatic diseases.

<h3>Introduction</h3> Almost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes. <h3>Methods</h3> We propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM literature, a review of policy documents and discussions with key informants. The framework development was guided by a combination of health systems conceptual frameworks and iCCM indices. <h3>Results</h3> The resulting framework yielded 10 thematic domains comprising 106 categories. These are complemented by a catalogue of critical questions that program designers, implementers and evaluators can ask at various stages of program development to stimulate meaningful discussion and explore the potential implications of implementation in decentralised settings. <h3>Conclusion</h3> The iCCM Systems Framework proposed here aims to complement existing intervention benchmarks and indicators by expanding the scope and depth of the thematic components that comprise it. Its elements can also be adapted for other complex community interventions. While not exhaustive, the framework is intended to highlight the many forces involved in iCCM to help managers better harmonise the organisation and evaluation of their programs and examine their interactions within the larger health system.