Integrated Community Case Management
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Across sub-Saharan Africa, many sick children and their parents do not have access to health facilities. However, over 50% of the childhood illnesses in the region can be attributed to diarrhea, malaria and pneumonia—diseases that do not require a medical professional to diagnose or treat. To supplement the gap in services for these easily treatable diseases, health programs are increasingly turning to integrated community case management (iCCM)—an approach where community-based health workers (CBHWs) are trained to identify, treat, and refer children with diarrhea, pneumonia, and malaria. Recent research suggests that the iCCM approach is promising. iCCM programs have successfully increased health coverage for sick children living in remote locations in several countries, such as the Democratic Republic of Congo, Honduras, Malawi, Niger, Rwanda, Senegal, Nepal, and Pakistan.
However, while iCCM programs have been endorsed by major international organizations—including the WHO, UNICEF, and USAID—as a key strategy for achieving Millennium Development Goal 4 to reduce child mortality, many countries have yet to implement or scale-up iCCM programs. Also, important indicators—such as the appropriate criteria for monitoring and evaluation, the ingredients necessary to achieve cost effectiveness, and the nature of supportive government policies—are still unclear. Additional research is needed to help fill these gaps and promote expansion of iCCM programs across the region.
Part of the reason for the hesitancy of many low income countries to implement iCCM programs is due to uncertainty about the structures and strategies needed to ensure iCCM success.
In order to reduce such uncertainty and support the roll-out of iCCM more broadly, TRAction is supporting research on three iCCM focus areas: developing cost and financing models; conducting embedded implementation research; and investigating effective policy development processes. These areas were chosen because of their relevance to iCCM planning and implementation in low and middle income countries.
iCCM Cost and Financing Analysis and Model Development
TRAction has awarded funding to Management Sciences for Health (MSH) to develop and disseminate a simple cost and financing model for integrated Community Case Management programs. Research for the model will be conducted in Malawi, Rwanda and a third country (to be identified), where iCCM programs are at different stages of development. Field testing of the model with only remote technical assistance will also be done in one or two other countries to ensure the usability of the tool.
The final model aims to measure cost efficiency and effectiveness, allowing users to calculate:
- Start-up and recurrent incremental costs and financing at the community, facility, district, regional and national levels;
- Incremental costs to support programs designed for each of the three diseases (diarrhea, malaria, and pneumonia) as well as costs to add other relevant interventions;
- Key drivers of cost and the primary costs, as a percent of total costs;
- Five-year projections with sustainability analysis;
- Program outputs;
- Cost effectiveness;
- Costs and costs per case treated of different types of iCCM programs;
- National and global iCCM financial indicators (as developed by the iCCM working group); and
- “What-if” scenarios to improve sustainability or reduce funding requirements.
The goal is to produce a model that is user-friendly and applicable across countries, eventually facilitating standardized analyses of iCCM programs around the globe. Such a model will help countries advocate for funding and allocate funds appropriately. It will also allow for better monitoring and control of costs, enabling the efficient use of scarce resources.
The project timeline will include:
- Development of the model prototype and user’s guide;
- Research in the three countries to inform, develop, adapt, and refine the tool;
- Field testing in one or two additional countries;
- Finalization of the model, user’s guide, and data collection tool;
- Dissemination of the model and its results;
- Preparation of the model for publication; and
- Provision of follow-up support to new users.
iCCM Implementation Research to be Embedded in an Operational Integrated Community Case Management (iCCM) Program
TRAction awarded funds to the Johns Hopkins University School of Public Health (JHUSPH) in collaboration with Save the Children, USA to examine innovative data collection approaches for monitoring implementation bottlenecks and evaluating progress of existing iCCM programs in Malawi and Mali. Better data and data collection systems will help iCCM program managers identify bottlenecks in service delivery—points where there are too few health professionals or too many health service users—and develop solutions to these problems. By making better data available to program managers and ministries of health, iCCM programs can be more responsive to community needs, better track and define their progress, and generate increasingly accurate reports for national and international stakeholders.
To achieve this goal, JHUSPH will:
- Identify, adapt and develop appropriate data collection, monitoring and evaluation approaches based on USAID/MCHIP’s iCCM benchmark indicators, which were developed as a global strategy to help program managers design, implement, monitor, and evaluate iCCM programs;
- Strengthen and streamline routine monitoring and data collection systems at the community level;
- Support the use of monitoring and evaluation data and indicators in decision-making to improve iCCM programs;
- Identify iCCM program bottlenecks; and
- Enhance systems to track progress over time.
In Malawi, the researchers will build on previous and ongoing implementation research to test alternative monitoring strategies, while in Mali the researchers will support the development and improvement of monitoring techniques in an emerging, national iCCM program.
The project timeline will include:
- Desk reviews of available data and indicators using the USAID iCCM global indicators
- Data quality audits to a assess the completeness and quality of available data
- Consulting with stakeholders to identify priority data needs
- Development of innovative approaches for collecting the identified priority data
- Documenting the feasibility, costs and quality of alternative approaches to data collection
- Documenting the use of existing and new iCCM data and further data needs
- Disseminating the findings from the research program on an on‐going basis
Policy Analysis of Community Case Management for Childhood and Newborn Illnesses
The USAID supported TRAction Project and UNICEF are co-funding researchers from Johns Hopkins University School of Public Health (JHUSPH) to carry out a one year, multi-country and global policy analysis of iCCM of childhood illness and newborn care in order to identify facilitating factors and barriers for iCCM policy reform and program development. The purpose of the research is to identify national and global challenges to reforming policies and designing iCCM programs, and develop a framework that can inform global strategies for scale-up of iCCM.
To achieve this goal, the researchers will identify facilitators and barriers to policy and program change; assess the roles of national and international actors in supporting or resisting policy and program development; assess the role of evidence in supporting policy and program development; and document the types of policies that support or inhibit iCCM implementation. This process will allow the researchers to determine which policy elements are critical to iCCM program implementation success.
The research will be conducted through two different approaches:
Global Level Analysis: The research team will examine the historical context of iCCM by reviewing key documents related to the evolution of community health workers and iCCM. Researchers will study the processes through which the policies evolved, reasons for their evolution, and key actors involved in the policy change. Literature reviews will be performed to identify key events, discussions, and recommendations related to iCCM programs. The researchers will also conduct key informant interviews to determine the factors that support policy shifts and the role of scientific evidence in policy changes.
- Country Case Studies: Qualitative, retrospective case studies of iCCM policies will be carried out in various countries to explore the role that different contexts, content, actors, and processes play in iCCM policy development. Countries for full-scale case studies include Kenya, Malawi, Mali, Mozambique, Burkina Faso, and Niger. Data will be collected through document reviews, a standard stakeholder analysis that will identify each stakeholder’s level of support for iCCM, and in-depth interviews with stakeholders and key informants. Findings will be compared across all study countries to identify points of difference and similarity, and to determine the influence of global policies on national iCCM processes.
The research results will be used to develop recommendations on methods for supporting policy changes that will facilitate scale-up of iCCM programs.