Integrated community case management: planning for sustainability in five African countries

Abstract

Background The World Health Organization (WHO) launched an initiative to plan for the sustainability of integrated community case management (iCCM) programmes supported by the Rapid Access Expansion (RAcE) Programme in five African countries in 2016. WHO contracted experts to facilitate sustainability planning among Ministries of Health, WHO, nongovernmental organisation grantees, and other stakeholders. Methods We designed an iterative and unique process for each RAcE project area which involved creating a sustainability framework to guide planning; convening meetings to identify and prioritise elements of the framework; forming technical working groups to build country ownership; and, ultimately, creating roadmaps to guide efforts to fully transfer ownership of the iCCM programmes to host countries. For this analysis, we compared priorities identified in roadmaps across RAcE project sites, examined progress against roadmaps via transition plans, and produced recommendations for short-term actions based on roadmap priorities that were unaddressed or needed further attention. Results This article describes the sustainability planning process, roadmap priorities, progress against roadmaps, and recommendations made for each project area. We found a few patterns among the prioritised roadmap elements. Overall, every project area identified priorities related to policy and coordination of external stakeholders including funders; supply chain management; service delivery and referral system; and communication and social mobilisation, indicating that these factors have persisted despite iCCM programme maturity, and are also of concern to new programmes. We also found that a facilitated process to identify and document programme priorities in roadmaps, along with deliberately planning for transition from an external implementer to a national system could support the sustainability of iCCM programmes by facilitating teams of stakeholders to accomplish explicit tasks related to transitioning the programme. Conclusions Certain common elements are of concern for sustaining iCCM programmes across countries, among them political leadership, supply chain management, data processes, human resources, and community engagement. Adapting and using a sustainability planning approach created an inclusive and comprehensive dialogue about systemic factors that influence the sustainability of iCCM services and facilitated changes to health systems in each country.

The role of governance in implementing sustainable global health interventions: review of health system integration for integrated community case management (iCCM) of childhood illnesses

“…65 Similarly, the WHO RaCE programme ensured inclusion of sustainability roadmaps and strategies to facilitate increased capacity to manage iCCM programmes. 37 While it is possible for actors involved in funding mechanisms, or strategy development to alter their line of work to suit necessary changes to drive more comprehensive programming, country-specific political structures may not be capable of restructuring budgetary lines domestically or reorganising programme hierarchical structures that can adequately support generalised comprehensive strategies and funding streams. From this stance, the country context and the actors within are integral in maintaining political will, prioritisation and improving internal collaborations so programmes can be effectively implemented.…”

“…This should accompany improved M&E schemes, supported by reliable and quality data, shared in accessible platforms among partners. 37 73 Local evidence is a significant factor in gaining and maintaining iCCM support; however, data and information-sharing with collaborating partners and other countries offers insight into successful strategies for scale-up, noting potential contextual limitations. 27 38 …”

District Health Teams’ Readiness to Institutionalize Integrated Community Case Management in the Uganda Local Health Systems: A Repeated Qualitative Study

“…[36][37][38] Thus, current recommendations arising from WHO consultation meetings and the general literature on iCCM discourage implementation of community programs in silos by requiring that primary health care strengthening programs target both community and the higher levels of care. [39][40][41] Within Uganda's decentralized health system, DHTs are more or less autonomous segments of the national health system, consisting of all recognized health sector actors whose activities should be reflected in the district health plan. 18 The MOH has the role of a principal agent with the mandate to encourage local institutions, such as the DHTs, to make choices that achieve the Lack of community-level accountability tools to capture how medicines are distributed to VHTs contributes to drug stock levels.…”

Home visits by community health workers for pregnant mothers and newborns: coverage plateau in Malawi

“…Analysis of supervision coverage and supply chain supports for other community-based programs such as iCCM are mixed. The HSAs interviewed as part of the evaluation of the larger iCCM program implemented through RAcE reported much higher levels of supervision, with two-thirds of the HSAs reporting supervision for iCCM in the last three months [19]. However, other studies of program support for iCCM found lower levels of supervision (38% supervision coverage in last three months) and breaches in supply chain management, suggesting that sustaining consistent levels of program support for HSAs to deliver community-based activities remains a persistent challenge for the MOH and partners [20].…”

“…A costing analysis found that it took an HSA 1.5 hours on average to conduct a CBMNC home visit, including time for preparation, travel and interaction with the family [14]. In addition to their role in CBMNC, HSAs are officially responsible for a wide range health and sanitation tasks at community and facility levels – estimated to be more than 250 [19,21]. These tasks include delivery of life-saving interventions such as supporting immunization outreach and providing assessment and treatment for childhood illness, and increased time spent on home visits could be a trade-off with other important health interventions.…”