iCCM Policy Analysis Webinar
Presentation and discussion of findings
from Mozambique and Malawi
January 21, 2016
Policy Analysis of Integrated Community
Case Management of Childhood
Illnesses:
Introduction to a Six-Country Case
Study
Sara C. Bennett
Johns Hopkins University Bloomberg School
of Public Health, on behalf of the iCCM
Policy Study Team
TRAction iCCM Webinar, 21st January 2016
Coverage of essential child health
services in Sub-Saharan Africa
• 31% of children with diarrhea receive ORS
• 37% of children with fever receive any antimalarial
• 39% of children with symptoms of pneumonia
receive antibiotics (Unicef 2014)
• Large gap in coverage of essential services
• Many children dying at home without
reaching a health facility
Joint statements on integrated
Community Case Management
• Between 2004 and 2012 WHO and UNICEF
produced a series of joint statements on iCCM
Defining iCCM
The integrated delivery for children under 5 of:
– Treatment for childhood pneumonia with antibiotics,
– Treatment for diarrhea with zinc and low osmolarity
ORS,
– Treatment for malaria with artemisinin combination
therapy (ACTs), and
– Home visits of newborns with treatment of neonatal
sepsis with antibiotics
…by community or lay health workers at
household and/or community levels.
Progress in adopting & implementing
iCCM
• By 2013 out of 44 Sub-Saharan African
countries:– 36 had written policies or plans for CCM of
diarrhea
– 35 for malaria
– 31 for pneumonia (Rasanathan 2014)
• Implementation somewhat uneven – fast
progress in some countries, much slower in
others
THE ICCM POLICY ANALYSIS STUDY
Policy Analysis of iCCM
• How do we explain the uneven progress in
adopting and implementing iCCM?
• What are the barriers and facilitators to policy
adoption and implementation? For example:– Is there active resistance from specific
stakeholders such as clinicians?
– Are there objectives to the content of the
proposed policy?
– Do policy-makers feel that they have sufficient
evidence to proceed?
Study Objective
• In-depth analysis of national policy change for
iCCM in six sub-Saharan African countries to
understand whether, how and why iCCM policies
were developed, including barriers and
facilitators to policy change.
• Aims:
– Document and analyze the specific expressions of policy
– Identify facilitators or barriers to policy and program
change
– Assess the role of ideas and evidence in policy and
program development
– Identify policy elements that enable the eventual
implementation
Policy Analysis Triangle
Context
Source:
Walt & Gilson 1994
Actors
-Individuals
- Groups
-Organizations
Content
Process
Qualitative Retrospective Country Case Studies varying by
-policy status
-nature of CHW cadre
-sub-regions
Mali
Burkina Faso
Niger
Kenya
Malawi
Mozambique
*iCCM Policy Study Team
Team
Institutional Partner Core team members
Jessica Shearer (McMaster
University)
Burkina Faso
Kenya
Great Lakes UniversityPamela A. Juma
Kisumu
Malawi
REACH Trust
Ireen Namakhoma, Hastings
Banda
Mali
MARIKANI
Brahima Diallo, Mamadou Konate
Mozambique
Universidade Eduardo
Mondlane
Baltazar Chilundo, Alda Mariano,
Julie Cliff
Niger
LASDEL
Sarah Dalgish (JHSPH) and Aissa
Diarra (LASDEL)
JHSPH Core
Team
Sara Bennett, Asha George, Daniela Rodriguez, Jessica
Shearer
Study Methods
• Document review
• Semi-structured interviews:
– Stakeholders in iCCM policy: Government officials,
development partners and multilateral organizations,
bilateral donors, civil society organizations, research
institutions, etc.
– Start with respondents identified in document review,
and snowball until saturation
• Fieldwork undertaken April – September 2012
• Thematic analysis using NVivo software by
country and JHSPH researchers
Data Collection
Country
Number
approached
Number
interviewed
Number
documents
reviewed
Burkina Faso
30
25
80+
Mali
35
33
33
Niger
37
32
113
Kenya
31
19
41
Malawi
30
20
29
Mozambique
40
21
50
Acknowledgements
Funding from
• Sincere appreciation to study participants for
sharing their time with us.
iCCM Policy
Development in Malawi
TRAction Project Webinar
21 January 2016
Ireen Namakhoma, REACH Trust
Daniela C. Rodriguez, Johns Hopkins School of Public Health
iCCM policy in Malawi
• iCCM was developed in 2007 (part of larger child survival
policy)  started implementation in 2009 via a cadre of paid
community health workers known as HSAs (Health
Surveillance Assistants)
• iCCM covers malaria, pneumonia, diarrhea, neonatal sepsis
(limited) as well as conjunctivitis
• iCCM is targeted at hard-to-reach areas (e.g. beyond 8km
radius from health facility)
Serious questions about implementation of iCCM were raised
during policy development, how were they addressed?
Main findings
Contributing factors to iCCM policy
development
Innovation characteristics
• Perceived need for innovation:
• Child survival was a persistent problem, as highlighted
by various sources of evidence
• Facility IMCI was not reaching children in communities
• Lancet series on child survival offered plausible
interventions
• Innovation and system compatibility
• The health worker shortage had led to the expansion of
the HSA cadre so HSAs seen as viable delivery
mechanism for iCCM  system readiness
• Earlier experiences with IMCI and other health
improvement programs aimed at community level (e.g.
DRF, BMHI)  system antecedents
Institution characteristics
• Leadership:
• Process led by MOH through consultative process that
engaged Child Health TWG
• Engaged development partners to address key
implementation questions
• Coordination among partners:
• Despite the MOH’s leadership in policy development,
getting internal agreement within MOH was challenging
• MOH coordinated across stakeholders, incl. other
Ministries, and presented plans to districts
• Development partners, esp. UNICEF and WHO, played a
supportive role to policy development and acted as
knowledge brokers
Institution characteristics, cont.
• Organizational capacity:
• Professional organizations raised concerns about
training and regulation of HSAs, but were overcome
• HSA supervision and overburdening were challenges
raised during policy development***
• Planned funding was felt to be inadequate for long-term
implementation of iCCM***
• Funds for iCCM are channeled through the SWAp, but
with substantial external support from donors***
***Still unresolved after 3 years of implementation
Implications of findings
Implications of the findings for local
country context
• Need for improved coordination of partners in iCCM
implementation especially at district and sub district level
• Government should commit to funding iCCM activities e.g
through raising budget allocation to health (to meet 15%
Abuja declaration)
• Need for strengthened HSA supervision, monitoring and
motivation.
Post-study
developments
Developments contributing towards
improving iCCM
• The findings contributed to development of the new Malawi
Child Health Strategy 2014-2020
• Has particular section tackling strategies for strengthening
iCCM
• Strategy recognizes need for sustainable funding
• New supervision guideline manual developed
• REACH Trust under REACHOUT consortium with support
from EU has been piloting peer and group HSA supervision
approaches
• Introduction of amoxyllin- dispersible tablets for pneumonia
for HSAs
THANK YOU
Re-launch of the official Community Health
Worker Program in Mozambique:
Is there a sustainable basis for iCCM policy?
Baltazar Chilundo (MD, PhD), Julie Cliff (FRCP, MScCHDC), Alda
Mariano (MD, MSc), Daniela Rodriguez (DrPH), Asha George (DrPH)
30
Analysis of sustainability of the official CHW
program and of iCCM policy
Context
Research question
Methods
Results
Concluding remarks and implications
31
Context
Remarkable progress
of reduction of child
mortality
Trends of Mozambican child mortality
1997 to 2011
Under 1 month
Under 12 month
Under 5 years
300
Government and
partners recognize
that more gains are
possible if there is
more emphasis on
effective interventions
at the community
level
250
245.3
200
154
150
101
100
50
138
143.7
57
97
93
64
48
42
30
0
DHS 1997
DHS 2003
MICS 2008
DHS 2011
32
Context
 The official CHW government
Program known as Elementary
Polyvalent Agents “Agentes
Polivalentes Elementares” was
established in 1978 and it
functioned with innumerous
operational challenges, being
suspended in 1989, but it was
relaunched in 2010 thanks to its
potential impact:
% distribution of U5 causes of mortality in
Mozambique (INE, 2007)
Other
29%
Malaria
42%
Measles
1%
 Majority of causes of mortality
Undernutrition
among children are of “ easy
2%
Diarrhea
solution” with emphasis on iCCM by
6%
CHW
Pnuemonia
AIDS
14%
6%
33
Context and Research question
 CHWs trained for four months to carry out
promoting / preventive (80%), first aid, activities
treatment of common diseases especially in
children such as Malaria, Pneumonia, Diarrhea
and referral of more serious cases = iCCM
 Given the past history of decline, a key issue is
whether the current revitalization of the CHW
program allows for a more sustainable basis.
Does the current revitalization of the
CHW program, which encapsulates
iCCM, exhibit characteristics that
facilitate or impede its sustainability?
Methods
 Study design
 Qualitative: retrospective case study (Yin, 2009)
done simultaneously across 6 SSA countries (+ Burkina
Faso, Kenya, Mali, Malawi, Niger)
 Data collection
 Performed in Maputo city, in 2012
 Literature review (n = 54)
 Key informant interviews (n=21)
 Analysis
 Thematic analysis using an Nvivo codebook
Thematic analysis using a
sustainability framework (Schell et
al. 2013)
 Facilitators of and barriers to CHW
sustainability for the domains:
 Strategic Planning
 Organizational capacity
 Program adaptation
 M&E
 Communication
 Funding stability
 Political support
 Partnership
 Public Health impact
36
Findings: Strategic Planning
Facilitators
• CHW program developed in a consultative manner across MOH
departments and with partners
• National policies and guidelines reviewed to avoid mistakes made in the
past, e.g. APE non-payment.
• After consultative process with drug regulatory agencies, MOH exercised
fiat regarding drug regulations allowing APEs to prescribe certain
medicines and mainstreaming medicines into the NHS and CHW kit
Barriers
• Poor coordination with MOH departments
• Ministry of Finance not included in consultations
• APEs have short-term contracts, low pay ( not full-time salary), and no
career path, causing potential retention problems
• CHWs not integrated into the civil service, due to their educational level,
despite precedence from other Ministries on how to incorporate
community level agents into government structures
37
Findings: Organizational Capacity
Facilitators
• Operational guidelines and tools developed
• APEs trained in standardized manner
• APEs equipped with necessary equipment and supplies to carry
out their tasks
• NGOs with programme experience willing to support supervision
and logistics
Barriers
• Weak supply chain, with frequent medicine stock-outs may
demotivate APEs and the community
• Weak supportive supervision systems
• Dependence on NGOs/ partners and difficulties with
harmonization may weaken government health systems and
oversight
38
Findings: Funding stability Barriers
only
 Program is entirely dependent on external
donors for salaries, drugs, supplies,
supervision, etc.
 Scale up is slow (36% = 2.270/6.343 APE) as
government requires partners to pay for
APEs comprehensively and not just for
training
 Funding partners targeting specific
provinces and districts, leaving others
without support, leading to geodiscrepancy in service delivery and
unequal distribution of APEs
 Weak and decreasing contribution of the
state budget to the health sector
FUNDING SOURCE BY DISTRICT, 2012
Adapted from UNICEF (2013). Data from MISAU – APE Program
UNICEF/CIDA
SAVE THE CHILDREN/UNICEF/CIDA
SAVE THE CHILDREN
MALARIA CONSORTIUM
PNG/UNICEF/USAID
UNICEF/USAID
HELP AGE
WORLD VISION
 Decrease of external support to the health
sector, pending response from Global Fund
audit recommendations
WORLD BANK
UNICEF/CIDA/WORLD BANK
WITHOUT APEs
Figure 1. Heterogeneity and multiplicity of funding sources to the APE programme in Mozambique by
districts, 2012
39
Concluding remarks and
implications
 Without careful attention to finance, human resources, supply
chain management, and quality assurance, the CHW program
including iCCM may yield disappointing results.
 To ensure sustainability, the government should commit itself to
fund the program from the state budget
 This study was presented to the health authorities and partners in
National Health Congress in September 2015 and within the TWG
of public health directorate at the MOH
 Partially thanks to this study MOH/Unicef are commissioning
development of the 1st strategic plan for the official CHW 2016 –
2020 which includes the need to define funding strategies taking
into account a scenario of sustainability
40
Muito obrigado!
Thanks
41
Reactions from our discussants
Rory Nefdt
Dyness Kasungami
iCCM Policy Analysis Findings from
Mozambique and Malawi
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iCCM Policy Analysis Findings from
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iCCM Policy Analysis Findings from
Mozambique and Malawi