Assessing the Integrated Community-Based Health Systems Strengthening initiative in northern Togo: a pragmatic effectiveness-implementation study protocol

Abstract

Background Over the past decade, prevalence of maternal and child morbidity and mortality in Togo, particularly in the northern regions, has remained high despite global progress. The causes of under-five child mortality in Togo are diseases with effective and low-cost prevention and/or treatment strategies, including malaria, acute lower respiratory infections, and diarrheal diseases. While Togo has a national strategy for implementing the integrated management of childhood illness (IMCI) guidelines, including a policy on integrated community case management (iCCM), challenges in implementation and low public sector health service utilization persist. There are critical gaps to access and quality of community health systems throughout the country. An integrated facility- and community-based initiative, the Integrated Community-Based Health Systems Strengthening (ICBHSS) initiative, seeks to address these gaps while strengthening the public sector health system in northern Togo. This study aims to evaluate the effect and implementation strategy of the ICBHSS initiative over 48 months in the catchment areas of 21 public sector health facilities. Methods The ICBHSS model comprises a bundle of evidence-based interventions targeting children under five, women of reproductive age, and people living with HIV through (1) community engagement and feedback; (2) elimination of point-of-care costs; (3) proactive community-based IMCI using community health workers (CHWs) with additional services including family planning, HIV testing, and referrals; (4) clinical mentoring and enhanced supervision; and (5) improved supply chain management and facility structures. Using a pragmatic type II hybrid effectiveness-implementation study, we will evaluate the ICBHSS initiative with two primary aims: (1) determine effectiveness through changes in under-five mortality rates and (2) assess the implementation strategy through measures of reach, adoption, implementation, and maintenance. We will conduct a mixed-methods assessment using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. This assessment consists of four components: (1) a stepped-wedge cluster randomized control trial using a community-based household survey, (2) annual health facility assessments, (3) key informant interviews, and (4) costing and return-on-investment assessments for each randomized cluster. Discussion Our research is expected to contribute to continuous quality improvement initiatives, optimize implementation factors, provide knowledge regarding health service delivery, and accelerate health systems improvements in Togo and more broadly. Trial registration ClinicalTrials.gov, NCT03694366, registered 3 October 2018

An Integrated Primary Care Initiative for Child Health in Northern Togo

“…In 2018, we initiated a type II pragmatic effectivenessimplementation study including a cluster-randomized stepped-wedge trial to address some of the methodologic limitations cited, specifically adding control clusters, and to further evaluate the impact of the ICBHSS initiative on primary health care uptake and child mortality in northern Togo. 56…”

Assessment of the Feasibility, Acceptability, and Impact of Implementing Seasonal Malaria Chemoprevention in Nampula Province, Mozambique: Protocol for a Hybrid Effectiveness-Implementation Study

“…Evaluating the implementation of SMC will generate knowledge on the feasibility and acceptability of this intervention in situ, including the challenges, barriers, and facilitators in the local context. Such findings can be useful to inform which intervention components are generalizable and which require local adaptation for other settings [ 31 ].…”

Proactive community case management decreased malaria prevalence in rural Madagascar: results from a cluster randomized trial

“…In sub-Saharan Africa (SSA), where transmission is higher, the scale-up of integrated community case management (iCCM) of childhood illnesses has increased access to life-saving interventions, including malaria care, for children under 5 years of age (CU5) [ 5 ]. As part of iCCM, CHWs test CU5 with fever using malaria rapid diagnostic tests (RDTs) and treat uncomplicated malaria with artemisinin-based combination therapies (ACTs), often free of charge [ 6 ]. The limitation of this community care model is that it excludes individuals older than 5 years and involves only passive detection of febrile cases; many cases remain undetected, increasing the risk of progression to severe disease and death, and contributing to ongoing transmission [ 5 ].…”