Lessons To Be Learned For Optimizing iCCM At Scale
When the stakes are millions of unnecessary child deaths, the universal wisdom to learn from failure is loaded with value and urgency. Every day, governments around the world are implementing policy with varying degrees of success, and learning from the experience. Rarely are these internal experiences studied with scientific methodology, synthesized for cross-country comparison, and shared publicly. When they are, and when human lives are at stake, applying lessons learned from failure becomes nothing less than a moral imperative.
The world has the tools necessary to end unnecessary child deaths. Community Case Management (CCM) of common childhood illnesses is an effective and equitable strategy to bring lifesaving health care to the world’s most vulnerable populations. A package of care delivered by community health workers (CHWs), CCM diagnoses, treats and refers sick children in the communities in which they live.
Recommended by WHO and UNICEF since 2004, CCM is based on a large body of evidence showing it to be effective in increasing access to care and reducing child mortality.
Most countries in sub-Saharan Africa have since adopted national policies for the integrated community case management of malaria, diarrhea, pneumonia, malnutrition and neonatal illness, a package of care known as iCCM.
In March, three independent evaluations were published in the American Journal of Tropical Medicine and Hygiene of iCCM scale-up in Burkina Faso (1), Ethiopia (2) and Malawi (3). The results of these studies ought to raise red flags for countries, like Mali, in the process of developing national iCCM scale-up: in each of the cases, iCCM at scale had no significant impact on access to care or child mortality.
ICCM programs have to be well-designed and well-implemented in order to deliver their proven outcomes. CHWs have to be adequately trained, deployed and supervised to deliver the iCCM package with quality of care. A closer look, and the Burkinabe, Ethiopian and Malawian programs share certain design and implementation shortcomings that could have caused them to fail at scale.
ICCM programs in Burkina, Ethiopia and Malawi were designed to increase access to care by stationing CHWs in health posts in remote rural villages, available to provide care in a passive manner to patients who seek them out. In Burkina and Ethiopia, patients are charged with user fees for access to CHW care. Across the board, CHWs received infrequent and undedicated supervision from health centre staff, and iCCM was delivered with poor quality of care: only a third of sick children in Burkina were correctly treated by CHWs; half the children in Ethiopia who needed referrals were actually referred; half of Malawian iCCM providers had received the supervision and supplies necessary to be deemed “iCCM-ready”.
Mali’s iCCM scale-up policy, in its current draft form, carries many similarities to the Burkinabe, Ethiopian and Malawian programs. CHWs are stationed in remote rural villages to provide reactive care, charge point-of-care fees, and receive undedicated supervision from otherwise occupied health centre staff. Muso and the Malian Ministry of Health are actively engaged in partnership to optimise the national policy for success, critically examining the results of these studies and testing together an alternative model designed to bring care to the world’s poorest communities.
Proactive Community Case Management, or ProCCM, builds off the global standard of iCCM while taking into account the multiplicity of barriers patients face to care. CHWs conduct door-to-door home visits, finding and connecting patients to care early. The ProCCM care package is provided in the home, along with preventative and reproductive health services, accompanied by the removal user fees. CHWs receive monthly supervision to ensure quality of care, which includes direct observation and community feedback, by a dedicated CHW supervisor.
Three years following the introduction of ProCCM, the periurban area of Yirimadjo saw a two-fold increase in access to care and a 10-fold difference in child mortality (4) By incorporating the lessons of others, Muso and the Ministry of Health hope to amplify and sustain this change, and better understand the mechanisms behind it. In April, Muso and the Ministry of Health launched ProCCM in its first rural site, with an embedded randomised controlled trial designed to test the impact of proactive case detection by CHWs.
Mali is presented with an extraordinary opportunity: one of rigorous scientific evaluation of failed policy at scale and one of in-country experience of what could, at scale, make history. National iCCM scale-up is too valuable, both its investment and its potential too great, to be destined to fail from the onset. If these lessons are learned and applied in time, it doesn’t have to.
Caroline Whidden is Muso’s Research Fellow. She holds a Masters in Public Policy (MPP) and a MSc in Global Health Science from the University of Oxford, and a BSc in Biochemistry and a BA in International Relations from Mount Allison University in New Brunswick, Canada.