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Whidden C, Kayentao K, Koné N, Liu J, Traoré MB, Diakité D, Coumaré M, Berthé M, Guindo M, Greenwood B, Chandramohan D, Leyrat C, Treleaven E, Johnson A. Effects of proactive vs fixed community health care delivery on child health and access to care: a cluster randomised trial secondary endpoint analysis. J Glob Health 2023; 13:04047. [PMID: 37083317 PMCID: PMC10122537 DOI: 10.7189/jogh.13.04047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
Background Professional community health workers (CHWs) can help achieve universal health coverage, although evidence gaps remain on how to optimise CHW service delivery. We conducted an unblinded, parallel, cluster randomised trial in rural Mali to determine whether proactive CHW delivery reduced mortality and improved access to health care among children under five years, compared to passive delivery. Here we report the secondary access endpoints. Methods Beginning from 26-28 February 2017, 137 village-clusters were offered care by CHWs embedded in communities who were trained, paid, supervised, and integrated into a reinforced public-sector health system that did not charge user fees. Clusters were randomised (stratified on primary health centre catchment and distance) to care during CHWs during door-to-door home visits (intervention) or based at a fixed village site (control). We measured outcomes at baseline, 12-, 24-, and 36-month time points with surveys administered to all resident women aged 15-49 years. We used logistic regression with cluster-level random effects to estimate intention-to-treat and per-protocol effects over time on prompt (24-hour) treatment within the health sector. Results Follow-up surveys between February 2018 and April 2020 generated 20 105 child-year observations. Across arms, prompt health sector treatment more than doubled compared to baseline. At 12 months, children in intervention clusters had 22% higher odds of receiving prompt health sector treatment than those in control (cluster-specific adjusted odds ratio (aOR) = 1.22; 95% confidence interval (CI) = 1.06, 1.41, P = 0.005), or 4.7 percentage points higher (adjusted risk difference (aRD) = 0.047; 95% CI = 0.014, 0.080). We found no evidence of an effect at 24 or 36 months. Conclusions CHW-led health system redesign likely drove the 2-fold increase in rapid child access to care. In this context, proactive home visits further improved early access during the first year but waned afterwards. Registration ClinicalTrials.gov NCT02694055.
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Affiliation(s)
- Caroline Whidden
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
- Department of Research, Monitoring & Evaluation, Muso, Bamako, Mali
| | - Kassoum Kayentao
- Department of Research, Monitoring & Evaluation, Muso, Bamako, Mali
- Malaria Research & Training Centre, Université des Sciences, des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Naimatou Koné
- Department of Research, Monitoring & Evaluation, Muso, Bamako, Mali
| | - Jenny Liu
- Institute for Health & Aging, University of California, San Francisco, San Francisco, California, USA
| | | | | | - Mama Coumaré
- Ministère de la Santé et du Développement Social, Mali
| | | | | | - Brian Greenwood
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Clémence Leyrat
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Emily Treleaven
- Institute for Social Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Ari Johnson
- Muso, Bamako, Mali
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, California, USA
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Pattnaik A, Mohan D, Zeger S, Kanyuka M, Kachale F, Marx MA. From raw data to a score: comparing quantitative methods that construct multi-level composite implementation strength scores of family planning programs in Malawi. Popul Health Metr 2022; 20:18. [PMID: 36050721 PMCID: PMC9438221 DOI: 10.1186/s12963-022-00295-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 03/27/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Data that capture implementation strength can be combined in multiple ways across content and health system levels to create a summary measure that can help us to explore and compare program implementation across facility catchment areas. Summary indices can make it easier for national policymakers to understand and address variation in strength of program implementation across jurisdictions. In this paper, we describe the development of an index that we used to describe the district-level strength of implementation of Malawi's national family planning program. METHODS To develop the index, we used data collected during a 2017 national, health facility and community health worker Implementation Strength Assessment survey in Malawi to test different methods to combine indicators within and then across domains (4 methods-simple additive, weighted additive, principal components analysis, exploratory factor analysis) and combine scores across health facility and community health worker levels (2 methods-simple average and mixed effects model) to create a catchment area-level summary score for each health facility in Malawi. We explored how well each model captures variation and predicts couple-years protection and how feasible it is to conduct each type of analysis and the resulting interpretability. RESULTS We found little difference in how the four methods combined indicator data at the individual and combined levels of the health system. However, there were major differences when combining scores across health system levels to obtain a score at the health facility catchment area level. The scores resulting from the mixed effects model were able to better discriminate differences between catchment area scores compared to the simple average method. The scores using the mixed effects combination method also demonstrated more of a dose-response relationship with couple-years protection. CONCLUSIONS The summary measure that was calculated from the mixed effects combination method captured the variation of strength of implementation of Malawi's national family planning program at the health facility catchment area level. However, the best method for creating an index should be based on the pros and cons listed, not least, analyst capacity and ease of interpretability of findings. Ultimately, the resulting summary measure can aid decision-makers in understanding the combined effect of multiple aspects of programs being implemented in their health system and comparing the strengths of programs across geographies.
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Affiliation(s)
- Anooj Pattnaik
- grid.21107.350000 0001 2171 9311Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E5541, Baltimore, MD 21205 USA
| | - Diwakar Mohan
- grid.21107.350000 0001 2171 9311Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E5541, Baltimore, MD 21205 USA
| | - Scott Zeger
- grid.21107.350000 0001 2171 9311Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E5541, Baltimore, MD 21205 USA
| | | | - Fannie Kachale
- grid.415722.70000 0004 0598 3405Reproductive Health Directorate, Ministry of Health, Lilongwe, Malawi
| | - Melissa A. Marx
- grid.21107.350000 0001 2171 9311Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E5541, Baltimore, MD 21205 USA
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Amouzou A, Bryce J, Walker N. Strengthening effectiveness evaluations to improve programs for women, children and adolescents. Glob Health Action 2022; 15:2006423. [PMID: 36098952 PMCID: PMC9481099 DOI: 10.1080/16549716.2021.2006423] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A full understanding of the pathways from efficacious interventions to population impact requires rigorous effectiveness evaluations conducted under realistic scale-up conditions at country level. In this paper, we introduce a deductive framework that underpins effectiveness evaluations. This framework forms the theoretical and conceptual basis for the 'Real Accountability: Data Analysis for Results' (RADAR) project, intended to address gaps in guidance and tools for the evaluation of projects being implemented at scale to reduce mortality among women and children. These gaps include needs for a framework to guide decisions about evaluations and practical measurement tools, as well as increased capacity in evaluation practice among donors and program planners at global, national and project levels. RADAR aimed to improve the evidence base for program and policy decisions in reproductive, maternal, newborn and child health and nutrition (RMNCH&N). We focus on five linked methodological steps - presented as core evaluation questions - for designing and implementing effectiveness evaluation of large-scale programs that support both the needs of program managers to improve their programs and the needs of donors to meet their accountability responsibilities. RADAR has operationalized each step with a tool to facilitate its application. We also describe cross-cutting methodological issues and broader contextual factors that affect the planning and implementation of such evaluations. We conclude with proposals for how the global RMNCH&N community can support rigorous program evaluations and make better use of the resulting evidence.
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Affiliation(s)
- Agbessi Amouzou
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jennifer Bryce
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Neff Walker
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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Kruk ME, Lewis TP, Arsenault C, Bhutta ZA, Irimu G, Jeong J, Lassi ZS, Sawyer SM, Vaivada T, Waiswa P, Yousafzai AK. Improving health and social systems for all children in LMICs: structural innovations to deliver high-quality services. Lancet 2022; 399:1830-1844. [PMID: 35489361 PMCID: PMC9077444 DOI: 10.1016/s0140-6736(21)02532-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/10/2021] [Accepted: 11/11/2021] [Indexed: 12/25/2022]
Abstract
Despite health gains over the past 30 years, children and adolescents are not reaching their health potential in many low-income and middle-income countries (LMICs). In addition to health systems, social systems, such as schools, communities, families, and digital platforms, can be used to promote health. We did a targeted literature review of how well health and social systems are meeting the needs of children in LMICs using the framework of The Lancet Global Health Commission on high-quality health systems and we reviewed evidence for structural reforms in health and social sectors. We found that quality of services for children is substandard across both health and social systems. Health systems have deficits in care competence (eg, diagnosis and management), system competence (eg, timeliness, continuity, and referral), user experience (eg, respect and usability), service provision for common and serious conditions (eg, cancer, trauma, and mental health), and service offerings for adolescents. Education and social services for child health are limited by low funding and poor coordination with other sectors. Structural reforms are more likely to improve service quality substantially and at scale than are micro-level efforts. Promising approaches include governing for quality (eg, leadership, expert management, and learning systems), redesigning service delivery to maximise outcomes, and empowering families to better care for children and to demand quality care from health and social systems. Additional research is needed on health needs across the life course, health system performance for children and families, and large-scale evaluation of promising health and social programmes.
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Affiliation(s)
- Margaret E Kruk
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA.
| | - Todd P Lewis
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Catherine Arsenault
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Center of Excellence in Women and Child Health and Institute for Global Health and Development, Aga Khan University, Karachi, Pakistan
| | - Grace Irimu
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya; Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Joshua Jeong
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Zohra S Lassi
- Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Susan M Sawyer
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia; Centre for Adolescent Health, Royal Children's Hospital, Parkville, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Tyler Vaivada
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Peter Waiswa
- Maternal, Newborn and Child Health Centre of Excellence, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Aisha K Yousafzai
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
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Allen KC, Whitfield K, Rabinovich R, Sadruddin S. The role of governance in implementing sustainable global health interventions: review of health system integration for integrated community case management (iCCM) of childhood illnesses. BMJ Glob Health 2021; 6:bmjgh-2020-003257. [PMID: 33789866 PMCID: PMC8016094 DOI: 10.1136/bmjgh-2020-003257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 02/26/2021] [Accepted: 03/04/2021] [Indexed: 01/16/2023] Open
Abstract
Improving health outcomes in countries with the greatest burden of under-5 child mortality requires implementing innovative approaches like integrated community case management (iCCM) to improve coverage and access for hard-to-reach populations. ICCM improves access for hard-to-reach populations by deploying community health workers to manage malaria, diarrhoea and pneumonia. Despite documented impact, challenges remain in programme implementation and sustainability. An analytical review was conducted using evidence from published and grey literature from 2010 to 2019. The goal was to understand the link between governance, policy development and programme sustainability for iCCM. A Governance Analytical Framework revealed thematic challenges and successes for iCCM adaptation to national health systems. Governance in iCCM included the collective problems, actors in coordination and policy-setting, contextual norms and programmatic interactions. Key challenges were country leadership, contextual evidence and information-sharing, dependence on external funding, and disease-specific stovepipes that impede funding and coordination. Countries that tailor and adapt programmes to suit their governance processes and meet their specific needs and capacities are better able to achieve sustainability and impact in iCCM.
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Affiliation(s)
- Koya C Allen
- Malaria Eradication Scientific Alliance (MESA), Barcelona Institute for Global Health, Hospital Clínic - Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Kate Whitfield
- Malaria Eradication Scientific Alliance (MESA), Barcelona Institute for Global Health, Hospital Clínic - Universitat de Barcelona, Barcelona, Catalunya, Spain
| | - Regina Rabinovich
- Malaria Elimination Initiative, Barcelona Institute for Global Health, Hospital Clínic - Universitat de Barcelona, Barcelona, Catalunya, Spain.,ExxonMobil Malaria Scholar in Residence, Department of Immunology and Infectious Diseases, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Salim Sadruddin
- Child Health, MOMENTUM Country and Global Leadership, Washington, DC, USA
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Beyene H, Kassa DH, Tadele HD, Persson L, Defar A, Berhanu D. Factors associated with the referral of children with severe illnesses at primary care level in Ethiopia: a cross-sectional study. BMJ Open 2021; 11:e047640. [PMID: 34112644 PMCID: PMC8194336 DOI: 10.1136/bmjopen-2020-047640] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
CONTEXT AND OBJECTIVE Ethiopia's primary care has a weak referral system for sick children. We aimed to identify health post and child factors associated with referrals of sick children 0-59 months of age and evaluate the healthcare providers' adherence to referral guidelines. DESIGN A cross-sectional facility-based survey. SETTING This study included data from 165 health posts in 52 districts in four Ethiopian regions collected from December 2018 to February 2019. The data included interviews with health extension workers, assessment of health post preparedness, recording of global positioning system (GPS)-coordinates of the health post and the referral health centre, and reviewing registers of sick children treated during the last 3 months at the health posts. We analysed the association between the sick child's characteristics, health post preparedness and distance to the health centre with referral of sick children by multivariable logistic regressions. OUTCOME MEASURE Referral to the nearest health centre of sick young infants aged 0-59 days and sick children 2-59 months. RESULTS The health extension workers referred 39/229 (17%) of the sick young infants and 78/1123 (7%) of the older children to the next level of care. Only 18 (37%) sick young infants and 22 (50%) 2-59 months children that deserved urgent referral according to guidelines were referred. The leading causes of referral were possible serious bacterial infection and pneumonia. Those being classified as a severe disease were referred more frequently. The availability of basic amenities (adjusted OR, AOR=0.38, 95% CI 0.15 to 0.96), amoxicillin (AOR=0.41, 95% CI 0.19 to 0.88) and rapid diagnostic test (AOR=0.18, 95% CI 0.07 to 0.46) were associated with less referral in the older age group. CONCLUSION Few children with severe illness were referred from health posts to health centres. Improving the health posts' medicine and diagnostic supplies may enhance adherence to referral guidelines and ultimately reduce child mortality.
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Affiliation(s)
- Habtamu Beyene
- Regional Health Bureau, Southern Nations Nationalities and Peoples' Region, Hawassa, Ethiopia
- College of Medicine and Health Sciences, School of Public Health, Hawassa University, Hawassa, Sidama, Ethiopia
| | - Dejene Hailu Kassa
- College of Medicine and Health Sciences, School of Public Health, Hawassa University, Hawassa, Sidama, Ethiopia
| | - Henok Dangiso Tadele
- College of Health Sciences, Department of Paediatrics and Child Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Lars Persson
- London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, UK
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Atkure Defar
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Della Berhanu
- London School of Hygiene and Tropical Medicine, Faculty of Infectious and Tropical Diseases, London, UK
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
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Chen N, Raghavan M, Albert J, McDaniel A, Otiso L, Kintu R, West M, Jacobstein D. The Community Health Systems Reform Cycle: Strengthening the Integration of Community Health Worker Programs Through an Institutional Reform Perspective. GLOBAL HEALTH: SCIENCE AND PRACTICE 2021; 9:S32-S46. [PMID: 33727319 PMCID: PMC7971380 DOI: 10.9745/ghsp-d-20-00429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 01/07/2021] [Indexed: 11/15/2022]
Abstract
To develop guidance for governments and partners seeking to scale community health worker programs, we developed a conceptual framework, collected observations from the scale-up efforts of 7 countries, workshopped the framework with technical groups and with country stakeholders, and reviewed literature in the areas of health and policy reform, change management, institutional development, health systems, and advocacy. We observed that successful scale-up is a complex process of institutional reform. Successful scale-up: (1) depends on a carefully choreographed, problem-driven political process; (2) requires that scaled program models are drawn from solutions that are available in a given health system context and aligned with the resources, capabilities, and commitments of key health sector stakeholders; and (3) emerges from iterative cycles of learning and improvement, rather than a single, linear scale-up effort. We identify stages of the reform process associated with each of these 3 findings: problem prioritization, coalition building, solution gathering, design, program readiness, launch, governance, and management and learning. The resulting Community Health Systems Reform Cycle can be used by government, donors, and nongovernmental partners to prioritize and design community health worker scale-up efforts, diagnose challenges or gaps in successful scale-up and integration, and coordinate the contributions of diverse stakeholders.
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Affiliation(s)
- Nan Chen
- Last Mile Health, Washington, DC, USA.
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Berhanu D, Okwaraji YB, Defar A, Bekele A, Lemango ET, Medhanyie AA, Wordofa MA, Yitayal M, W/Gebriel F, Desta A, Gebregizabher FA, Daka DW, Hunduma A, Beyene H, Getahun T, Getachew T, Woldemariam AT, Wolassa D, Persson LÅ, Schellenberg J. Does a complex intervention targeting communities, health facilities and district health managers increase the utilisation of community-based child health services? A before and after study in intervention and comparison areas of Ethiopia. BMJ Open 2020; 10:e040868. [PMID: 32933966 PMCID: PMC7493123 DOI: 10.1136/bmjopen-2020-040868] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Ethiopia successfully reduced mortality in children below 5 years of age during the past few decades, but the utilisation of child health services was still low. Optimising the Health Extension Programme was a 2-year intervention in 26 districts, focusing on community engagement, capacity strengthening of primary care workers and reinforcement of district accountability of child health services. We report the intervention's effectiveness on care utilisation for common childhood illnesses. METHODS We included a representative sample of 5773 households with 2874 under-five children at baseline (December 2016 to February 2017) and 10 788 households and 5639 under-five children at endline surveys (December 2018 to February 2019) in intervention and comparison areas. Health facilities were also included. We assessed the effect of the intervention using difference-in-differences analyses. RESULTS There were 31 intervention activities; many were one-off and implemented late. In eight districts, activities were interrupted for 4 months. Care-seeking for any illness in the 2 weeks before the survey for children aged 2-59 months at baseline was 58% (95% CI 47 to 68) in intervention and 49% (95% CI 39 to 60) in comparison areas. At end-line it was 39% (95% CI 32 to 45) in intervention and 34% (95% CI 27 to 41) in comparison areas (difference-in-differences -4 percentage points, adjusted OR 0.49, 95% CI 0.12 to 1.95). The intervention neither had an effect on care-seeking among sick neonates, nor on household participation in community engagement forums, supportive supervision of primary care workers, nor on indicators of district accountability for child health services. CONCLUSION We found no evidence to suggest that the intervention increased the utilisation of care for sick children. The lack of effect could partly be attributed to the short implementation period of a complex intervention and implementation interruption. Future funding schemes should take into consideration that complex interventions that include behaviour change may need an extended implementation period. TRIAL REGISTRATION NUMBER ISRCTN12040912.
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Affiliation(s)
- Della Berhanu
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Health Systems and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Yemisrach Behailu Okwaraji
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Atkure Defar
- Health Systems and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Abebe Bekele
- Health Systems and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Ephrem Tekle Lemango
- Maternal and Child Health Directorate, Ethiopia Ministry of Health, Addis Ababa, Ethiopia
| | - Araya Abrha Medhanyie
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Muluemebet Abera Wordofa
- Department of Population and Family Health, Faculty of Public Health, Jimma University, Jimma, Ethiopia
| | - Mezgebu Yitayal
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Fitsum W/Gebriel
- College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Alem Desta
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | - Fisseha Ashebir Gebregizabher
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
- Tigray Regional Health Bureau, Mekelle, Ethiopia
| | - Dawit Wolde Daka
- Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
| | - Alemayehu Hunduma
- Department of Population and Family Health, Faculty of Public Health, Jimma University, Jimma, Ethiopia
- Oromia Regional Health Bureau, Addis Ababa, Ethiopia
| | - Habtamu Beyene
- College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
- Southern Nations, Nationalities & Peoples Regional Health Bureau, Hawassa, Ethiopia
| | - Tigist Getahun
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- Amhara Regional Health Bureau, Baher Dar, Ethiopia
| | - Theodros Getachew
- Health Systems and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amare Tariku Woldemariam
- Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Desta Wolassa
- Health Systems and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Lars Åke Persson
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Health Systems and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Joanna Schellenberg
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Nanyonjo A, Kertho E, Tibenderana J, Källander K. District Health Teams' Readiness to Institutionalize Integrated Community Case Management in the Uganda Local Health Systems: A Repeated Qualitative Study. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:190-204. [PMID: 32606091 PMCID: PMC7326515 DOI: 10.9745/ghsp-d-19-00318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 03/04/2020] [Indexed: 11/28/2022]
Abstract
District health teams failed to transition from partner-supported integrated community case management (iCCM) programs to locally-run and fully-institutionalized programs. Successful iCCM institutionalization requires local ownership with increased coordination among governmental and nongovernmental actors at the national and district levels. Introduction: Several countries have adopted integrated community case management (iCCM) as a strategy for improved health service delivery in areas with poor health facility coverage. Early implementation of iCCM is often run by nongovernmental organizations financed by donors through projects. Such projects risk failure to transition into programs run by the local health system upon project closure. Engagement of subnational health authorities such as district health teams (DHTs) is essential for a smooth transition. Methods: We used a repeated qualitative study design to assess the readiness of and progress made by DHTs in institutionalizing iCCM into the functions of locally decentralized health systems in 9 western Uganda districts. Readiness data were derived from structured group interviews with DHTs before iCCM policy adoption in 2010 and again in 2015. Progressive institutionalization achievements were assessed through key informant interviews with targeted DHT members and local government district planners in the same areas. Findings: In the readiness study, DHTs expressed commitment to institutionalize iCCM into the local health system through the development of district-specific iCCM activity work plans and budgets. The DHTs further suggested that they would implement district-led training, motivation, and supervision of community health workers; procurement of iCCM medicines and supplies; and advocacy activities for inclusion of iCCM indicators into the national health information systems. After iCCM policy adoption, follow-up study data findings showed that iCCM was largely not institutionalized into the local district health system functions. The poor institutionalization was attributed to lack of stewardship on how to transition from externally supported implementation to district-led programming, conflicting guidelines on community distribution of medicines, poor community-level accountability systems, and limited decision-making autonomy at the district level. Conclusion: Successful institutionalization of iCCM requires local ownership with increased coordination and cooperation among governmental and nongovernmental actors at both the national and district levels.
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Affiliation(s)
| | | | | | - Karin Källander
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Amouzou A, Jiwani SS, da Silva ICM, Carvajal-Aguirre L, Maïga A, Vaz LME. Closing the inequality gaps in reproductive, maternal, newborn and child health coverage: slow and fast progressors. BMJ Glob Health 2020; 5:e002230. [PMID: 32133181 PMCID: PMC7042586 DOI: 10.1136/bmjgh-2019-002230] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 12/18/2019] [Indexed: 11/04/2022] Open
Abstract
Introduction Universal Health Coverage (UHC) is a critical goal under the Sustainable Development Goals (SDGs) for health. Achieving this goal for reproductive, maternal, newborn and child health (RMNCH) service coverage will require an understanding of national progress and how socioeconomic and demographic subgroups of women and children are being reached by health interventions. Methods We accessed coverage databases produced by the International Centre for Equity in Health, which were based on reanalysis of Demographic and Health Surveys, Multiple Indicator Cluster Surveys and Reproductive and Health Surveys. We limited the data to 58 countries with at least two surveys since 2008. We fitted multilevel linear regressions of coverage of RMNCH, divided into four main components-reproductive health, maternal health, child immunisation and child illness treatment-to estimate the average annual percentage point change (AAPPC) in coverage for the period 2008-2017 across these countries and for subgroups defined by maternal age, education, place of residence and wealth quintiles. We also assessed change in the pace of coverage progress between the periods 2000-2008 and 2008-2017. Results Progress in RMNCH coverage has been modest over the past decade, with statistically significant AAPPC observed only for maternal health (1.25, 95% CI 0.90 to 1.61) and reproductive health (0.83, 95% CI 0.47 to 1.19). AAPPC was not statistically significant for child immunisation and illness treatment. Progress, however, varied largely across countries, with fast or slow progressors spread throughout the low-income and middle-income groups. For reproductive and maternal health, low-income and lower middle-income countries appear to have progressed faster than upper middle-income countries. For these two components, faster progress was also observed in older women and in traditionally less well-off groups such as non-educated women, those living in rural areas or belonging to the poorest or middle wealth quintiles than among groups that are well off. The latter groups however continue to maintain substantially higher coverage levels over the former. No acceleration in RMNCH coverage was observed when the periods 2000-2008 and 2008-2017 were compared. Conclusion At the dawn of the SDGs, progress in coverage in RMNCH remains insufficient at the national level and across equity dimensions to accelerate towards UHC by 2030. Greater attention must be paid to child immunisation to sustain the past gains and to child illness treatment to substantially raise its coverage across all groups.
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Affiliation(s)
- Agbessi Amouzou
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Safia S Jiwani
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Abdoulaye Maïga
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lara M E Vaz
- Global Health, Save the Children, Washington DC, District of Columbia, USA
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Lungu EA, Darker C, Biesma R. Determinants of healthcare seeking for childhood illnesses among caregivers of under-five children in urban slums in Malawi: a population-based cross-sectional study. BMC Pediatr 2020; 20:20. [PMID: 31952484 PMCID: PMC6966883 DOI: 10.1186/s12887-020-1913-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 01/07/2020] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND There is considerable evidence that health systems, in so far as they ensure access to healthcare, promote population health even independent of other determinants. Access to child health services remains integral to improving child health outcomes. Cognisant that improvements in child health have been unevenly distributed, it is imperative that health services and research focus on the disadvantaged groups. Children residing in urban slums are known to face a health disadvantage that is masked by the common view of an urban health advantage. Granted increasing urbanisation rates and proliferation of urban slums resulting from urban poverty, the health of under-five children in slums remains a public health imperative in Malawi. We explored determinants of healthcare-seeking from a biomedical health provider for childhood symptoms of fever, cough with fast breathing and diarrhoea in three urban slums of Lilongwe, Malawi. METHODS This was a population-based cross-sectional study involving 543 caregivers of under-five children. Data on childhood morbidity and healthcare seeking in three months period were collected using face-to-face interviews guided by a validated questionnaire. Data were entered in CS-Pro 5.0 and analysed in SPSS version 20 using descriptive statistics and logistic regression analyses. RESULTS 61% of caregivers sought healthcare albeit 53% of them sought healthcare late. Public health facilities constituted the most frequently used health providers. Healthcare was more likely to be sought: for younger than older under-five children (AOR = 0.54; 95% CI: 0.30-0.99); when illness was perceived to be severe (AOR = 2.40; 95% CI: 1.34-4.30); when the presenting symptom was fever (AOR = 1.77; 95% CI: 1.10-2.86). Home management of childhood illness was negatively associated with care-seeking (AOR = 0.54; 95% CI: 0.36-0.81) and timely care-seeking (AOR = 0.44; 95% CI: 0.2-0.74). Caregivers with good knowledge of child danger signs were less likely to seek care timely (AOR = 0.57; 95% CI: 0.33-0.99). CONCLUSIONS Even in the context of geographical proximity to healthcare services, caregivers in urban slums may not seek healthcare or when they do so the majority may not undertake timely healthcare care seeking. Factors related to the child, the type of illness, and the caregiver are central to the healthcare decision making dynamics. Improving access to under-five child health services therefore requires considering multiple factors.
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Affiliation(s)
| | - Catherine Darker
- Department of Public Health & Primary Care, Trinity College Dublin, Tallaght Hospital, Dublin 24, 24 Ireland
| | - Regien Biesma
- Global Health Unit, Department of Health Sciences, University of Groningen, P.O Box 196, 9700 AD Groningen, Netherlands
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12
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Whidden C, Thwing J, Gutman J, Wohl E, Leyrat C, Kayentao K, Johnson AD, Greenwood B, Chandramohan D. Proactive case detection of common childhood illnesses by community health workers: a systematic review. BMJ Glob Health 2019; 4:e001799. [PMID: 31908858 PMCID: PMC6936477 DOI: 10.1136/bmjgh-2019-001799] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/25/2019] [Accepted: 09/28/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Identifying design features and implementation strategies to optimise community health worker (CHW) programmes is important in the context of mixed results at scale. We systematically reviewed evidence of the effects of proactive case detection by CHWs in low-income and middle-income countries (LMICs) on mortality, morbidity and access to care for common childhood illnesses. METHODS Published studies were identified via electronic databases from 1978 to 2017. We included randomised and non-randomised controlled trials, controlled before-after studies and interrupted time series studies, and assessed their quality for risk of bias. We reported measures of effect as study investigators reported them, and synthesised by outcomes of mortality, disease prevalence, hospitalisation and access to treatment. We calculated risk ratios (RRs) as a principal summary measure, with CIs adjusted for cluster design effect. RESULTS We identified 14 studies of 11 interventions from nine LMICs that met inclusion criteria. They showed considerable diversity in intervention design and implementation, comparison, outcomes and study quality, which precluded meta-analysis. Proactive case detection may reduce infant mortality (RR: 0.52-0.94) and increase access to effective treatment (RR: 1.59-4.64) compared with conventional community-based healthcare delivery (low certainty evidence). It is uncertain whether proactive case detection reduces mortality among children under 5 years (RR: 0.04-0.80), prevalence of infectious diseases (RR: 0.06-1.02), hospitalisation (RR: 0.38-1.26) or increases access to prompt treatment (RR: 1.00-2.39) because the certainty of this evidence is very low. CONCLUSION Proactive case detection may provide promising benefits for child health, but evidence is insufficient to draw conclusions. More research is needed on proactive case detection with rigorous study designs that use standardised outcomes and measurement methods, and report more detail on complex intervention design and implementation. PROSPERO REGISTRATION NUMBER CRD42017074621.
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Affiliation(s)
- Caroline Whidden
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Julie Thwing
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention Center for Global Health, Atlanta, Georgia, USA
| | - Julie Gutman
- Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention Center for Global Health, Atlanta, Georgia, USA
| | - Ethan Wohl
- Philadelphia College of Osteopathic Medicine, Georgia Campus, Suwanee, Georgia, USA
| | - Clémence Leyrat
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Kassoum Kayentao
- Malaria Research and Training Center, Université des Sciences des Techniques et des Technologies de Bamako, Bamako, Mali
| | - Ari David Johnson
- ZSFG Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Brian Greenwood
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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Whidden C, Treleaven E, Liu J, Padian N, Poudiougou B, Bautista-Arredondo S, Fay MP, Samaké S, Cissé AB, Diakité D, Keita Y, Johnson AD, Kayentao K. Proactive community case management and child survival: protocol for a cluster randomised controlled trial. BMJ Open 2019; 9:e027487. [PMID: 31455700 PMCID: PMC6720240 DOI: 10.1136/bmjopen-2018-027487] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Community health workers (CHWs)-shown to improve access to care and reduce maternal, newborn, and child morbidity and mortality-are re-emerging as a key strategy to achieve health-related Sustainable Development Goals (SDGs). However, recent evaluations of national programmes for CHW-led integrated community case management (iCCM) of common childhood illnesses have not found benefits on access to care and child mortality. Developing innovative ways to maximise the potential benefits of iCCM is critical to achieving the SDGs. METHODS AND ANALYSIS An unblinded, cluster randomised controlled trial in rural Mali aims to test the efficacy of the addition of door-to-door proactive case detection by CHWs compared with a conventional approach to iCCM service delivery in reducing under-five mortality. In the intervention arm, 69 village clusters will have CHWs who conduct daily proactive case-finding home visits and deliver doorstep counsel, care, referral and follow-up. In the control arm, 68 village clusters will have CHWs who provide the same services exclusively out of a fixed community health site. A baseline population census will be conducted of all people living in the study area. All women of reproductive age will be enrolled in the study and surveyed at baseline, 12, 24 and 36 months. The survey includes a life table tracking all live births and deaths occurring prior to enrolment through the 36 months of follow-up in order to measure the primary endpoint: under-five mortality, measured as deaths among children under 5 years of age per 1000 person-years at risk of mortality. ETHICS AND DISSEMINATION The trial has received ethical approval from the Ethics Committee of the Faculty of Medicine, Pharmacy and Dentistry, University of Bamako. The results will be disseminated through peer-reviewed publications, national and international conferences and workshops, and media outlets. TRIAL REGISTRATION NUMBER NCT02694055; Pre-results.
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Affiliation(s)
| | - Emily Treleaven
- Population Studies Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Jenny Liu
- Department of Social and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Nancy Padian
- School of Public Health, University of California, Berkeley, San Francisco, California, USA
| | | | - Sergio Bautista-Arredondo
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health, Cuernavaca, Mexico
| | - Michael P Fay
- Biostatistics Research Branch, National Institutes of Allergy and Infectious Disease, Bethesda, Maryland, USA
| | - Salif Samaké
- Ministry of Health & Social Affairs, Bamako, Mali
| | | | | | | | - Ari D Johnson
- Research, Monitoring & Evaluation, Muso, Bamako, Mali
- ZSFG Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Kassoum Kayentao
- Research, Monitoring & Evaluation, Muso, Bamako, Mali
- Malaria Research & Training Centre, University of Sciences Techniques and Technologies of Bamako, Bamako, Mali
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Prosnitz D, Herrera S, Coelho H, Moonzwe Davis L, Zalisk K, Yourkavitch J. Evidence of Impact: iCCM as a strategy to save lives of children under five. J Glob Health 2019; 9:010801. [PMID: 31263547 PMCID: PMC6594661 DOI: 10.7189/jogh.09.010801] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background In 2013, the World Health Organization (WHO) launched the Rapid Access Expansion (RAcE) programme in the Democratic Republic of Congo, Malawi, Mozambique, Niger, and Nigeria to increase coverage of diagnostic, treatment, and referral services for malaria, pneumonia, and diarrhea among children ages 2-59 months. In 2017, a final evaluation of the six RAcE sites was conducted to determine whether the programme goal was reached. A key evaluation objective was to estimate the reduction in childhood mortality and the number of under-five lives saved over the project period in the RAcE project areas. Methods The Lives Saved Tool (LiST) was used to estimate reductions in all-cause child mortality due to changes in coverage of treatment for the integrated community case management (iCCM) illnesses – malaria, pneumonia, and diarrhea – while accounting for other changes in maternal and child health interventions in each RAcE project area. Data from RAcE baseline and endline household surveys, Demographic and Health Surveys, and routine health service data were used in each LiST model. The models yielded estimated change in under-five mortality rates, and estimated number of lives saved per year by malaria, pneumonia and diarrhea treatment. We adjusted the results to estimate the number of lives saved by community health worker (CHW)-provided treatment. Results The LiST model accounts for coverage changes in iCCM intervention coverage and other health trends in each project area to estimate mortality reduction and child lives saved. Under five mortality declined in all six RAcE sites, with an average decline of 10 percent. An estimated 6200 under-five lives were saved by malaria, pneumonia, and diarrhea treatment in the DRC, Malawi, Niger, and Nigeria, of which approximately 4940 (75 percent) were saved by treatment provided by CHWs. This total excludes Mozambique, where there were no estimated under-five lives saved likely due to widespread stockouts of key medications. In all other project areas, lives saved by CHW-provided treatment contributed substantially to the estimated decline in under-five mortality. Conclusions Our results suggest that iCCM is a strategy that can save lives and measurably decrease child mortality in settings where access to health facility services is low and adequate resources for iCCM implementation are provided for CHW services.
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Affiliation(s)
| | - Samantha Herrera
- ICF, Rockville, Maryland, USA.,Save the Children, Washington, D.C., USA
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15
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Zalisk K, Guenther T, Prosnitz D, Nsona H, Chimbalanga E, Sadruddin S. Achievements and challenges of implementation in a mature iCCM programme: Malawi case study. J Glob Health 2019; 9:010807. [PMID: 31263552 PMCID: PMC6594665 DOI: 10.7189/jogh.09.010807] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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16
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Guenther T, Nsona H, Makuluni R, Chisema M, Jenda G, Chimbalanga E, Sadruddin S. Home visits by community health workers for pregnant mothers and newborns: coverage plateau in Malawi. J Glob Health 2019; 9:010808. [PMID: 31275568 PMCID: PMC6596344 DOI: 10.7189/jogh.09.010808] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Home visits by community health workers (CHWs) during pregnancy and soon after delivery are recommended to improve newborn survival. However, as the roles of CHWs expand, there are concerns regarding the capacity of community health systems to deliver high effective coverage of home visits. The WHO's Rapid Access Expansion (RAcE) program supported the Malawi Ministry of Health to align their Community-Based Maternal and Newborn Care (CBMNC) package with the latest WHO guidelines and to implement and evaluate the feasibility and coverage of home visits in Ntcheu district. METHODS A population-based survey of 150 households in Ntcheu district was conducted in July-August 2016 after approximately 10 months of CBMNC implementation. Thirty clusters were selected proportional-to-size using the most recent census. In selected clusters, five households with mothers of children under six months of age were randomly selected for interview. The Health Surveillance Assistants (HSAs) providing community-based services to the same clusters were purposively selected for a structured interview and register review. RESULTS Less than one third of pregnant women (30.7%; 95% confidence interval CI = 21.7%-41.5%) received a home visit during pregnancy and only 20.7% (95% CI = 13.0%-29.4%) received the recommended two visits. Coverage of postnatal visits was even lower: 11.4% (95%CI = 6.8%-18.5%) of mothers and newborns received a visit within three days of delivery and 20.7% (95%CI = 12.7%-32.0%) received a visit within the first eight days. Reaching newborns soon after delivery requires timely participation of the family and/or health facility staff to notify the HSA - yet only 42.9% (95% CI = 33.4%-52.9%) of mothers reported that the HSA was informed of the delivery. Coverage of postnatal home visits among those who informed the HSA was significantly higher than among those in which the HSA was not informed (46.7% compared to 1.3%; P = 0.00). Most HSAs had the necessary equipment and supplies and were active in CBMNC: 83.9% (95% CI = 70.2%-97.6%) of HSAs had pregnancy home visits and 77.4% (95% CI = 61.8%-93.0%) had postnatal home visits documented in their registers for the previous three months. CONCLUSIONS We found low coverage of home visits during pregnancy and soon after delivery in a well-supported program delivery environment. Most HSAs were conducting home visits, but not at the level needed to reach high coverage. These findings were similar to previous studies, calling into question the feasibility of the current visitation schedule. It is time to re-align the CBMNC package with what the existing platform can deliver and identify strategies to better support HSAs to implement home visits to those who would benefit most.
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Affiliation(s)
- Tanya Guenther
- Abt Associates, Dili, Timor-Leste
- At the time this paper was first drafted, Ms.
Guenther was employed by Save the Children, USA
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Heidkamp R. The National Evaluation Platform for Maternal, Newborn, and Child Health, and Nutrition: From idea to implementation. J Glob Health 2019; 7:020305. [PMID: 29302313 PMCID: PMC5735774 DOI: 10.7189/jogh.07.020305] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Rebecca Heidkamp
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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18
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Whidden C, Kayentao K, Liu JX, Lee S, Keita Y, Diakité D, Keita A, Diarra S, Edwards J, Yembrick A, Holeman I, Samaké S, Plea B, Coumaré M, Johnson AD. Improving Community Health Worker performance by using a personalised feedback dashboard for supervision: a randomised controlled trial. J Glob Health 2018; 8:020418. [PMID: 30333922 PMCID: PMC6162089 DOI: 10.7189/jogh.08.020418] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Countries across sub-Saharan Africa are scaling up Community Health Worker (CHW) programmes, yet there remains little high-quality research assessing strategies for CHW supervision and performance improvement. This randomised controlled trial aimed to determine the effect of a personalised performance dashboard used as a supervision tool on the quantity, speed, and quality of CHW care. METHODS We conducted a randomised controlled trial in a large health catchment area in peri-urban Mali. One hundred forty-eight CHWs conducting proactive case-finding home visits were randomly allocated to receive individual monthly supervision with or without the CHW Performance Dashboard from January to June 2016. Randomisation was stratified by CHW supervisor, level of CHW experience, and CHW baseline performance for monthly quantity of care (number of household visits). With regression analysis, we used a difference-in-difference model to estimate the effect of the intervention on monthly quantity, timeliness (percentage of children under five treated within 24 hours of symptom onset), and quality (percentage of children under five treated without protocol error) of care over a six-month post-intervention period relative to a three-month pre-intervention period. RESULTS Use of the Dashboard during monthly supervision significantly increased the mean number of home visits by 39.94 visits per month (95% CI = 3.56-76.3; P = 0.031). Estimated effects on secondary outcomes of timeliness and quality were positive but not statistically significant. Across both study arms, CHW quantity, timeliness, and quality of care significantly improved over the study period, during which time all CHWs received dedicated monthly supervision, although effects plateaued over time. CONCLUSIONS Our findings suggest that dedicated monthly supervision and personalised feedback using performance dashboards can increase CHW productivity. Further operational research is needed to understand how to sustain the performance improvements over time. TRIAL REGISTRATION ClinicalTrials.gov (NCT03684551).
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Affiliation(s)
| | - Kassoum Kayentao
- Muso, Bamako, Mali, and San Francisco, California, USA
- Malaria Research & Training Center, University of Sciences Techniques and Technologies of Bamako, Mali
| | - Jenny X Liu
- University of California San Francisco, Department of Social and Behavioral Sciences, San Francisco, California, USA
| | - Scott Lee
- Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | - Samba Diarra
- Malaria Research & Training Center, University of Sciences Techniques and Technologies of Bamako, Mali
| | | | | | | | - Salif Samaké
- Malian Ministry of Health and Public Hygiene, Bamako, Mali
| | - Boureima Plea
- Malian Ministry of Health and Public Hygiene, Bamako, Mali
| | - Mama Coumaré
- Malian Ministry of Health and Public Hygiene, Bamako, Mali
| | - Ari D Johnson
- Muso, Bamako, Mali, and San Francisco, California, USA
- University of California San Francisco, ZSFG Division of Hospital Medicine, San Francisco, California, USA
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Macicame I, Magaço A, Cassocera M, Amado C, Feriano A, Chicumbe S, Jone J, Fernandes Q, Ngale K, Vignola E, De Schacht C, Roberton T. Intervention heroes of Mozambique from 1997 to 2015: estimates of maternal and child lives saved using the Lives Saved Tool. J Glob Health 2018. [PMID: 30574297 PMCID: PMC6300161 DOI: 10.7189/jogh.08.021202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background As one of several countries that pledged to achieve the Millennium
Development Goals (MDGs), Mozambique sought to reduce child, neonatal, and
maternal mortality by two thirds by 2015. This study examines the impact of
Mozambique’s efforts between 1997 and 2015, highlighting the increases
in intervention coverage that contributed to saving the most lives. Methods A retrospective analysis of available household survey data was conducted
using the Lives Saved Tool (LiST). Baseline mortality rates, cause-of-death
distributions, and coverage of child, neonatal, and maternal interventions
were entered as inputs. Changes in mortality rates, causes of death, and
additional lives saved were calculated as results. Due to limited coverage
data for the year 2015, we reported most results for the period 1997-2011.
For 2011-2015 we reported additional lives saved for a subset of
interventions. All analyses were performed at national and provincial
level. Results Our modelled estimates show that increases in intervention coverage from 1997
to 2011 saved an additional 422 282 child lives (0-59 months),
85 450 neonatal lives (0-1 month), and 6528 maternal lives beyond
those already being saved at baseline coverage levels in 1997. Malaria
remained the leading cause of child mortality from 1997 to 2011;
prematurity, asphyxia, and sepsis remained the leading causes of neonatal
mortality; and hemorrhage remained the leading cause of maternal
mortality. Interventions to reduce acute malnutrition and promote
artemisinin-based combination therapy (ACT) for malaria were responsible for
the largest number of additional child lives saved in the 1997-2011 period.
Increases in coverage of delivery management were responsible for most
additional newborn and maternal lives saved in both periods in
Mozambique. Conclusion Mozambique has made impressive gains in reducing child mortality since 1997.
Additional effort is needed to further reduce maternal and neonatal
mortality in all provinces. More lives can be saved by continuing to
increase coverage of existing health interventions and exploring new ways to
reach underserved populations.
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Affiliation(s)
- Ivalda Macicame
- Instituto Nacional de Saúde, Ministry of Health, Maputo, Mozambique
| | - Amílcar Magaço
- Instituto Nacional de Saúde, Ministry of Health, Maputo, Mozambique
| | - Marta Cassocera
- Instituto Nacional de Saúde, Ministry of Health, Maputo, Mozambique
| | - Celeste Amado
- Direcçăo Nacional de Saúde Pública, Ministry of Health, Maputo, Mozambique
| | - Américo Feriano
- Instituto Nacional de Saúde, Ministry of Health, Maputo, Mozambique
| | - Sérgio Chicumbe
- Instituto Nacional de Saúde, Ministry of Health, Maputo, Mozambique
| | - Jorge Jone
- Instituto Nacional de Saúde, Ministry of Health, Maputo, Mozambique
| | - Quinhas Fernandes
- Direcçăo Nacional de Saúde Pública, Ministry of Health, Maputo, Mozambique
| | - Kátia Ngale
- Johns Hopkins University - Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Emilia Vignola
- Johns Hopkins University - Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Timothy Roberton
- Johns Hopkins University - Bloomberg School of Public Health, Baltimore, Maryland, USA
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Amouzou A, Kanyuka M, Hazel E, Heidkamp R, Marsh A, Mleme T, Munthali S, Park L, Banda B, Moulton LH, Black RE, Hill K, Perin J, Victora CG, Bryce J. Independent Evaluation of the Integrated Community Case Management of Childhood Illness Strategy in Malawi Using a National Evaluation Platform Design. Am J Trop Med Hyg 2018; 94:1434-1435. [PMID: 27252480 PMCID: PMC4889770 DOI: 10.4269/ajtmh.16-0110b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
| | | | | | | | - Andrew Marsh
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. E-mails: , , and
| | - Tiope Mleme
- National Statistical Office, Zomba, Malawi. E-mail:
| | - Spy Munthali
- Chancellor College, University of Malawi, Zomba, Malawi. E-mail:
| | - Lois Park
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. E-mail:
| | | | | | | | | | - Jamie Perin
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. E-mails: , , , and
| | | | - Jennifer Bryce
- Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. E-mail:
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21
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Dalglish SL, Vogel JJ, Begkoyian G, Huicho L, Mason E, Root ED, Schellenberg J, Estifanos AS, Ved R, Wehrmeister FC, Labadie G, Victora CG. Future directions for reducing inequity and maximising impact of child health strategies. BMJ 2018; 362:k2684. [PMID: 30061111 PMCID: PMC6283368 DOI: 10.1136/bmj.k2684] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Sarah L Dalglish
- Department of Maternal, Newborn, Child, and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Joanna J Vogel
- Department of Maternal, Newborn, Child, and Adolescent Health, World Health Organization, Geneva, Switzerland
| | | | - Luis Huicho
- Centro de Investigación en Salud Materna e Infantil, Centro de Investigación para el Desarrollo Integral y Sostenible and School of Medicine, Universidad Peruana Cayetano Heredia Lima, Peru
| | | | - Elisabeth Dowling Root
- Department of Geography and Division of Epidemiology, Ohio State University, Columbus, Ohio, USA
| | - Joanna Schellenberg
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Abiy Seifu Estifanos
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Rajani Ved
- National Health Systems Resource Center, New Delhi, India
| | - Fernando C Wehrmeister
- International Center for Equity in Health, Postgraduate Program in Epidemiology, Universidade Federal de Pelotas, Pelotas, Brazil
| | - Guilhem Labadie
- Department of Maternal, Newborn, Child, and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Cesar G Victora
- International Center for Equity in Health, Postgraduate Program in Epidemiology, Universidade Federal de Pelotas, Pelotas, Brazil
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22
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Hardy V, Thompson M, Muula AS. Evaluating mobile solutions of integrated Community Case Management (iCCM): Making the final connection. Malawi Med J 2018; 29:332-334. [PMID: 29963291 PMCID: PMC6019543 DOI: 10.4314/mmj.v29i4.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Victoria Hardy
- Department of Family Medicine, University of Washington, Seattle, WA 98195-4696, USA
| | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, WA 98195-4696, USA
| | - Adamson S Muula
- Department of Public Health, School of Public Health and Family Medicine, College of Medicine, Malawi.,Africa Center of Excellence in Public Health and Herbal Medicine, University of Malawi, Blantyre, Malawi
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23
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Holeman I, Johnson A, Kayentao K, Keita Y, Odindo S, Whidden C. The Case for Community Health Innovation Networks. PROCEEDINGS OF THE 1ST ACM SIGCAS CONFERENCE ON COMPUTING AND SUSTAINABLE SOCIETIES 2018. [PMCID: PMC8020721 DOI: 10.1145/3209811.3212705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This commentary1 outlines the rationale for building community health innovation
networks in settings of poverty and high burdens of disease. These networks
integrate deep research expertise and sustained implementation infrastructure,
with the aim of streamlining the design, building and scale up of evidence-based
technical innovations for community health. Drawing on our experiences
establishing such networks in Mali and Kenya, we discuss the importance of: 1)
sustaining operational capacity to strengthen health systems; 2) being strategic
about how we embed design research within ongoing implementation efforts; and 3)
institutional partnerships that invest in infrastructure to support a series of
studies and innovation efforts over time. Without claiming to offer any
‘quick and easy’ solutions, we argue that this approach has real
potential to address the gap between research and practice in technical
innovation for global health and sustainable development.
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Affiliation(s)
| | - Ari Johnson
- University of California at San, Francisco and Muso, USA
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24
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Altaras R, Montague M, Graham K, Strachan CE, Senyonjo L, King R, Counihan H, Mubiru D, Källander K, Meek S, Tibenderana J. Integrated community case management in a peri-urban setting: a qualitative evaluation in Wakiso District, Uganda. BMC Health Serv Res 2017; 17:785. [PMID: 29183312 PMCID: PMC5706411 DOI: 10.1186/s12913-017-2723-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 11/10/2017] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Integrated community case management (iCCM) strategies aim to reach poor communities by providing timely access to treatment for malaria, pneumonia and diarrhoea for children under 5 years of age. Community health workers, known as Village Health Teams (VHTs) in Uganda, have been shown to be effective in hard-to-reach, underserved areas, but there is little evidence to support iCCM as an appropriate strategy in non-rural contexts. This study aimed to inform future iCCM implementation by exploring caregiver and VHT member perceptions of the value and effectiveness of iCCM in peri-urban settings in Uganda. METHODS A qualitative evaluation was conducted in seven villages in Wakiso district, a rapidly urbanising area in central Uganda. Villages were purposively selected, spanning a range of peri-urban settlements experiencing rapid population change. In each village, rapid appraisal activities were undertaken separately with purposively selected caregivers (n = 85) and all iCCM-trained VHT members (n = 14), providing platforms for group discussions. Fifteen key informant interviews were also conducted with community leaders and VHT members. Thematic analysis was based on the 'Health Access Livelihoods Framework'. RESULTS iCCM was perceived to facilitate timely treatment access and improve child health in peri-urban settings, often supplanting private clinics and traditional healers as first point of care. Relative to other health service providers, caregivers valued VHTs' free, proximal services, caring attitudes, perceived treatment quality, perceived competency and protocol use, and follow-up and referral services. VHT effectiveness was perceived to be restricted by inadequate diagnostics, limited newborn care, drug stockouts and VHT member absence - factors which drove utilisation of alternative providers. Low community engagement in VHT selection, lack of referral transport and poor availability of referral services also diminished perceived effectiveness. The iCCM strategy was widely perceived to result in economic savings and other livelihood benefits. CONCLUSIONS In peri-urban areas, iCCM was perceived as an effective, well-utilised strategy, reflecting both VHT attributes and gaps in existing health services. Depending on health system resources and organisation, iCCM may be a useful transitional service delivery approach. Implementation in peri-urban areas should consider tailored community engagement strategies, adapted selection criteria, and assessment of population density to ensure sufficient coverage.
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Affiliation(s)
- Robin Altaras
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
| | - Mark Montague
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
| | - Kirstie Graham
- Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2R 4LT, UK
| | - Clare E Strachan
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda.,London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT, UK
| | - Laura Senyonjo
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
| | - Rebecca King
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Helen Counihan
- Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2R 4LT, UK.
| | - Denis Mubiru
- Malaria Consortium Uganda, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
| | - Karin Källander
- Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2R 4LT, UK.,Karolinska Institutet, Tomtebodavägen 18A, 17177, Stockholm, Sweden
| | - Sylvia Meek
- Malaria Consortium, Development House, 56-64 Leonard Street, London, EC2R 4LT, UK
| | - James Tibenderana
- Malaria Consortium Africa, Plot 25 Upper Naguru East Road, P.O. Box 8045, Kampala, Uganda
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25
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Oliphant NP, Daniels K, Odendaal WA, Besada D, Manda S, Kinney M, White Johansson E, Lunze K, Johansen M, Doherty T. Integrated community case management of childhood illness in low- and middle-income countries. Hippokratia 2017. [DOI: 10.1002/14651858.cd012882] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Nicholas P Oliphant
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria; Program Division, LAC; Chemin de Blandonnet 8 Vernier Geneva Switzerland 1214
- University of the Western Cape; School of Public Health; Robert Sobukwe Road Cape Town South Africa 7535
| | - Karen Daniels
- South African Medical Research Council; Health Systems Research Unit; PO Box 19070 Cape Town South Africa 7505
- University of Cape Town; Health Policy and Systems Division, School of Public Health and Family Medicine; Observatory, Cape Town Western Cape South Africa 7925
| | - Willem A Odendaal
- South African Medical Research Council; Health Systems Research Unit; PO Box 19070 Cape Town South Africa 7505
| | - Donela Besada
- South African Medical Research Council; Health Systems Research Unit; PO Box 19070 Cape Town South Africa 7505
| | - Samuel Manda
- South African Medical Research Council; Biostatistics Unit; Pretoria South Africa
- School of Public Health, University of Witwatersrand; Division of Epidemiology and Biostatistics; Johannesburg South Africa
| | - Mary Kinney
- Save the Children; Global Health and Nutrition; Edgemead Western Cape South Africa 7441
| | - Emily White Johansson
- Uppsala Universitet; International Maternal and Child Health, Department of Womens and Childrens Health; SE-751 85 Sweden Uppsala
| | - Karsten Lunze
- Boston University, School of Medicine; Department of Medicine; Boston Massachusetts USA 02118
| | - Marit Johansen
- Norwegian Institute of Public Health; Department for Evidence Synthesis; Pilestredet Park 7 Oslo Norway N-0130
| | - Tanya Doherty
- University of the Western Cape; School of Public Health; Robert Sobukwe Road Cape Town South Africa 7535
- South African Medical Research Council; Health Systems Research Unit; PO Box 19070 Cape Town South Africa 7505
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26
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Ballard M, Montgomery P. Systematic review of interventions for improving the performance of community health workers in low-income and middle-income countries. BMJ Open 2017; 7:e014216. [PMID: 29074507 PMCID: PMC5665298 DOI: 10.1136/bmjopen-2016-014216] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To systematically review and critically appraise the evidence for the effects of interventions to improve the performance of community health workers (CHWs) for community-based primary healthcare in low- and middle-income countries. DESIGN Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. METHODS 19 electronic databases were searched with a highly sensitive prespecified strategy and the grey literature examined, completed July 2016. Randomised controlled trials evaluating interventions to improve CHW performance in low- and middle-income countries were included and appraised for risk of bias. Outcomes were biological and behavioural patient outcomes (primary), use of health services, quality of care provided by CHWs and CHW retention (secondary). RESULTS Two reviewers screened 8082 records; 14 evaluations were included. Due to heterogeneity and lack of clear outcome data, no meta-analysis was conducted. Results were presented in a narrative summary. The review found one study showing no effect on the biological outcomes of interest, though these moderate quality data may not be indicative of all biological outcomes. It also found moderate quality evidence of the efficacy of performance improvement interventions for (1) improving behavioural outcomes for patients, (2) improving use of services by increasing the absolute number of patients who access services and, perhaps, better identifying those who would benefit from such services and (3) improving CHW quality of care in terms of upstream measures like completion of prescribed activities and downstream measures like adherence to treatment protocols. Nearly half of studies were compound interventions, making it difficult to isolate the effects of individual performance improvement intervention components, though four specific strategies pertaining to recruitment, supervision, incentivisation and equipment were identified. CONCLUSIONS Variations in recruitment, supervision, incentivisation and equipment may improve CHW performance. Practitioners should, however, assess the relevance and feasibility of these strategies in their health setting prior to implementation. Component selection experiments on a greater range of interventions to improve performance ought to be conducted.
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Affiliation(s)
- Madeleine Ballard
- Centre for Evidence-Based Intervention, University of Oxford, Oxford, UK
| | - Paul Montgomery
- Department of Social Policy and Social Work, University of Birmingham, Birmingham, UK
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27
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Ratnayake R, Ratto J, Hardy C, Blanton C, Miller L, Choi M, Kpaleyea J, Momoh P, Barbera Y. The Effects of an Integrated Community Case Management Strategy on the Appropriate Treatment of Children and Child Mortality in Kono District, Sierra Leone: A Program Evaluation. Am J Trop Med Hyg 2017; 97:964-973. [PMID: 28722630 PMCID: PMC5590598 DOI: 10.4269/ajtmh.17-0040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/19/2017] [Indexed: 11/07/2022] Open
Abstract
Integrated community case management (iCCM) aims to reduce child mortality in areas with poor access to health care. iCCM was implemented in 2009 in Kono district, Sierra Leone, a postconflict area with high under-five mortality rates (U5MRs). We evaluated iCCM's impact and effects on child health using cluster surveys in 2010 (midterm) and 2013 (endline) to compare indicators on child mortality, coverage of appropriate treatment, timely access to care, quality of care, and recognition of community health workers (CHWs). The sample size was powered to detect a 28% decline in U5MR. Clusters were selected proportional to population size. All households were sampled to measure mortality and systematic random sampling was used to measure coverage in a subset of households. We used program data to evaluate utilization and access; 5,257 (2010) and 3,649 (2013) households were surveyed. U5MR did not change significantly (4.54 [95% confidence interval [CI]: 3.47-5.60] to 3.95 [95% CI: 3.06-4.83] deaths per 1,000 per month (P = 0.4)) though a relative change smaller than 28% could not be detected. CHWs were the first source of care for 52% (2010) and 50.9% (2013) of children. Coverage of appropriate treatment of fever by CHWs or peripheral health units increased from 45.5% [95% CI: 39.2-52.0] to 58.2% [95% CI: 50.5-65.5] (P = 0.01); changes for diarrhea and pneumonia were not significant. The continued reliance on the CHW as the first source of care and improved coverage for the appropriate treatment of fever support iCCM's role in Kono district.
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Affiliation(s)
- Ruwan Ratnayake
- Health Unit, International Rescue Committee, New York, New York
| | - Jeffrey Ratto
- Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Colleen Hardy
- Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Curtis Blanton
- Emergency Response and Recovery Branch, Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Laura Miller
- International Rescue Committee, Freetown, Sierra Leone
| | - Mary Choi
- Health Unit, International Rescue Committee, New York, New York
| | - John Kpaleyea
- International Rescue Committee, Freetown, Sierra Leone
| | | | - Yolanda Barbera
- Health Unit, International Rescue Committee, New York, New York
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28
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Perin J, Kim JS, Hazel E, Park L, Heidkamp R, Zeger S. Hierarchical Statistical Models to Represent and Visualize Survey Evidence for Program Evaluation: iCCM in Malawi. PLoS One 2016; 11:e0168778. [PMID: 28036399 PMCID: PMC5201252 DOI: 10.1371/journal.pone.0168778] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 12/06/2016] [Indexed: 11/28/2022] Open
Abstract
Policy and Program evaluation for maternal, newborn and child health is becoming increasingly complex due to changing contexts. Monitoring and evaluation efforts in this area can take advantage of large nationally representative household surveys such as DHS or MICS that are increasing in size and frequency, however, this analysis presents challenges on several fronts. We propose an approach with hierarchical models for cross-sectional survey data to describe evidence relating to program evaluation, and apply this approach to the recent scale up of iCCM in Malawi. We describe careseeking for children sick with diarrhea, pneumonia, or malaria with empirical Bayes estimates for each district of Malawi at two time points, both for careseeking from any source, and for careseeking only from health surveillance assistants (HSA). We do not find evidence that children in areas with more HSA trained in iCCM are more likely to seek care for pneumonia, diarrhea, or malaria, despite evidence that many indeed are seeking care from HSA. Children in areas with more HSA trained in iCCM are more likely to seek care from a HSA, with 100 additional trained health workers in a district corresponding to a 2% average increase in careseeking from HSA. The hierarchical models presented here provide a flexible set of methods that describe the primary evidence for evaluating iCCM in Malawi and which could be extended to formal causal analyses, and to analysis for other similar evaluations with national survey data.
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Affiliation(s)
- Jamie Perin
- Department of International Health, Johns Hopkins University, Baltimore, MD, United States of America
- * E-mail:
| | - Ji Soo Kim
- Department of Biostatistics, Johns Hopkins University, Baltimore, MD, United States of America
| | - Elizabeth Hazel
- Department of International Health, Johns Hopkins University, Baltimore, MD, United States of America
| | - Lois Park
- Department of International Health, Johns Hopkins University, Baltimore, MD, United States of America
| | - Rebecca Heidkamp
- Department of International Health, Johns Hopkins University, Baltimore, MD, United States of America
| | - Scott Zeger
- Department of International Health, Johns Hopkins University, Baltimore, MD, United States of America
- Department of Biostatistics, Johns Hopkins University, Baltimore, MD, United States of America
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29
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Hazel E, Bryce J. On Bathwater, Babies, and Designing Programs for Impact: Evaluations of the Integrated Community Case Management Strategy in Burkina Faso, Ethiopia, and Malawi. Am J Trop Med Hyg 2016; 94:568-570. [PMID: 26936991 PMCID: PMC4775892 DOI: 10.4269/ajtmh.94-3intro1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Elizabeth Hazel
- *Address correspondence to Elizabeth Hazel, Institute for International Programs, Johns Hopkins University (IIP-JHU), 615 North Wolfe Street, Baltimore, MD 21205. E-mail:
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30
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Doherty T, Kerber K, Kinney M, Mason J. Approaches to Evaluate the Impact of Community-Based Delivery Strategies. Am J Trop Med Hyg 2016; 94:1433. [PMID: 27252479 PMCID: PMC4889769 DOI: 10.4269/ajtmh.16-0110a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, School of Public Health, University of the Western Cape, Cape Town, South Africa. E-mail:
| | | | - Mary Kinney
- Save the Children, Washington, DC. E-mails: and
| | - John Mason
- Department of Global Community Health and Behavioral Sciences, Tulane School of Public Health and Tropical Medicine, New Orleans, LA. E-mail:
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