Integrated Community Case Management (iCCM) of the leading causes of child death (pneumonia, diarrhea and malaria) is emerging as a policy and programmatic priority for many sub-Saharan countries. While there is a significant body of scientific evidence that supports iCCM, this may not necessarily be translated into supportive policies or programmatic designs that allow for the effective scaling up of iCCM in many countries. There is little systematic documentation or strategic analysis of how iCCM policies and programs are emerging in sub-Saharan countries. This TRAction funded research consists of a retrospective policy analysis of the factors supporting and/or inhibiting policy reform and program design for iCCM in Niger, Burkina Faso, Kenya, Mali, Mozambique, Malawi, and at the global level, with a view to informing both national and global level policies.
The purpose of this study was to identify national and global challenges to reforming policies and designing iCCM programs, and inform global strategies for scaling-up iCCM. Data was collected through document reviews, literature searches, a standard stakeholder analysis to identify each stakeholder’s level of support for iCCM in select countries, and in-depth key informant interviews. Specific objectives included:
Policy Content: In all countries, iCCM was not a stand-alone policy; instead it was many times part of Integrated Management of Childhood Illnesses (IMCI) program. Community Health Worker (CHW) profiles varied between countries with some building upon paid cadres while others worked to establish a program based on volunteers.
Policy Context: The history of primary health care and CHW programs in each country had a substantial impact on policy development. Availability of funding to support drugs and scale up and training of a paid CHW cadre influenced successful policy formulation across all countries.
Actors: Policy development was generally led by Ministry of Health (MoH) technocrats, with resistance from medically trained senior officials. Interactions were generally between MoH officials, multi/bilateral agencies and NGOs with little involvement at higher levels of government
Policy Process: Much of iCCM policy originated from the perception that countries were not meeting the Millennium Development Goals (MDG), specifically MDG 4. With IMCI not performing as hoped and swelling support for iCCM from international agencies, a policy window opened for iCCM. Though contextual factors and financing allowed for iCCM development, policy was completed in pieces and by different technical groups, making coordination a challenge.
Role of Evidence: Although local evidence was highly valued, much scientific and experiential evidence cited during policy development came more from outside the country. Where there was a shortage of local evidence on key issues, there was potential to slow the policy process.
Coordination and integration of iCCM and sustainability of the approach emerged as important elements to consider in future policy formulation. Integration across iCCM conditions varied with more difficulties faced in countries with well-funded, parallel malaria programs. Questions remain about the long-term financing and sustainability of iCCM policy and its implementation as there is a lack of plans for long-term funding and no Ministry of Finance involvement in policy discussions.
Overall, the study demonstrated that policies present during policy formulation, emerge as challenges in implementation, if not addressed. Other recommendations to consider during policy formulation to support successful scale-up and sustainability of iCCM include:
These lessons learned as well as identified facilitators and barriers to iCCM policy change are summarized in the Tropical Medicine and International Health journal article "Policy challenges facing integrated community case management in Sub-Saharan Africa".
TRAction and its partners used research results to develop recommendations on methods for supporting iCCM policy changes that will facilitate scale-up of iCCM programs. These were shared with stakeholders through a variety of channels as listed below:
Dissemination will continue through development of technical documents, participation in key stakeholder groups, sharing results at global and local events.