Community case management in Nicaragua: lessons in fostering adoption and expanding implementation.

Community case management (CCM) as applied to child survival is a strategy that enables trained community health workers or volunteers to assess, classify, treat and refer sick children who reside beyond the reach of fixed health facilities. The Nicaraguan Ministry of Health (MOH) and Save the Children trained and supported brigadistas (community health volunteers) in CCM to improve equitable access to treatment for pneumonia, diarrhoea and dysentery for children in remote areas. In this article, we examine the policy landscape and processes that influenced the adoption and implementation of CCM in Nicaragua. Contextual factors in the policy landscape that facilitated CCM included an international technical consensus supporting the strategy; the role of government in health care provision and commitment to reaching the poor; a history of community participation; the existence of community-based child survival strategies; the decentralization of implementation authority; internal MOH champions; and a credible catalyst organization. Challenges included scepticism about community-level cadres; resistance from health personnel; operational gaps in treatment norms and materials to support the strategy; resource constraints affecting service delivery; tensions around decentralization; and changes in administration. In order to capitalize on the opportunities and overcome the challenges that characterized the policy landscape, stakeholders pursued various efforts to support CCM including sparking interest, framing issues, monitoring and communicating results, ensuring support and cohesion among health personnel, supporting local adaptation, assuring credibility and ownership, joint problem solving, addressing sustainability and fostering learning. While delineated as separate efforts, these policy and implementation processes were dynamic and interactive in nature, balancing various tensions. Our qualitative analysis highlights the importance of supporting routine monitoring and documentation of these strategic operational policy and management issues vital for CCM success. We also demonstrate that while challenges to CCM adoption and implementation exist, they are not insurmountable.

Community case management of childhood illness in Nicaragua: transforming health systems in underserved rural areas.

While social factors broadly determine health outcomes, strategic health workforce innovations such as community case management (CCM) can redress social inequalities in access to health care. Community case management enables trained health workers to assess children, diagnose common childhood infections, administer medicines, and monitor life-saving treatment in the poor, remote communities where they reside. This article reports on research that combined focus group discussions and key informant interviews to examine the perceptions of multiple stakeholders, with monitoring data, in order to assess programmatic results, limitations, and lessons learned in implementing CCM in Nicaragua. We found that CCM increases the use of curative services by poor children with pneumonia, diarrhea, or dysentery by five to six-fold over facility-based services. Apart from dramatically increasing geographic access to treatment for underserved groups, our qualitative research suggests that Nicaragua's CCM model also addresses the managerial challenges and social relations that underpin good quality of care, care-giver knowledge and awareness, and community mobilization, all health system-strengthening factors that are central to equitably and effectively improving child health. While our findings are promising, we suggest areas for further operational research to strengthen CCM program learning and functioning.

Human resources for health: a gender analysis

In this paper I discuss gender issues manifested within health occupations and across them. In particular, I examine gender dynamics in medicine, nursing, community health workers and home carers. I also explore from a gender perspective issues concerning delegation, migration and violence, which cut across these categories of health workers. These occupational categories and themes reflect priorities identified by the terms of reference for this review paper and also the themes that emerged from the accessed literature. This paper is based on a desk review of literature accessed through the internet, search engines, correspondence with other experts and reviewing bibliographies of existing material. These efforts resulted in a list of 534 articles, chapters, books and reports. Although most of the literature reviewed was in English, some of it was also in Spanish and Portuguese. Material related to training and interpersonal patient-provider relations that highlights how occupational inequalities affect the availability and quality of health care is covered by other review papers commissioned by the Women and Gender Equity Knowledge Network. (AU)