Approaches to support continued iCCM implementation during a flooding emergency in rural Bangladesh.

BACKGROUND: More evidence is needed on how integrated community case management (iCCM) service delivery is affected and on how to maintain service availability during crises. This study documented the implementation of iCCM through two cadres of community health workers (community health care providers [CHCPs] and village doctors [VDs]) in communities that were affected by a 2015 flooding emergency in Bangladesh. METHODS: We conducted a retrospective case study to assess iCCM services provided by CHCPs and VDs during a flooding emergency that occurred from June to August 2015. We purposively selected nine unions within four sub-districts in Bhola District. In this mixed methods study, we analyzed trends in quantitative service delivery indicators over the time period from January 2015 to February 2016. Qualitative data were obtained through 28 in-depth interviews and 13 focus group discussions with policy makers, implementers, supervisors, CHCPs, VDs, community leaders, and caregivers of under-five children. RESULTS: All stakeholders reported disruptions in iCCM service delivery and in access to CHCPs and VDs for community members. The quantitative data showed a 30% reduction in average number of children who received treatment from both CHCPs and VDs during flooding months compared to pre-flood months (from 2273/month to 1593/month). There was also an increase in the number of children referred by CHCPs and VDs, reduced supervision, and increased stock-outs of commodities during the flooding months. CHCPs and VDs, in collaboration with community members, came up with several locally adapted initiatives to maintain iCCM services, including changing clinic hours according to the tide, organizing temporary clinics at alternative sites that were located on higher ground, use of community boats to visit clients in their homes, and use of mobile phones for communication with supervisors and community members. CONCLUSION: Our study results demonstrate that iCCM services can continue during a natural disaster, albeit with significant disruptions. Ad hoc adaptations to services by local implementers and community members were key in maintaining availability of services during the emergency. In future emergencies, service delivery could be significantly strengthened by enacting key preparedness activities prior to a natural disaster such as severe flooding.

The resilience of integrated community case management in acute emergency: a case study from Unity State, South Sudan.

BACKGROUND: An active conflict in South Sudan in late 2013/early 2014 displaced approximately 2 million people over the course of several months. In May 2015, the International Rescue Committee and UNICEF conducted a mixed-methods case study of the impact of that acute emergency on integrated community case management (iCCM) of childhood illness programming in Payinjiar County, Unity State. The objective was to document the operations of an iCCM program during an acute crisis and to assess the program's ability to continue operations. RESULTS: This mixed-methods case study is comprised of semi-structured interviews and focus groups with key stakeholders such as policymakers, program implementers, community health workers (CHWs), and caregivers on their experience with iCCM programming during this time period. Routine program data were also analyzed to assess the effect of the crisis on key health indicators. FINDINGS: Internally displaced persons (IDPs) nearly doubled the population in Payinjiar. Some displaced CHWs continued to provide treatment in host communities when they were able to take supplies with them. Despite no formal community mobilization effort by the iCCM program, many IDPs identified CHWs in the communities they were displaced to and obtained care from them. Caregivers who had been internally displaced reported preferring care from CHWs especially in contrast to risking an insecure journey to health facilities. The total number of treatments provided per month by CHWs dropped during the acute crisis, but recovered to pre-crisis levels within six months. CHW supervisors attempted to continue supervision by utilizing their networks to track down displaced CHWs and assess the security situation prior to visits. The monthly supervision rate dropped to the lowest level of 77% in February 2014, but rebounded to 91% by August 2014. Several CHWs and community leaders qualitatively validated this claim of sustained supervision. CONCLUSIONS: CHWs, including those who were internally displaced, continued to provide treatment for childhood illnesses during an acute emergency, and service provision recovered faster to pre-crisis levels than the formal health sector. International donors and humanitarian actors should recognize iCCM as a potentially high-impact humanitarian response. Flexible funding from donors would enable further evidence generation on iCCM approaches and improvements that could both sustain and enhance programming in acute crisis.

Community health workers during the Ebola outbreak in Guinea, Liberia, and Sierra Leone.

BACKGROUND: The role of community health workers (CHWs) in the West Africa Ebola outbreak has been highlighted to advocate for increasing numbers of CHWs globally to build resilience, strengthen health systems, and provide emergency response capacity. However, the roles CHWs played, the challenges they faced, and their effectiveness during the outbreak are not well documented. This study assessed the impact of Ebola on community-based maternal, newborn, and child health (MNCH) services, documented the contribution of CHWs and other community-based actors to the Ebola response, and identified lessons learned to strengthen resilience in future emergencies. METHODS: This mixed methods study was conducted in Guinea, Liberia, and Sierra Leone, with data collected in four Ebola-affected districts of each country. Qualitative data were collected through in-depth interviews and focus group discussions with stakeholders at national, district, and community levels. Quantitative program data were used to assess trends in delivery of community-based MNCH services. RESULTS: There was a sharp decline in MNCH service provision due to weak service delivery, confusion over policy, and the overwhelming nature of the outbreak. However, many CHWs remained active in their communities and were willing to continue providing services. When CHWs received clear directives and were supported, service provision rebounded. Although CHWs faced mistrust and hostility from community members because of their linkages to health facilities, the relationship between CHWs and communities proved resilient over time, and CHWs were more effectively able to carry out Ebola-related activities than outsiders. Traditional birth attendants, community health committees, community leaders, and traditional healers also played important roles, despite a lack of formal engagement or support. Service delivery weaknesses, especially related to supply chain and supervision, limited the effectiveness of community health services before, during, and after the outbreak. CONCLUSIONS: CHWs and other community-level actors played important roles during the Ebola outbreak. However, maintenance of primary care services and the Ebola response were hampered because community actors were engaged late in the response and did not receive sufficient support. In the future, communities should be placed at the forefront of emergency preparedness and response plans and they must be adequately supported to strengthen service delivery.

A qualitative exploration of care-seeking pathways for sick children in the rural Oromia region of Ethiopia.

BACKGROUND: Ethiopia has experienced rapid improvements in its healthcare infrastructure, such as through the recent scale up of integrated community case management (iCCM) delivered by community-based health extension workers (HEWs) targeting children under the age of five. Despite notable improvements in child outcomes, the use of HEWs delivering iCCM remains very low. The aim of our study was to explain this phenomenon by examining care-seeking practices and treatment for sick children in two rural districts in the Oromia Region of Ethiopia. METHODS: Using qualitative methods, we explored perceptions of child illness, influences on decision-making processes occurring over the course of a child's illness and caregiver perceptions of available community-based sources of child illness care. Sixteen focus group discussions (FGDs) and 40 in-depth interviews (IDIs) were held with mothers of children under age five. For additional perspective, 16 IDIs were conducted fathers and 22 IDIs with health extension workers and community health volunteers. RESULTS: Caregivers often described the act of care-seeking for a sick child as a time of considerable uncertainty. In particular, mothers of sick children described the cultural, social and community-based resources available to minimize this uncertainty as well as constraints and strategies for accessing these resources in order to receive treatment for a sick child. The level of trust and familiarity were the most common dynamics noted as influencing care-seeking strategies; trust in biomedical and government providers was often low. CONCLUSIONS: Overall, our research highlights the multiple and dynamic influences on care-seeking for sick children in rural Ethiopia. An understanding of these influences is critical for the success of existing and future health interventions and continued improvement of child health in Ethiopia.

Effects of the integrated Community Case Management of Childhood Illness Strategy on Child Mortality in Ethiopia: A Cluster Randomized Trial.

We conducted a cluster randomized trial of the effects of the integrated community case management of childhood illness (iCCM) strategy on careseeking for and coverage of correct treatment of suspected pneumonia, diarrhea, and malaria, and mortality among children aged 2-59 months in 31 districts of the Oromia region of Ethiopia. We conducted baseline and endline coverage and mortality surveys approximately 2 years apart, and assessed program strength after about 1 year of implementation. Results showed strong iCCM implementation, with iCCM-trained workers providing generally good quality of care. However, few sick children were taken to iCCM providers (average 16 per month). Difference in differences analyses revealed that careseeking for childhood illness was low and similar in both study arms at baseline and endline, and increased only marginally in intervention (22.9-25.7%) and comparison (23.3-29.3%) areas over the study period (P = 0.77). Mortality declined at similar rates in both study arms. Ethiopia's iCCM program did not generate levels of demand and utilization sufficient to achieve significant increases in intervention coverage and a resulting acceleration in reductions in child mortality. This evaluation has allowed Ethiopia to strengthen its strategic approaches to increasing population demand and use of iCCM services.

Coverage and equitability of interventions to prevent child mortality in rural Jimma and West Hararghe Zones, Oromia Region, Ethiopia.

BACKGROUND: Interventions to prevent childhood illnesses are important components of the Ethiopian Health Extension Program (HEP). Although the HEP was designed to reduce inequities in access to health care, there is little evidence on equitability of preventive interventions in Ethiopia. PURPOSE: This article describes coverage of preventive interventions and how many interventions individual children received We also examined which factors were associated with the number of preventive interventions received, and assessed the extent to which interventions were equitably distributed. METHODS: We conducted a cross-sectional survey in 3,200 randomly selected households in the rural Jimma and West Hararghe Zones of Ethiopia's Oromia Region. We calculated coverage of 10 preventive interventions and a composite of eight interventions (co-coverage) representing the number of interventions received by children. Mul- tiple linear regressions were used to assess associations between co-coverage and explanatory variables. Finally, we assessed the equitability of preventive interventions by comparing coverage among children in the poorest and the least poor wealth quintiles. RESULTS: Coverage was less than 50% for six of the 10 interventions. Children received on average only three of the eight interventions included in the co-coverage calculation. Zone, gender, caretaker age, religion, and household wealth were all significantly associated with co-coverage, controlling for key covariates. Exclusive breastfeeding, vaccine uptake, and vitamin A supplementation were all relatively equitable. On the other hand, coverage of insecticide-treated nets or indoor residual spraying (ITN/IRS) and access to safe water were significantly higher among the least poor children compared to children in the poorest quintile. CONCLUSION: Coverage of key interventions to prevent childhood illnesses is generally low in Jimma and West Hararghe. Although a number of interventions were equitably distributed, there were marked wealth-based inequities for interventions that are possessed at the household level, even among relatively homogeneous rural communities.

Coverage and Equitability of Interventions to Prevent Child Mortality in Rural Jimma and West Hararghe Zones; Oromia Region; Ethiopia

Background: Interventions to prevent childhood illnesses are important components of the Ethiopian Health Extension Program (HEP). Although the HEP was designed to reduce inequities in access to health care; there is little evidence on equitability of preventive interventions in Ethiopia. Purpose: This article describes coverage of preventive interventions and how many interventions individual children received. We also examined which factors were associated with the number of preventive interventions received; and assessed the extent to which interventions were equitably distributed. Methods: We conducted a cross-sectional survey in 3;200 randomly selected households in the rural Jimma and West Hararghe Zones of Ethiopia's Oromia Region. We calculated coverage of 10 preventive interventions and a composite of eight interventions (co-coverage) representing the number of interventions received by children. Multiple linear regressions were used to assess associations between co-coverage and explanatory variables. Finally; we assessed the equitability of preventive interventions by comparing coverage among children in the poorest and the least poor wealth quintiles. Results: Coverage was less than 50 for six of the 10 interventions. Children received on average only three of the eight interventions included in the co-coverage calculation. Zone; gender; caretaker age; religion; and household wealth were all significantly associated with co-coverage; controlling for key covariates. Exclusive breastfeeding; vaccine uptake; and vitamin A supplementation were all relatively equitable. On the other hand; coverage of insecticide-treated nets or indoor residual spraying (ITN/IRS) and access to safe water were significantly higher among the least poor children compared to children in the poorest quintile. Conclusion: Coverage of key interventions to prevent childhood illnesses is generally low in Jimma and West Hararghe. Although a number of interventions were equitably distributed; there were marked wealth-based inequities for interventions that are possessed at the household level; even among relatively homogeneous rural communities