Integrated community case management of malaria, pneumonia and diarrhoea across three African countries: A qualitative study exploring lessons learnt and implications for further scale up

Abstract

Numerous studies highlight the effectiveness of an integrated approach for the management of malaria, pneumonia and diarrhoea at the community level. There has however been little study on lessons learnt from implementation in practice and stakeholder experiences which could inform future programmatic planning and evaluation frameworks. A participatory, qualitative evaluation was conducted in the three varied settings of South Sudan, Uganda and Zambia, which have seen the scale up of integrated community case management (iCCM) over the last five years. All key in–country stakeholders were consulted on study design, with a particular focus on scope and methodology. Data collection methods included stakeholder consultations (key informant interviews, focus group discussions), and a review of project and Ministry of Health documentation. Data analysis followed the Framework Approach. Results suggest that iCCM implementation generally followed national pre–agreed guidelines. Overarching key programmatic recommendations included: collaboration with implementing partners in planning stages to positively impact on community acceptance and ownership; adoption of participatory training methods adapted to low literacy populations; development of alternative support supervision methods such as peer support groups; full integration of community level data into the health management information system and emphasizing data analysis, use and feedback at all levels; strengthened supply chains through improved quantification and procurement of commodities in conjunction with the national distribution network; community engagement to establish a support system for community health workers to increase their motivation; enhanced sensitisation and behaviour change communication to raise awareness and usage of appropriate health services; and advocacy at the national level for funding and logistical support for the continuation and integration of iCCM. This qualitative study is a valuable contribution in understanding the ‘hows’ of iCCM implementation with key insights for improved feasibility and acceptability. Main findings show how community support to iCCM and community health workers is necessary for sustained health benefits coupled with a focus on strengthening and ‘enabling’ the public health system. The participatory study design and methodologies used enabled the scope of the research enquiry to effectively capture various stakeholder perspectives.

Community dialogues for child health: results from a qualitative process evaluation in three countries

“…This corresponds to a previous review which found that community sensitization around seeking timely and appropriate treatment led caregivers to favour CHWs over traditional healers as first point of care [43]. These findings confirm that such participatory approaches can improve dialogue and action-oriented decision-making and increase participation by communities, families and individuals, which can result in increased demand for health services and information seeking/sharing and positive changes in individual behaviours and social norms and practices [18].…”

Quality improvement practices to institutionalize supply chain best practices for iCCM: Evidence from Rwanda and Malawi

“…The lack of available medication severely limited the capacity of CHWs, led to poor community attitudes toward iCCM and CHWs in general, and resulted in increased attendance at health centers. 9 A survey that examined availability and cost of essential medicines in 14 sub-Saharan African countries found that only 3 countries had Central Medical Stores with greater than 50% of national essential medications available. 10 An OxFam study in Malawi found that only about 9% of health centers had sufficient stocks of essential medicines, including for pneumonia and diarrhea, requiring ill patients to be treated with inappropriate medication, travel further distances to reach health centers with the appropriate medicine, visit a private and more expensive health care provider, visit a traditional healer, or go without treatment.…”

Protocol for the evaluation of a complex intervention aiming at increased utilisation of primary child health services in Ethiopia: a before and after study in intervention and comparison areas

“…Ethiopian studies showed that community engagement activities could expand the use and quality of perinatal care [37] and increase the coverage of postnatal care [38]. Community support to iCCM activities and community health workers is needed for sustained health benefits coupled with a focus on strengthening and enabling the public health system [39].…”