The resilience of integrated community case management in acute emergency: a case study from Unity State, South Sudan

Abstract

BackgroundAn active conflict in South Sudan in late 2013/early 2014 displaced approximately 2 million people over the course of several months. In May 2015, the International Rescue Committee and UNICEF conducted a mixed-methods case study of the impact of that acute emergency on integrated community case management (iCCM) of childhood illness programming in Payinjiar County, Unity State. The objective was to document the operations of an iCCM program during an acute crisis and to assess the program’s ability to continue operations.ResultsThis mixed-methods case study is comprised of semi-structured interviews and focus groups with key stakeholders such as policymakers, program implementers, community health workers (CHWs), and caregivers on their experience with iCCM programming during this time period. Routine program data were also analyzed to assess the effect of the crisis on key health indicators.FindingsInternally displaced persons (IDPs) nearly doubled the population in Payinjiar. Some displaced CHWs continued to provide treatment in host communities when they were able to take supplies with them. Despite no formal community mobilization effort by the iCCM program, many IDPs identified CHWs in the communities they were displaced to and obtained care from them. Caregivers who had been internally displaced reported preferring care from CHWs especially in contrast to risking an insecure journey to health facilities. The total number of treatments provided per month by CHWs dropped during the acute crisis, but recovered to pre-crisis levels within six months. CHW supervisors attempted to continue supervision by utilizing their networks to track down displaced CHWs and assess the security situation prior to visits. The monthly supervision rate dropped to the lowest level of 77% in February 2014, but rebounded to 91% by August 2014. Several CHWs and community leaders qualitatively validated this claim of sustained supervision.ConclusionsCHWs, including those who were internally displaced, continued to provide treatment for childhood illnesses during an acute emergency, and service provision recovered faster to pre-crisis levels than the formal health sector. International donors and humanitarian actors should recognize iCCM as a potentially high-impact humanitarian response. Flexible funding from donors would enable further evidence generation on iCCM approaches and improvements that could both sustain and enhance programming in acute crisis.

Health system resilience: a literature review of empirical research

“…Overall, the empirical studies identified differed in terms of their disciplinary tradition or conceptual background. Studies from the public health sciences tended to converge in three groups: (1) quantitative studies focusing on service delivery, making use of service utilization indicators provide an easily accessible measure to assess resilience before, during and after a crisis ( Paterson et al 2014 ; Gizelis et al 2017 ; Sochas et al 2017 ; Kozuki et al 2018 ; Ray-Bennett et al 2019 ), (2) qualitative studies focusing on the health workforce, influenced by ideas of ‘everyday resilience’ and addressing the contributions of social connectedness and leadership on health system resilience ( Mash et al 2008 ; Witter et al 2017 ; Raven et al 2018 ; Brooke-Sumner et al 2019 ; Thude et al 2019 ), and (3) studies taking a broad perspective of health system resilience, looking at multiple health system building blocks or aspects of a health system to assess resiliency ( Ager et al 2015 ; Ammar et al 2016 ; Fukuma et al 2017 ; Ling et al 2017 ; Meyer et al 2018 ; Watts et al 2018 ).…”

“… Kozuki et al (2018) use a process evaluation methodology to document the ability of an integrated community case management programme to continue operation during the active conflict of 2013 and 2014 in South Sudan. The authors use routine programme data, including reporting, supervision, contact, treatment and referral rates, as well as interviews and focus groups with key stakeholders to evaluate the programme’s resiliency.…”

Health services for women, children and adolescents in conflict affected settings: experience from North and South Kivu, Democratic Republic of Congo

“…Task shifting and contingency plans enable TFPs to continue their activities although with delays. Allocating tasks to lower-level health care providers and CHWs are proving an effective strategy to increase access to service not only in resource poor countries [30], but also in humanitarian settings [31][32][33] and during major epidemics [34]. A major challenge of such a decentralized effort identified in crisis settings [32,34], but applicable to the Kivu as well, is ensuring continuous access to essential medicines to CHWs, as supply chains often struggle to reach health centers.…”

Implementing integrated community case management during conflict in Yemen

“…Given the high burden of these illnesses in humanitarian settings, there is a need to assess the feasibility of implementing iCCM in these complex environments. Studies on iCCM and other community-based maternal, newborn, and child health services in emergency settings have shown that CHWs can continue providing routine services and can improve emergency response if they are adequately supported [ 12 - 17 ].…”