A systems approach to assessing complexity in health interventions: an effectiveness decay model for integrated community case management

Abstract

Complexity is inherent to any system or program. This is especially true of integrated interventions, such as integrated community case management (iCCM). iCCM is a child health strategy designed to provide services through community health workers (CHWs) within hard-to-reach areas of low-and-middle-income countries (LMICs). It is comprised of many interlinked program components, processes and stakeholders. Elucidating the complexity of such programs is essential to designing interventions that respond to local contexts and successfully plan for sustainable integration. A pragmatic approach has yet to be developed that holistically assesses the many dimensions of iCCM or other integrated programs, their alignment with local systems, and how well they provide effective care. We propose an accessible systems approach to both measuring systems effectiveness and assessing its underlying complexity using a combination of systems thinking tools. We propose an effectiveness decay model for iCCM implementation to measure where patient loss occurs along the trajectory of care. The approach uses process mapping to examine critical bottlenecks of iCCM processes, their influence on effectiveness decay, and their integration into local systems; regression analysis and structural equation modeling to determine effects of key indicators on programmatic outcomes; and qualitative analysis with causal loop diagramming to assess stakeholder dynamics and their interactions within the iCCM program. An accurate assessment of the quality, effectiveness, and strength of community-based interventions relies on more than measuring core indicators and program outcomes; it requires an exploration of how its actors and core components interact as part of a system. Our approach produces an interactive iCCM effectiveness decay model to understand patient loss in context, examines key systems issues, and uses a range of systems thinking tools to assess the dynamic interactions that coalesce to produce observed program outcomes.

The building blocks of community health systems: a systems framework for the design, implementation and evaluation of iCCM programs and community-based interventions

“…This begins when a case successfully attains contact with the CHW; receives a diagnostic test (in the case of fever or cough and fast breathing); is appropriately treated and/or referred; until finally exiting the care pathway through adhered referral and/or follow-up by the CHW. 7 While these activities require guidelines for diagnosis and case management to ensure quality and consistency, it is insufficient to simply assure the existence of nondescript plans or algorithms. These must address the specificities of diverse treatment options and diagnostic instruments, suit the organisational context and align with country policy.…”

“…For iCCM to optimise its programmatic potential, it is generally recognised that many systems influences must coalesce to ensure scaleable implementation and equitable coverage 6 7. Quality and consistent supervision of CHWs, an enabling policy environment, a comprehensive community mobilisation campaign, continuously available commodities, among a host of other conditions are considered necessary to position iCCM as an effective strategy 8–14.…”

Starting at the community: Treatment seeking pathways of children with suspected severe malaria in Uganda

“…For the treatment seeking pathways and malaria case management, we used the effectiveness decay model for community health interventions and its pathways representation as Sankey diagrams. 20 To build the Sankey diagram, we used Tableau Public (https://public.tableau.com). Indicators were calculated as absolute numbers and proportions.…”

Assessing Determinants of Programmatic Performance of Community Management of Malaria, Pneumonia, and Diarrhea in Children in Africa: Protocol and Data Collection for a Mixed Methods Evaluation of Integrated Community Case Management

“…This protocol builds upon existing systems thinking theory and a methodological approach to assess complexity in community health interventions [ 9 ]. This study protocol deals specifically with steps 2, 3, and 4 of the systems approach, namely process mapping, quantitative analysis, and qualitative analysis.…”

“…We applied a mixed methods concurrent triangulation design with an intersecting systems theoretical lens [ 9 - 12 ]. Data collection occurs in five discrete tranches:…”