Sarah Rohde Nicholas Oliphant Donnela Besada www.jogh.org [email protected] South Africa Cape Town 7535 Parow Francie van Zijl Drive South African Medical Research Council Health Systems Research Unit Ms Emmanuelle Daviaud Correspondence to: 3 2 1 Emmanuelle Daviaud implications for sustainability case management (iCCM) in six African countries: Costs of implementing integrated community UNICEF,NewYork,NY,USA  Western Cape,CapeTown,SouthAfrica School ofPublicHealth,Universitythe Africa Medical ResearchCouncil,CapeTown,South Health SystemsResearchUnit,SouthAfrican  • doi:10.7189/jogh.07.010403 1 , DavidSanders 1 , NatalieLeon 3 , TanyaDoherty 1 , 2 , 1 , 1,2 180/1000 in 1990 to 83/1000 in 2015 [ 201583/1000 in to 1990 180/1000 in still has the highest under–five mortality rate, despite a 54% decline from births1990in43/1000to (53%reduction) 2015,insub–Saharan Africa Although under–five mortality reduced globally from 91 deaths/1000 live Background within national health systems. integration its strengthen and services iCCM sustain to required is developed as a priority to improve demand. Continued donor support investment.Utilization remainshowever,low strategiesand bemust mortality. An economic cost of under US$ 1/capita/yConclusions represents a sound per capita but 8% in Niger. 0.06–US$0.74),betweenpublicofhealth2%0.5% andexpenditure (US$ population total capita per 0.8 US$ under to amount would up scale Country utilization). low with countries in 20% (by ment utilization would add up to 2 hours a week, but reduce cost per treat CHWsspenthoursweekiCCM.30%increaseonfrom9a Ato 1 in ment ranged from US$ 13 (2015 USD) in Ghana to US$ 2 in Malawi. influenced by the level of utilization. Weighted economic costrepresented economicbetweenperof22%and 93% coststreatment per treat 603 treatments/community health worker (CHW)/y. Consultation cost Niger. and in between 10 There were 1 over Ethiopia to der–five in Results Country scale–up is modeled for all children under 5 in rural areas. modeled.wereutilization in increase 30% a implicationsof nancial percentagepublichealthexpenditurethecapita. of fi Timeper and sessedbycalculating the per capita financial cost of the program a as as Affordabilityis perspective.provider a fromtreatment per costs implementation costs to calculate incremental economic and financial Methods budgeting, and does not cover cost–effectiveness. coststoprovider (health system and donors) toinform planning and on focuses paper The implications. scale–up country–level assesses implementation in regions supported by UNICEF in six countries and arrhea. This paper presents the results of an economic servicesanalysis by communityof iCCMhealth workers for malaria, pneumonia and di referralthroughdiagnosis,treatmentmonthsand children2–59 for introduced(iCCM)wasmentimproveessential to access toservices poor access remains a challenge. Integrated community case manage der–five mortality. Low cost, high impact interventions exist, however Utilization of iCCM services varied from 0.05 treatment/y/un The analysisThecombines annualised year 1set–up costsand 1 Sub–Saharan Africa still reports thehighest rates unof iCCMaddresses unmetneedsimpactsandunder 5 on June 2017 • Vol. 7 No. 1 • 010403 1 , 2 ]. The major causes of these ofcausesmajor The ]. global journal of health ------

VIEWPOINTSPAPERS PVIEWPOINTSapers June 2017 • Vol. 7 No. 1 • 010403 Daviaud etal. METHODS ities is poor, especially for families in rural and hard to reach areas [ cost, high impact interventions and effective delivery strategies exist [ deathslargelyarepreventable neonatal disorders,– diarrhea,whichlow pneumoniafor malaria and– bique 70% of the stipend was costed reflecting the share of Malaria, Diarrhea and Pneumonia (MDP) Malaria, Diarrhea and of share reflectingcosted the wasstipend the of 70%bique (value of time spent on program). In Mali the stipend was fixed, independent of time spent. In Mozam cluding financial costs (although annualisation of capital is calculated differently) and opportunity costs incurred for the program by UNICEF. Economic costs covered all resources up Incrementaltofinancial economic calculated. and are costs district Financial costs reflect additional expendituresupervision, in We used actual data for number of CHWs, size of target population and number of treatments delivered.Mali. Costing of consumables and supervision was based on clinical protocols and commodities,supervisionallowances supervisorsfor schedules.reviewand meetings stipends CHWandMozambique in and tems costs included government provider time, while program costs, included training,This bicycles,analyses combineskits and a budget–holder/program (UNICEF) and health systems perspective. Health sys Costs 1 na and Mozambique), combined with work from health posts (Ethiopia, Malawi, Mali and Niger). by volunteers while in the other countries CHWs are paid. The program was based on home visits (Gha tasks. Ghana, Mali and Mozambique created or revitalized their CHW cadre. In Ghana iCCM isronmental providedissues, staffed withpaidCHWs supervised healthby centers staff. iCCMwasaddedtheir to Community–basedcare existed inEthiopia, Malawi andNiger focusing onmother andchild andenvi iCCM program description supervisors, CHWs, users and other stakeholders. We visited each country for approximately 10 days and interviewed Ministry of Health officials, partners, [ jointwithfundingfrom Department the Foreign ofAffairs, Trade Development,and Canada(DFATD) Strengtheningprogram(CI/IHSS) 2012–2013in [ This analysis was part of a multi–country evaluation of the Catalytic Initiative/ Integrated Health Systems spective. It does not cover costs to households, nor does it assess cost–effectiveness. up and affordability. This paper focuses specifically on cost to government and donors, the provideridentifying per factors which affect cost of treatment and possible areas of greater efficiency to supportentsthe results scale–ofan economic analysis ofiCCM implementation insix sub–Saharan African countries, is critical for both governments and funders to assess value for money and affordability. This paper pres ing a major share of funding [8]. Understanding the resources required to implement countriesand scale in up sub–SaharaniCCM Africa in 2005 to 28 by 2013, spearheaded by donor–driven initiatives providFollowing the UNICEF endorsement, uptake of the strategy by national governments was rapid, from 7 born illness [ by trained and equipped CHWs. iCCM may also cover treatment of severe acute malnutrition and new pected pneumonia and diarrhea among children aged 2–59 months (hereafter referred to as under–five) ment services for children [ community case management (iCCM) as an equity–focused strategy to improve access to essential treat larlyin the context of task–shifting [ declinethe80s,theendofthereat renewed is interest CHWsimproveinto accessservices to particu Followingdevelopmentthecommunity ofhealth worker(CHW) programmes their 1970s, and the in portsupervisionfor developmentand monitoringof evaluationand systems) [ CI/IHSS had a strong health systems strengthening focus (training, provision of drugs and supplies, sup ventiveand curative services [ were supporting iCCM in additional regions. vices. This study focuses on those regions within countries supported by UNICEF,mainlypreventive interventions, shifted it focustrainingalthoughto andequipping CHWsdelivertoother iCCMser donors 10 presents additional country information. ]. Ethiopia, Ghana, Malawi, Mali, Mozambique and Niger were selected for support. 8 ].

7 ], with integrated diagnosis, treatment and referral services for malaria, sus 4 – 6 ].In 2012, WHO and UNICEF issued a joint statement on integrated 3 ],with increasing evidence of their effectiveness in providing pre 2 9 ]. Theseprogrammes]. wereestablishedUNICEF by 2 ]. 1 ]. However, access to health facil www.jogh.org 11 • doi:10.7189/jogh.07.010403 ]. Initially]. supporting Table ------Table 1. CI – Catalytic Initiative, CHW – community health worker, iCCM – integrated community case management www.jogh.org Educational background required Gender CHW characteristics: Full monthly salary (US$) Based in community or health post Population <5 per CHW Duration of iCCM training (in years) Program design elements: Duration of basic training Pre–existing CHW cadre % population living in rural areas Under 5 mortality per 1000 live births, 2013 Public Health Expenditure per capita 2013 in 2015 US$ GDP per capita 2013 in 2015 US$ C Part of civil service Months since at scale (iCCM trained CHWs >80%) Implementation year costed Implementation Design & set up Time frame: Treatments per capita under 5 in 2013 in CI districts Average iCCM treatments/y/CHW CHWs/Supervisor iCCM trained CHWs Program implementation: Hours on iCCM per CHW/week CHW attrition rate ontext Contextual factors • doi:10.7189/jogh.07.010403 30% increase in demand. per year. Time on iCCM was also used in the sensitivity analysis to assess time impact and feasibility of a calculate the average time per week per CHW. It was assumed that a CHW works supervisionan averageorcommunity meetingsof 46andon visits weekstothe time clinic forCHW refilling 4) of kits. treatment 5) The above without enabled to visits other for fraction small a adding and load, case in ments tivetests) while requiring CHWtime; drawing onthemalaria positivity rate, theshare ofmalaria treat hold level. 3) An additional 20% of visits was added to reflect visits without treatment (eg, Malaria nega a previous costing study in Malawi [ CHW time on iCCM was calculated as follows: 1) Average visit duration was set at 30 minutes (based on CHW time ed, from UNICEF and CI/IHSS program documents. supervision visits, attrition rates, number of treatments per condition, and number of under–fives targetData were also obtained for the CI regions on the numbers of CHWs trained, frequency and duration of fices. apart from malaria supplies in Mozambique, local cost of drugs were provided by UNICEF country of- UNICEF,fromsourced were tests and drugs All (RDT). tests diagnostic rapid and drugs of costs unit salaries/stipend, supervisors allowances, CHW and supervisors attrition training, rate, equipment, malaria of positivity type rate per andspan life and kits CHW bicycles/motorbikes, districts: CI/IHSS the for records financial offices country retrospectivelyUNICEF fromcollected were costs holder Budget on a basic agricultural worker’s wage [ treatments among under–fives since CHWs also treat adults. For Ghana volunteers, time value was based Grade 8–10 2012–2013 2010–2013 2007–2010 Health post All female 27 E 1 year 0.05 thiopia 377 504 4% 1.2 Yes Yes 40 81 64 15 11 20

6 8 116 13 12 ]). 2) Travel time was added when iCCM was provided at house ]. Most illiterate 3 Community 50% female 2012–2013 2007–2013 2007–2010 Volunteer 16 5 days 1827 G 0.27 8% 1.0 Yes No 72 47 78 60 36 10 30 hana

3 Sustainability ofimplementingintegratedcommunitycasemanagement 812 43% female 2012–2013 2011–2013 2007–2011 Health post 9 40 days th 1847 0.27 360 123 660 134 M grade 4% 3.1 Yes No 15 62 21 80 2 4 ali 28% female 2012–2013 2008–2013 2007–2008 Health post 12 3 months M 1018 th 0.46 632 110 240 546 3% 7.2 Yes Yes 84 68 13 11 10 alawi grade 6 June 2017 • Vol. 7 No. 1 • 010403 Community 30% female 2012–2013 2010–2013 2007–2010 M 4 months 7 ozambique th 0.14 735 605 905 grade 3% 3.0 Yes No 23 68 87 19 40 13 25 99 No, but paid by 33% female 2012–2013 2007–2013 2007–2008 Health post state grant 12 6 months 2560 th 1.05 N 576 104 419 100 603 7% 8.6 Yes 82 10 35 grade iger 6 3 - - - -

VIEWPOINTSPAPERS PVIEWPOINTSapers June 2017 • Vol. 7 No. 1 • 010403 Daviaud etal. Set–up costs were annualized, using a 3% discount rate for economic costs [ Analysis the only year where iCCM was at scale in the 6 countries ( Set–up data were collected for several years, and for 1equipment, year training)for andthe theimplementation third is thephase: implementation the yearphase. Phases2012/13, 2 andbecause theywillincurrednotbe 3 againiCCMscaled–up.ifis are Second theset–up is phase (purchasethe of focus of this study. the intervention, of the training and of materials). These, often substantial, one–off costs iCCMare costs notare includedincurred in 3 overlapping phases. First is the design phase (formative research, design of Time line and analysis time horizon tistical Tables [17]. sta - UNICEF from the extracted was 2013 in Worldunder–fives of number The [16]. databank Bank the from obtained were population rural and total 2013 and expenditure health on Data program. (government capita per (PHE) expenditure health public 2013 country the of percentage a as expressed then we which areas, study in population total capita We used financial costs to calculate the budgetary implications of the program: cost per CHW and per Affordability ( plied. Incremental government and budget–holder economic costs place,are and 5 presentedyears in countriesseparately without refresherand training.combined CHWs and supervisors attrition rates were ap training for CHWs and supervisors was allocated 10 life years when refresher training–mentorship took intervention,lengthperon–goingoftraininglikelyasan the ofspannotlifeprogram: in of but initial ment cost was based on the life span of each piece of equipment. Similarly, we annualised trainingforfinancial costs, costs. In the perspective of assessing cost of an on–going program, annualisation of equip [ treatment. Financialcostspertreatment arepresented in consumables by treatment is weighted by the relative sharechildren of malaria, have beendiarrhea tested; and with pneumonia a positivity treatments. rate of 60%, 167 RDTschildren used need per to child be tested.testing positive:The average with cost a 40% of positivity rate,Variable if 100 childrencosts included aredrugs treatedand RDTs forused. Malariamalaria, positivity 250 rate was used tocalculate the number of in 2012/13 represent “the consultation cost”. the annualised costs. The annualised fixed costs per CHW divided by theances numberforsupervision andmeetings, ofandbicycles shareor treatmentsmotorbike of costs), andoverheads of5%per of CHW forCHWs’ direct supervisors and district/zonal supervisors, share of supervisors’ salary package, allow CHW salaries/stipends and allowances for meetings, supervision and management costs (iCCM training tationcosts were combined to calculate annual fixed costs per CHW: CHW iCCM training, equipment, Fixed costs per CHW, independent of the number of treatments: annualised set–up and 1 year implemen Table 2 12 Figure 1. ], then translated into US$, using the 2015 local US$ exchange rate [ treatment (2015 US$). ). Costs are presented in US dollars 2015, updating 2013 local currency with local inflation rate Financial cost per

4 Figure1 , highlighting, theshare consultation of costper Table 1 + donors), as a proxy for affordability of the affordabilityof for proxy a as donors), ). www.jogh.org 15 ]. 14 ] and straight depreciation • doi:10.7189/jogh.07.010403 - - - - www.jogh.org • doi:10.7189/jogh.07.010403 zambique, but 1.8% in Malawi, 2.7% in Mali and 7.4% in Niger ( inMalawi and Niger, representing under 0.6% of the 2013 PHE per capita in Ethiopia, Ghana and Mo paid by UNICEF. Financial costs range from US$ 0.06 per capita total population in Ethiopia to US$ 0.74 es from US$ 101 in Ghana to US$ 2 047 in Niger ( ure 1 na, largely reflecting the ratio of CHWs per supervisor ( cost represented a significant share of CHW fixed cost, from US$ 324 in Mozambique to US$ 51cluding in consumables) Gha ranged from US$ 88 in Mali to US$ 13 in Ethiopia. Management and supervision othercomparedcountries.daysin 6 toAnnualised equipment costs:bicycles, relevant, if kits(exand TrainingMozambique,andMalicostshigherarein respectively)dayslonger with training 23 and (15 lization, and over US$ 11 in Ethiopia and Ghana. in Ghana, but in Niger would be 28% higher to 11 hours a week. A 30% increase in utilization could be With 30% higher utilization, time on iCCM would increase by 10% to just over 1 hour a week per CHW Implications of increased utilization 25% and 30% in Ghana and Malawi and 36% in Ethiopia ( Government paid from 5% of economic costs in Mali to under 20% in Mozambique and Niger, between Affordability only, at a weighted average of US$ 0.34 per treatment ( weighted average of US$ 0.11 for drugs (excluding for malaria). In Ghana, patients contribute for drugs 9.3).Userfeesareimplemented countries.twoin Mali patientsInconsultation per 0.2US$ pay a and respectively),10.5US$ to 2.4 US$US$diarrhea$12.9 (financial forto to0.7 1.3from US$ cost US$ Economiccostmalariaper treatment rangesGhanainMalawi(financial14frominUS$ to 3US$ cost are 50% more expensive than at national level (distribution costs andmalaria revenue variedfor the fromclinic) 40% ( to 67%. Drug pricing systems also differed:(Paracetamol), in orMali, in Niger, drugs usingdistributed the more expensivefrom clinics drug ASAQ for malaria treatment.Cost of Positivity consumables rates for per condition varied, partly due to differencesCost per treatmentin protocols, with use of additional drugs Mozambique to around 1 full day in Malawi and Niger ( Ethiopia,TimeestimatediniCCMwasCHWlessper onGhana,weekor betweenhoursMaliand a 3 the number of under–fives per CHW, from 72 in Ghana to 632 in Malawi. Annual number of iCCM treatments per CHW ranged from 10 in Ghana to 603 in Niger, influenced by level for about a year ( functioningthatbeen atonly had MozambiqueCHWs Ethiopia,andtheMalawiGhana, in and 2011 In Niger over 80% of the trained CHWs operated in 2013, in Mali the majority of CHWs were trained in Country contexts RESULTS fives living in rural areas. costper capita. We then modeled the national program cost ifthe program was scaled upto all under– in the CI districts and assessed the implications for CHW time, consultation cost, cost per treatment and We modeled the impact of a 30% increase in demand, keeping the ratio of children per CHW observed Sensitivity analysis alised economic fixed costs per CHW ( bythe state. Financial cost per consultation ranged from US$ 0.1 inMalawi toUS$ in 9Ghana. Annu reflecting the pre–existence of community–based care with CHWs and supervisors salaries already paid Annualised financial fixed costs per CHW ranged from US$ 811 in Mali to US$ 55 in Malawi, lower costs Fixed costs per CHW and consultation cost ), with an economic cost per consultation between under US$ 1 in Malawi and Niger with high uti Table 1 ). Table 2 5 ) ranged from US$ 128 in Ghana to US$ 870 in Mali ( Sustainability ofimplementingintegratedcommunitycasemanagement Table 4 Figure 1 Table 1 Table 1 ). Table 2 ) and supervisors’ daily allowance. ). ). Table 4 ), while 100% of financial costs were June 2017 • Vol. 7 No. 1 • 010403 ), program cost per CHW rang Table 3 ). Fig ------

VIEWPOINTSPAPERS PVIEWPOINTSapers June 2017 • Vol. 7 No. 1 • 010403 Daviaud etal. CHW – community health worker, iCCM – integrated community case management Table 2. Table 3. Share budget holder Share government cost Share consultation cost Economic cost/treatment Average consumable/treatment Consultation cost/treatment Number of iCCM treatments/CHW/year Combined cost per treatment: Supplies (drugs/tests) per CHW Sub–total Fixed Cost per CHW Total cost per CHW Training Combined costs per CHW: Equipment Other Overheads 5% % ICCM Government cost per CHW Supplies (drugs/tests) per CHW: Salary/stipend Management & supervision Sub–total Fixed Cost per CHW % ICCM Equipment Management & Supervision Other Overheads 5% Training Government cost per CHW: Salary/Stipend Supplies (Drugs/Tests) per CHW Budget holder cost per CHW Sub–total Fixed Cost per CHW % ICCM Training UNICEF Malaria Share of treatments (%): Other Overheads 5% Equipment Diarrhea Management & supervision Salary/stipend Pneumonia Total Malaria including rapid diagnostic test Cost consumables per treatment (US$): Diarrhea Pneumonia Pneumonia Diarrhea Malaria Economic cost per treatment including consultation (US$): cost Economic costs per provider and per treatment (2015 US$) Cost of consumables per iCCM treatment (2015 US$)

per CHW

6 E E 12.4 11.5 1.74 0.69 0.26 11.8 12.2 13.3 thiopia thiopia 237 100 155 100 152 100 104 100 219 134 0.9 64 36 89 20 18 20 13 11 85 31 51 31 18 17 30 13 41 29 85 4 3 7 – – G G 13.5 12.6 1.56 0.35 0.39 12.9 12.9 14.1 132 100 100 100 100 122 0.9 75 25 90 10 10 18 44 51 33 10 22 99 10 10 16 49 29 44 32 19 33 89 hana hana 6 2 2 4 – – 1075 1023 2.73 1.03 0.09 134 247 179 834 247 111 834 100 M M 828 776 8.3 1.8 6.5 6.6 7.5 9.2 95 77 59 70 82 88 53 70 69 70 55 75 59 88 20 21 53 5 4 7 – – ali ali www.jogh.org M M 1135 2.32 0.61 0.13 546 749 100 100 332 238 100 804 238 749 100 100 386 332 2.1 1.4 0.7 0.8 1.3 3.0 29 71 19 12 36 17 93 12 54 36 13 33 alawi alawi 55 7 3 7 – – – • doi:10.7189/jogh.07.010403 M M ozambiquez ozambique 1.51 0.30 0.33 531 105 324 160 118 442 206 160 100 452 363 5.6 0.8 4.8 5.1 5.1 6.3 17 83 83 99 79 70 32 89 57 70 79 70 26 96 40 57 29 31 89 6 9 – – 2360 1859 2015 1859 4.84 0.61 1.24 N N 603 100 345 307 100 307 100 100 502 345 156 4.0 3.1 0.9 2.1 1.5 5.7 15 85 47 73 25 74 17 37 36 47 54 74 18 27 iger iger 9 1 8 – – www.jogh.org • doi:10.7189/jogh.07.010403 remain under US$ 1 per capita. Table 4. ability of services (supply side), but to demand, as documented in under–fivemany in Ethiopiacountries to over 1 in Niger.[ Low utilization does not appear to be mainly related to avail Utilization of iCCM services in UNICEF supported districts varied from 0.05 MDP treatment per year per D of the country PHE. in rural areas, the cost per CHW would remain the same, iCCM would representIfthe program with between30% increased 0.4%utilization andwas scaled–up 7.7% to cover all the country under–fives living Affordability of scale–up additionaldueto consumables ( share of cost per treatment, the decrease is small (2 to 4%). Total costs of the program increase,per however,treatment would be about 20% lower. In Malawi and Niger, absorbedwhere consultationby the existingcost representsCHWs. In a Ethiopia,small Ghana, Mali, and Mozambique economic and financial costs Table 5. Utilization rates, through consultation cost, impacts directly on cost per treatment. They were the high treatment by CHWs (half of the payment was used for CHW incentives), almost certainly deterring use. patientsGhanaregistered National HealthforInsurance received for treatmentpaidfree clinics but at reduced by two–thirds in an iCCM district in Mali, translating into demand more than doubling [ 10 times that of Ethiopia with low levels of stock outs. User fees stock–outscontribute were tomost markedlow in demand:Malawi [ user fees were proxyforavailability ofiCCM services: 377children perCHW inEthiopia and576 inNiger. Medicine informal providers [ ger, but much lower in Malawi at 13%. All countries reported low levels (10–15%) of care seeking from 80%did not seek treatment for the 3 conditions, 60% in Ghana, 50% in Mozambique, and 40% in Ni Share of 2013 Public Health Expenditure per capita (%) If scaled up to all rural areas: Share of 2013 Public Health Expenditure per capita (%) Increase in program cost (%) Financial cost/capita total population Financial cost/CHW Utilization +30%: Decrease in cost per treatment (%) Utilization +30% Current utilization Additional financial cost/treatment: Increase in program cost Share of 2013 Public Health Expenditure per capita (%) Utilization +30% Current utilization Hours per week on iCCM: Financial cost/CHW Current utilization: Decrease in cost per treatment Utilization +30% Current utilization Economic cost per treatment: Financial cost/capita total population iscussion iCCM impact on 2013 Public Health Expenditure (2015 US$) Impact on time and costs of increased utilization 9 ]. Demand does not seem linked to the size of the under 5 population per CHW, a Table5 ). Financial). coststheprogramof withhigher utilization would 9 7 ] but at 0,5 the number of treatments per child per year, was E 10.0 12.4 thiopia –20 –19 6.3 7.9 1.4 1.2 4 5 Sustainability ofimplementingintegratedcommunitycasemanagement E 0.07 0.06 thiopia 163 158 0.4 0.4 0.4 G 10.7 13.5 –21 –21 7.8 9.9 1.0 1.0 hana 2 3 G 0.20 0.20 104 101 0.2 0.3 0.3 hana –19 –18 M 6.5 7.9 3.6 3.1 6.8 8.3 6 7 ali 1132 1058 0.61 0.57 M 1.8 2.7 June 2017 • Vol. 7 No. 1 • 010403 3 ali M 1.5 1.5 9.0 7.2 2.0 2.1 26 25 –3 –4 alawi M 1029 0.29 0.23 804 1.8 2.2 1.8 alawi 9 ]. In Ethiopia around M ozambique M –21 –20 3.7 4.1 3.6 3.0 4.5 5.6 ozambique 3 4 0.11 0.11 482 458 0.4 0.6 0.6 11.0 N 18 3.3 3.4 8.6 3.9 4.0 2604 2047 27 27 –2 –2 0.94 0.74 N iger 7.7 9.4 7.4 iger ]. In - - -

VIEWPOINTSPAPERS PVIEWPOINTSapers June 2017 • Vol. 7 No. 1 • 010403 Daviaud etal. budgetline in government budget and CHW salaries were paid by government in only 5countries [ iCCMpolicy and implementation insub–Saharan Africa reported that only out9 of 33countries had a ofcommitted domesticresources.surveyhavecountries, few Asix these in levelpolicyrecognized at up to 63% [ Asystematic review of iCCM effectiveness reported a reduction in all–cause mortality in under–fives by vices which threatens their sustainability. These countries are likely to remain dependent on foreign assistance to maintain and scale–up iCCMGhana ser and Mozambique, under 2% in Malawi and Mali but 8% in Niger with the lowest PHE per capita. ita total population, in most countries a small percentage of the PHE per capita: under 0.5% in Ethiopia, Scaling up the program to cover all rural areas would amount for all countries to under US$ 0.8 per cap considered CHW deployment even in volunteer–based programs. wouldbe 47% lower, and incentive payments per CHW would double, emphasizing the need for more treatmentaverageperiCCM,cost onweek ahours village,1.2spendwouldpers/he CHWWith one CHWs per village, each covered an average of 72 children, compared to over 360 in the other countries. amplewiththe highest costper treatment, duefixedto costs per volunteer and low utilization. With 2 The assumption that volunteers cost little, so many can be recruited, was contradicted by the Ghana ex pervision visits and use of simple supervision checklists [ resourcecapacity; some ofthese could beaddressed through mentorship atfacility level, integrated su lenges with consistent supervision including insufficient funding for supervisors travelManagement and overwhelmed and supervision were a significant cost driver. Most countries however report recurrentcosting [ chal Similar differences between paid workers and volunteers were observed in another multi–countryvolunteers.Ghanaamong 8% iCCMat contributed),andhave may nurse a become to pathingcareer(clear Attrition rate has cost implications for training. It was under 4% for paid CHWs, except for Niger at 7% have contributed to low utilization. ever it was only 3 days in Ghana for often illiterate volunteers withoutiCCM trainingprevious duration IMCI also impactedtraining, on costs: whichfrom 6 daysmay in 3 countries to 23 in Mozambique. How dren over five in the same family. services be extended to older children, while CHWs indicated the difficulty of denying treatment to chil can be combined with other community–based activities: Across countries, communities requested that childhealth. A30% increase in utilization would add under 1to 2hours aweek, indicating that iCCM week,representshoursa small9portion motherCHWs’ whosetimetofocusmainandaisoffrom 1 does not squeeze out other existing activities and that increased utilization is manageable. programEstimatingimportanttheCHWs’workloadEstimatedensureisonadding totimethattoiCCMCHWs time multi–country assessment of iCCM costs [ pertreatment inEthiopia andGhana butonly 22%inNiger. Similar findings were reported in another Economic cost per consultation was US$ 12.6 in Ghana and US$ 0.7 in Malawi, representing 93% of cost active strategies to increase demand for existing programs before moving to scale–up. est contributor to the efficiency, and likely effectiveness, of the programs, pointing to the necessity of pro needs rather than replacing facility care seeking [ creasing coverage of fixed health facilities staffed with nurses [ with care closer to home. There is also increasing evidence of CHWs cost–effectiveness compared to in and from averting serious illness through early treatment. Families also experience time and cost savings iCCM costs need to be considered in light of expected savings from possibly reduced workload at clinics announced a unified plan to scale–up iCCM, with increased resources to Inexpand 2014 in theUNICEF, near term [ the Global Fund and the Reproductive, Maternal, Newborn and Childthe NHI. Health Trust Fund public service (a pre–condition to allocate funds for their stipends). In Ghana CHWs are not included in municipalities; the Mozambican government is reluctant to include CHWs as a new staff category of the InMali there isuncertainty asto whether CHWs will bepaid from user fees orfunded bygovernment/ that delivery of curative services strengthens the preventive role of CHWs [ 19 ]. 21 ]. To sustain this, proactive support by governments is needed. Although iCCM has been

19 8 ]. 25 ]. Costing of iCCM activities must also acknowledge 20 ]. 23 , 24 ]. In Niger CHWs addressed unmet www.jogh.org 26 ]. • doi:10.7189/jogh.07.010403 22 ]. 8 ]. ------www.jogh.org • doi:10.7189/jogh.07.010403 costs should be measured [ tation costs were measured for 1 year, recent guidelines suggest that a wider window of implementation programs volunteers whose cost has not been included. Second, in its measurement grams methods:were mostlyimplemen too recent to assess effectiveness. Additionally, CHWs work was supportediCCM andby multi–affordability and does not include an analysis of value for money, a pre–requisite,Thiseconomic analysisbutseveral has limitations: the scope:focusesfirst,its pro it resourcein on implications of Limitations tial platform of care within national health systems. foreseeable future and should have a concurrent focus on strengthening integration of iCCM as dependentcountryancontextiseconomic on and outlook. essen Continued requireddonorsupport isthe for ernments is central for sustainability of iCCM and CHW platforms. Benefits fromAligning strategiesfunding and support such with as national iCCM priorities, along with political will and commitment of gov ening demand must become the priority. highlights that iCCM can represent a very sound investment. Once services have beenmostly built–up,too recent strengthto assess effectiveness, a financial cost in this study of under US$ 1 per capitamortality. per5reductions undercontribute year,andtoin needs unmet service can programs thewereWhile By addressing at community level the three main causes of deaths of children aged 2–59 months, iCCM CONCLUSIONS of the health system as a consequence of the program in a way a Budget Impact Analysis would do [ affordabilityisbased onpercapita spending anddoes notinclude possible savings/costs toother levels reflectnot districtsdidother iCCM tricts anddata potentiallywith different profiles.cost Additionally tation is that the modeling of extending the program to all rural areas was made by extrapolating CI dis showed that our assumption of 30 minutes per visit is unlikely to be an underestimation. Another limi observation.visitsinformalobservationcountryHoweverduring on thancountries rather all for ings mentation.CHW time on the program was based on the same assumptions of length of visit and meet costshasthebenefit estimatingof costs per protocol,as but does not reflect variations actualin imple addition,normativescale.Inthetation atapproach calculating for used commodities supervision and replaced and training redone, and cannot be considered as one–off costs. costs,annualised set–upimplementationand costsarecombined sinceovertimeequipmentbe tohas recurrentfromcostsseparatingset–up than implications.rather budgetary Second, calculation of the A strength of this analysis is the separation of economic from financial costs to avoid double–counting in Funding: uscript are those of the authors and do not necessarily represent the views of UNICEF. Competing interests: and contributed to subsequent drafts and approved the final version for publication. visits. ED and DB analysed the data. ED, DB and TD prepared the first draft of the paper. All authors design,reviewed and data collection materials. ED, TD, SR, NL, DS, DB and NO participated in the country evaluation Authorshipcontribution: Council (EC026–9/2012). Ethicalapproval: decision to submit for publication. paper for publication. The evaluation team had full access to all study data and had final responsibility for the norole in the study design, data collection, data analysis, data interpretation or in the decision to submit the Medical Research Council and the National Research Foundation South Africa. The sponsors of the study had Disclaimer: tance with the country field missions. likeacknowledgeto theUNICEF country offices and Ministries Healthof the six countriesof for their assis Acknowledgments: ing author) and declare no conflict of interest. form disclosure form at http://www.icmje.org/coi_disclosure.pdf (available upon request from the correspond Department ofForeign Affairs, Trade andDevelopment Canada (DFATD); UNICEF; South African NO was employed by UNICEF at the time of the study. The findings and conclusions in this man This study was approvedethicsstudywasSouthAfricancommitteeThisthetheMedical by ofResearch TD and DS are supported by the National Research Foundation, South Africa. We would The authors declare no competing interests. All authors have completed the ICMJE uni ED conceptualisedED study.the developedTDand protocol,DStheNL, ED, study 27 ], however in this evaluation there was only 1 common year of implemen 9 Sustainability ofimplementingintegratedcommunitycasemanagement June 2017 • Vol. 7 No. 1 • 010403 28 - - - - ]. ------

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