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Review of Systematic Challenges to the Scale-Up of Integrated Community Case Management

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Review of Systematic Challenges to the Scale-Up of Integrated Community Case Management Review of Systematic Challenges to the Scale-up of Integrated Community Case Management Emerging Lessons & Recommendations from the Catalytic Initiative (CI/IHSS) April 2012 Maternal, Newborn and Child Health Working Paper unite for children UNICEF Health Section, Program Division i Review of Systematic Challenges to the Scale-up of Integrated Community Case Management: Emerging Lessons & Recommendations from the Catalytic Initiative (CI/IHSS) © United Nations Children’s Fund (UNICEF), New York, 2012 Knowledge Management and Implementation Research Unit, Health Section, Program Division UNICEF 3 UN Plaza, New York, NY 10017 Photography: Michael Crook April 2012 This is a working document. It has been prepared to facilitate the exchange of knowledge and to stimulate discussion. The findings, interpretations and conclusions expressed in this paper are those of the authors and do not necessarily reflect the policies or views of UNICEF or of the United Nations. The text has not been edited to official publication standards, and UNICEF accepts no responsibility for errors. The designations in this publication do not imply an opinion on legal status of any country or territory, or of its authorities, or the delimitation of frontiers. The editors of the series are Theresa Diaz, Julia Kim and Alyssa Sharkey of UNICEF Program Division. For more information on the series, or to submit a working paper, please contact [email protected] or [email protected]. Cover Photo: Mother with child being assessed by a community health worker in village of Tiegouecourani, Mali ii Maternal, NEwbORN and CHILD Health Working PAPER April 2012 Review of Systematic Challenges to the Scale-up of Integrated Community Case Management Emerging Lessons & Recommendations from the Catalytic Initiative (CI/IHSS) Kristin Oliver, Mark Young, Nick Oliphant, Theresa Diaz, Julia Kim Keywords: Africa, Catalytic Initiative, community case management, community health worker, diarrhea, malaria, maternal and child health, pneumonia Comments may be addressed by email to the authors: [email protected], [email protected] cc: [email protected], [email protected] and [email protected] iii Acknowledgements UNICEF would like to thank the Canadian International Development Agency (CIDA) for their support of the Catalytic Initiative, Integrated Health Systems Strengthening Program (CI/IHSS). we are grateful for the assistance provided by: george Fom Ameh, Adeline Azrack, Luigi D Aquino , Dougoufana bagayoko, Khaled bensaid, gunter boussery, Emanuele Capobianco, Anirban Chatterjee, Mickey Chopra , guy Clarysse, Tedbabe Degefie, Khassoum Diallo, Luula Mariano, Rory Nefdt, Adama Ouedraogo, Luwei Pearson, Tesfaye Shiferaw, Mariame Sylla, Daniel Yayemain, Texas Zamasiya. Community health worker in village of Samatan, Mali prepares a rapid diagnostic test (RDT) for malaria iv Table of Contents Acknowledgements....................................................................................................................................iv Executive Summary.....................................................................................................................................vi Introduction................................................................................................................................................1 Methods.......................................................................................................................................................2 Findings........................................................................................................................................................2 1. The deployment, supervision, motivation and retention of community health workers as the backbone of iCCM....................................................................................................................3 1.1 Deployment of community health workers....................................................................................3 1.2 Inadequate Supervision of CHws...................................................................................................4 1.3 Motivation and Retention of CHws................................................................................................6 2. Maintaining reliable supply chains.......................................................................................................6 3. Demand side barriers to utilisation......................................................................................................8 4. weak monitoring and evaluation systems..........................................................................................11 5. The need for supportive government policies and engagement to achieve sustainable progress.....16 Discussion .................................................................................................................................................19 Conclusions and Recommendations........................................................................................................21 1. Addressing supply-side barriers, including strengthening deployment and support of CHws and supply chain management...........................................................................................21 2. Addressing Demand-side barriers to utilisation of services...............................................................22 3. Strengthening monitoring and evaluation systems............................................................................22 References.................................................................................................................................................24 Annexes......................................................................................................................................................24 1. brief description of the evolution of CCM programmes in the CI/IHSS countries.............................26 2. CCM survey on activities of CHws (Updated through KI interviews with Country Offices)................28 v Executive Summary This paper presents an overview of challenges and lessons learned across the six sub-Saharan Africa countries which are part of the Catalytic Initiative (CI/IHSS) - Ethiopia, ghana, Malawi, Mali, Mozambique, and Niger. Drawing from review and analysis of over 50 programme documents, as well as correspondence with a range of programme key informants, the paper highlights important multi-country experience on the common challenges to scale-up of intervention packages for child survival, in particular the delivery approach of integrated community case management (iCCM). Such challenges include: 1) the deployment, supervision, motivation and retention of community health workers as the backbone of iCCM; 2) maintaining reliable supply chains; 3) demand side barriers to utilisation; 4) weak monitoring and evaluation systems, and 5) the need for supportive government policies and engagement to achieve sustainable progress. Although some of these challenges have been previously documented in the public health literature, others are unique - and the paper highlights examples and case studies which collectively illustrate how the six countries have begun to respond to these bottlenecks using a range of innovative approaches. The paper concludes by consolidating emerging lessons, questions and recommendations that will be critical for informing iCCM progress moving forward, as well as contributing to the growing body of knowledge on implementation of iCCM programmes. Diarrhea Through the and Cataly.c pneumonia Ini.a.ve, iCCM treatment has been scaled-­‐up in six high offer burden perhaps countries the of Africa to greatest untapped opportuni3es address limited to access further to appropriate progress treatment towards MDG 4… for pneumonia, diarrhea, and malaria Mali Ethiopia 1,651 ASCs trained in iCCM 20,000 HEWs with basic training; and deployed to 41/49 11,754 HEWs trained in iCCM districts and deployed to 66/514 districts Malawi Niger 3,696 HSAs with basic training; 1,020 2,426 ASCs trained in iCCM and trained in iCCM and deployed to hard-­‐ deployed to 42/42 districts to-­‐reach areas within 10/28 districts Ghana 16,500 CBAs trained in iCCM for malaria and diarrhea; of which Mozambique 9,935 also trained in CCM of 1,650 APEs with training in c-­‐ pneumonia and deployed to IMCI; 179 APEs trained in iCCM 55/176 districts and deployed to 8/128 districts | 1 Source: UNICEF 2011 Annual Reports to CIDA on the Cataly3c Ini3a3ve and key informant interviews (2011-­‐2012) vi Introduction The Catalytic Initiative, Integrated Health Systems Strengthening Program (CI/IHSS) aims to intensify efforts to achieve the United Nations Millennium Development goals (MDg) 4 & 5 by developing the capacity of country-led health systems to deliver a limited set of integrated, proven, high impact interventions, and strengthen health systems at the front-line level. It is jointly funded by CIDA and UNICEF, and is being implemented in Ethiopia, ghana, Malawi, Mali, Mozambique, and Niger. The CI/IHSS programme (which began in late 2007 and will extend through 2012), supports government and/or civil society organizations to equip, train and supervise front-line workers to deliver the intervention package, as specified below. The CI/IHSS programme has been designed to align with the policies and planning of the government of each country. In this way it is helping to strengthen health systems and expand access to services in hard to reach
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