Integrated Community Case Management (iCCM) to improve child health: Key implementation challenges and potential solutions

By: Alyssa Sharkey

Pneumonia, diarrhea and malaria together account for more than half of deaths among children ages 6 months to 5 years. New preventive interventions – such as the pneumococcal and rotavirus vaccines – will help reduce this mortality burden. But ensuring prompt and effective treatment of these all-too-common illnesses (particularly among disadvantaged children without easy access to services) remains essential to reducing child mortality and achieving MDG4 (reduction in under-5 mortality).

Numerous governments and their partners are implementing a strategy called “integrated Community Case Management,” or iCCM. iCCM enables Community Health Workers (CHWs) to provide life-saving interventions to address common childhood killers that formerly were only provided by facility-based nurses or doctors. These CHWs complete short courses, generally provided either by ministry of health staff or NGOs, so that they are able to obtain the skills and knowledge necessary to provide appropriate care.

Key iCCM interventions include oral rehydration therapy (ORT) and zinc for diarrhea, oral antibiotics for pneumonia, and rapid diagnostic tests and antimalarials (principally artemesinin-based combination therapy) for malaria. The evidence for each of these interventions independently is growing:

ORS and zinc are known to be effective against childhood diarrhea mortality: ORS can prevent 93 percent (1) of diarrhea deaths and zinc can prevent 23 percent (2) of diarrhea deaths
implementing CCM of pneumonia can prevent 70 percent of pneumonia-related mortality in children under-five (3)
implementing CCM of malaria for children under-five has the potential to prevent overall mortality by 40 percent, malaria-specific mortality by 60 percent, and severe malaria morbidity by 53 percent. (4,5)

Evidence is now mounting that combining treatment for these childhood diseases into an integrated program such as iCCM can be effective in achieving high treatment coverage and delivering high quality care for sick children in the most disempowered communities. This access to care, in turn, is expected to result in a reduction of childhood deaths in the areas with the highest burden of disease.

In addition to being effective and safe, (6) evidence is growing that CHWs can deliver high quality care via CCM. A study in Malawi for example revealed that 68 percent of classifications of common illnesses by community health workers agreed with the physician “gold standard”, and 63 percent of children were prescribed appropriate medication (7).

Given iCCM’s promise, we need to learn from existing programs’ experiences; by sharing lessons learned (both positive and negative) we can support more communities and governments to respond to challenges that arise when implementing iCCM.

Questions for discussion:

What are the biggest challenges you have experienced (or can foresee) when implementing an iCCM program? Challenges could relate to the supply side of the system (for example, ensuring a continuous supply of essential medicines for CHWs or ensuring good supervision practices); they could also relate to the demand side of the system (for example, gaining the trust of families to utilize iCCM services).

Please share any possible solutions you have used, or are currently testing, to resolve the challenges created by iCCM programs.

Are mobile health technologies (such as text messaging via cell phones or GPS technologies) used in conjunction with iCCM helpful in addressing implementation challenges? If so, how? Please share any examples from the field.

Alyssa Sharkey is a Health Specialist in Knowledge Management at UNICEF New York. Her current focus is to support UNICEF’s approach to improve health equity, particularly in the most deprived localities. Alyssa holds a PhD in Population, Family and Reproductive Health, and a Master of Health Science in Maternal and Child Health from the Johns Hopkins School of Public Health, as well as a Master of Science in Medicine from the University of Cape Town. She has worked as a policy researcher and program manager in the field of maternal and child health for over 15 years both in the United States and internationally.

References:

1. Munos MK, Fischer Walker CL and Black RE. The effect of oral rehydration solution and recommended home fluids on diarrhea mortality. International Journal of Epidemiology 2010;39:i75–i87

2. Fischer Walker CL and Black RE. Zinc for the treatment of diarrhoea: effect on diarrhoea morbidity, mortality and incidence of future episodes.International Journal of Epidemiology 2010;39:i63–i69

3. Theodoratou E, Al-Jilaihawi S, Woodward F, et al. The effect of case management on childhood pneumonia mortality in developing countries.International Journal of Epidemiology 2010; 39:i155-i171

4. Kidane G, Morrow RH (2000). Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomized trial. Lancet, 356:550–555.

5. Sirima SB (2003). Early treatment of childhood fevers with pre-packaged antimalarial drugs in the home reduces severe malaria morbidity in Burkina Faso. Tropical Medicine and International Health, 8:1–7.

6. Rowe SY, Kelly JM, Olewe MA, Kleinbaum DG, McGowan JE, Jr., McFarland DA, et al. Effect of multiple interventions on community health workers’ adherence to clinical guidelines in Siaya district, Kenya. Trans R Soc Trop Med Hyg 2007;101(2):188-202.

7. Institute for International Programs (2010). Quality of care provided to sick children by health surveillance assistants in Malawi: Report on preliminary findings. Baltimore, MD: The Johns Hopkins Bloomberg School of Public Health.

Comments

jarudo says

November 9, 2013 at 8:42 pm

This is an excellent idea

This is an excellent idea that I have been looking for in the past two weeks. I am doing my doctoral in epidemiology and am interested in trying out the use of mobile phones in conjuction with training of CHW on IMCI in management of childhood illness in western Kenya with a view of improving childhood illness outcomes. After training on IMCI, CHWs will be able to access short texts reminding them of what signs and symptoms to look for and treatment required or in need be – recommend referral to the nearest facility. I will also explore possibilities of using GPS to locate the households where CHWs report child illness in case follow up by health worker is needed.

Mobile technology is already in use in the proposed study area but CHWs have not been trained on IMCI and are having difficulty diagnosing the three major childhood illnesses. Furthermore, the CHWs are still not able to access essential drugs to manage such cases at the household level.

Having read about your presentation, I do now realize the import of undertaking this study and the potential contribution it would have in increasing the body of knowledge on the implementation of iCCM by CHWs using mobile technology.