The costs of integrated community case management (iCCM) programs: A multi–country analysis

Abstract

BackgroundIntegrated community case management (iCCM) can be an effective strategy for expanding the provision of diarrhea, pneumonia, and malaria services to children under 5 years old but there are concerns in some countries about the corresponding cost and impact. This paper presents and compares findings from a multi–country analysis of iCCM program costs.MethodsData on coverage, utilization, and costs were collected as part of two sets of studies conducted between 2011 and 2013 for iCCM programs in seven sub–Saharan African countries: Cameroon, the Democratic Republic of the Congo, Malawi, Senegal, Sierra Leone, South Sudan and Zambia. The data were used to compare some elements of program performance as well as costs per capita and costs per service (which are key indicators of resource allocation and efficiency).ResultsAmong the seven countries, iCCM utilization ranged from a total of 0.26 to 3.05 contacts per capita (children 2–59 months) per year for the diseases treated, representing a range of 2.7% to 36.7% of the expected numbers of cases. The total recurrent cost per treatment ranged from US$ 2.44 to US$ 13.71 for diarrhea; from US$ 2.17 to US$ 17.54 for malaria (excluding rapid diagnostic testing); and from US$ 1.70 to US$ 12.94 for pneumonia. In some of the country programs, the utilization of iCCM services was quite low and this, together with significant fixed costs, particularly for management and supervision, resulted in services being quite costly. Given the differences across the countries and programs, however, these results should be treated as indicative and not definitive.ConclusionA comprehensive understanding of iCCM program costs and results can help countries obtain resources and use them efficiently. To be cost–effective and affordable, iCCM programs must be well–utilized while program management and supervision should be organized to minimize costs and ensure quality of care. iCCM programs will not always be low–cost, however, particularly in small, remote villages where supervision and supply challenges are greater. Further research is needed to determine the cost–effectiveness of iCCM programs and corresponding patient and service delivery costs.

Who are the real community health workers in Tshopo Province, Democratic Republic of the Congo?

“…iCCM has been implemented in over 50 countries, notably in sub-Saharan Africa, where policymakers have seen it as a solution to the lack of reach of the formal health system 14. However, lack of demand from the community and low utilisation of services have limited impact and cost-effectiveness of iCCM programmes, possibly due to insufficient community engagement 15 16…”

Perceived Quality of Care of Community Health Worker and Facility-Based Health Worker Management of Pneumonia in Children Under 5 Years in Western Kenya: A Cross-Sectional Multidimensional Study

“…21 This is important because iCCM programs, which have low utilization and likely low acceptance of services are the least costeffective, do not lead to decreases in mortality, and may decrease demand for biomedical health care, leading the most marginalized to seek care from ineffective providers. 1,22 In the current study, we sought to determine the level of community acceptance of CHWs capacity to diagnose and treat sick children with pneumonia at the community level when compared with facility-based health-care workers in western Kenya. Building on the work of other groups in East Africa, 23 we used an adapted version of the Primary Care Assessment Survey (PCAS) 24 to evaluate perceptions of caregivers who sought medical attention for their children with pneumonia.…”

Where to from here? Policy and financing of integrated community case management (iCCM) of childhood illness in sub–Saharan Africa

“…Second, the often abstract concept of “sustainable financing” for iCCM needs to be tackled fully and unpacked, again with more granularity for the widely differing contexts in which iCCM is being implemented. Recent progress on costing of iCCM [ 18 ], along with the new opportunities provided by the Global Fund, can be built upon. But there is a need for a frank conversation on what part domestic financing can and should play in underwriting iCCM services.…”