Achievements and challenges of implementation in a mature iCCM programme: Malawi case study.

BACKGROUND: Malawi has a mature integrated community case management (iCCM) programme that is led by the Ministry of Health (MOH) but that still relies on donor support. From 2013 until 2017, under the Rapid Access Expansion (RAcE) programme, the World Health Organization supported the MOH to expand and strengthen iCCM services in four districts. This paper examines Malawi's iCCM programme performance and implementation strength in RAcE districts to further strengthen the broader programme. METHODS: Baseline and endline household surveys were conducted in iCCM-eligible areas of RAcE districts. Primary caregivers of recently-sick children under five were interviewed to assess changes in care-seeking and treatment over the project period. Health surveillance assistants (HSAs) were surveyed at endline to assess iCCM implementation strength. RESULTS: Care-seeking from HSAs and treatment of fever improved over the project period. At endline, however, less than half of sick children were brought to an HSA, many caregivers reported a preference for providers other than HSAs, and perceptions of HSAs as trusted providers of high-quality, convenient care had decreased. HSA supervision and mentorship were below MOH targets. Stockouts of malaria medicines were associated with decreased care-seeking from HSAs. Thirty percent of clusters had limited or no access to iCCM (no HSA or an HSA providing iCCM services less than 2 days per week); 50% had moderate access (an HSA providing iCCM services 2 to 4 days per week; and 20% had high access (a resident HSA providing iCCM services 5 or more days per week). Moderate access to iCCM was associated with increased care-seeking from HSAs, increased treatment by HSAs, and more positive perceptions of HSAs compared to areas with limited or no access. Areas with high access to iCCM did not show further improvements above areas with moderate access. CONCLUSIONS: Availability of well-equipped and supported HSAs is critical to the provision of iCCM services. Additional qualitative research is needed to examine challenges and to inform potential solutions. Malawi's mature iCCM programme has a strong foundation but can be improved to strengthen the continuity of care from communities to facilities and to ultimately improve child health outcomes.

Assessment of the monitoring and evaluation system for integrated community case management (ICCM) in Ethiopia: a comparison against global benchmark indicators.

BACKGROUND: Program managers require feasible, timely, reliable, and valid measures of iCCM implementation to identify problems and assess progress. The global iCCM Task Force developed benchmark indicators to guide implementers to develop or improve monitoring and evaluation (M&E) systems. OBJECTIVE: To assesses Ethiopia's iCCM M&E system by determining the availability and feasibility of the iCCM benchmark indicators. METHODS: We conducted a desk review of iCCM policy documents, monitoring tools, survey reports, and other rele- vant documents; and key informant interviews with government and implementing partners involved in iCCM scale-up and M&E. RESULTS: Currently, Ethiopia collects data to inform most (70% [33/47]) iCCM benchmark indicators, and modest extra effort could boost this to 83% (39/47). Eight (17%) are not available given the current system. Most benchmark indicators that track coordination and policy, human resources, service delivery and referral, supervision, and quality assurance are available through the routine monitoring systems or periodic surveys. Indicators for supply chain management are less available due to limited consumption data and a weak link with treatment data. Little information is available on iCCM costs. CONCLUSION: Benchmark indicators can detail the status of iCCM implementation; however, some indicators may not fit country priorities, and others may be difficult to collect. The government of Ethiopia and partners should review and prioritize the benchmark indicators to determine which should be included in the routine M&E system, especially since iCCMdata are being reviewed for addition to the HMIS. Moreover, the Health Extension Worker's reporting burden can be minimized by an integrated reporting approach.

A health systems approach to integrated community case management of childhood illness: methods and tools.

Integrated community case management (iCCM) of childhood illness is an increasingly popular strategy to expand life-saving health services to underserved communities. However, community health approaches vary widely across countries and do not always distribute resources evenly across local health systems. We present a harmonized framework, developed through interagency consultation and review, which supports the design of CCM by using a systems approach. To verify that the framework produces results, we also suggest a list of complementary indicators, including nine global metrics, and a menu of 39 country-specific measures. When used by program managers and evaluators, we propose that the framework and indicators can facilitate the design, implementation, and evaluation of community case management.

Benchmarks to measure readiness to integrate and scale up newborn survival interventions.

Neonatal mortality accounts for 40% of under-five child mortality. Evidence-based interventions exist, but attention to implementation is recent. Nationally representative coverage data for these neonatal interventions are limited; therefore proximal measures of progress toward scale would be valuable for tracking change among countries and over time. We describe the process of selecting a set of benchmarks to assess scale up readiness or the degree to which health systems and national programmes are prepared to deliver interventions for newborn survival. A prioritization and consensus-building process was co-ordinated by the Saving Newborn Lives programme of Save the Children, resulting in selection of 27 benchmarks. These benchmarks are categorized into agenda setting (e.g. having a national newborn survival needs assessment); policy formulation (e.g. the national essential drugs list includes injectable antibiotics at primary care level); and policy implementation (e.g. standards for care of sick newborns exist at district hospital level). Benchmark data were collected by in-country stakeholders teams who filled out a standard form and provided evidence to support each benchmark achieved. Results are presented for nine countries at three time points: 2000, 2005 and 2010. By 2010, substantial improvement was documented in all selected countries, with three countries achieving over 75% of the benchmarks and an additional five countries achieving over 50% of the benchmarks. Progress on benchmark achievement was accelerated after 2005. The policy process was similar in all countries, but did not proceed in a linear fashion. These benchmarks are a novel method to assess readiness to scale up, an important construct along the pathway to scale for newborn care. Similar exercises may also be applicable to other global health issues.