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

Abstract

IntroductionAlmost all sub-Saharan African countries have adopted some form of integrated community case management (iCCM) to reduce child mortality, a strategy targeting common childhood diseases in hard-to-reach communities. These programs are complex, maintain diverse implementation typologies and involve many components that can influence the potential success of a program or its ability to effectively perform at scale. While tools and methods exist to support the design and implementation of iCCM and measure its progress, these may not holistically consider some of its key components, which can include program structure, setting context and the interplay between community, human resources, program inputs and health system processes.MethodsWe propose a Global South-driven, systems-based framework that aims to capture these different elements and expand on the fundamental domains of iCCM program implementation. We conducted a content analysis developing a code frame based on iCCM literature, a review of policy documents and discussions with key informants. The framework development was guided by a combination of health systems conceptual frameworks and iCCM indices.ResultsThe resulting framework yielded 10 thematic domains comprising 106 categories. These are complemented by a catalogue of critical questions that program designers, implementers and evaluators can ask at various stages of program development to stimulate meaningful discussion and explore the potential implications of implementation in decentralised settings.ConclusionThe iCCM Systems Framework proposed here aims to complement existing intervention benchmarks and indicators by expanding the scope and depth of the thematic components that comprise it. Its elements can also be adapted for other complex community interventions. While not exhaustive, the framework is intended to highlight the many forces involved in iCCM to help managers better harmonise the organisation and evaluation of their programs and examine their interactions within the larger health system.

Prehospital use of point-of-care tests by community health workers: a scoping review

“…Practical considerations and expert opinion both advocate in favor of implementing POCTs in LMICs; however, after decades of malaria RDT use and subsequent treatment in the prehospital setting, many challenges were identified ( 1 , 6 – 8 ). Particularly, financial constraints, limits to supervision and monitoring of CHWs, and a paucity of evidence related to clinical outcomes, constrains progress and possible transformation adaptation ( 5 – 8 , 23 ). To improve evaluation for navigating these complexities, a recent content analysis of iCCM programs proposed several frameworks to manage and evaluate programs ( 23 ).…”

“…Particularly, financial constraints, limits to supervision and monitoring of CHWs, and a paucity of evidence related to clinical outcomes, constrains progress and possible transformation adaptation ( 5 – 8 , 23 ). To improve evaluation for navigating these complexities, a recent content analysis of iCCM programs proposed several frameworks to manage and evaluate programs ( 23 ). This overview allows program managers to prepare for process evaluation, sustainability, adequate monitoring, and outcome measurements.…”

Systems Thinking for Supply Chains: Identifying Bottlenecks Using Process Mapping of a Child Health Intervention in the Democratic Republic of the Congo (DRC)

“…We apply the principles of enterprise architecture to assess the supply chains of an integrated community case management (iCCM) program targeting childhood malaria, pneumonia, and diarrhea in a province of DRC. iCCM is considered a complex intervention due to its reliance on interconnected healthcare subsystems, and the unpredictable dynamics of the actors that operate within them [11]. We overlaid the application of the process mapping tool with the categories of the supply chain and commodities building block of the Community Health Systems Framework, which classifies an defines specific areas for the assessment of supply chains in community health systems of LMICs (Figure 1) [11].…”

“…iCCM is considered a complex intervention due to its reliance on interconnected healthcare subsystems, and the unpredictable dynamics of the actors that operate within them [11]. We overlaid the application of the process mapping tool with the categories of the supply chain and commodities building block of the Community Health Systems Framework, which classifies an defines specific areas for the assessment of supply chains in community health systems of LMICs (Figure 1) [11]. These include the themes of drugs and commodities; quantification; procurement; distribution and transport; resupply and allocation; availability and stockouts; inventory and storage; protocols and standard operating procedures; and commodity quality and sustainability.…”