iCCM Policy Analysis Webinar

Presentation and discussion of findings from Mozambique and Malawi

January 21, 2016

Policy Analysis of Integrated Community Case Management of Childhood Illnesses: Introduction to a Six-Country Case Study

Sara C. BennettJohns Hopkins University Bloomberg School of

Public Health, on behalf of the iCCM Policy Study Team

TRAction iCCM Webinar, 21st January 2016

Coverage of essential child health services in Sub-Saharan Africa

• 31% of children with diarrhea receive ORS• 37% of children with fever receive any anti-

malarial• 39% of children with symptoms of pneumonia

receive antibiotics (Unicef 2014)

• Large gap in coverage of essential services• Many children dying at home without reaching a health facility

• Between 2004 and 2012 WHO and UNICEF produced a series of joint statements on iCCM

Joint statements on integrated Community Case Management

Defining iCCM

The integrated delivery for children under 5 of: – Treatment for childhood pneumonia with antibiotics,– Treatment for diarrhea with zinc and low osmolarity ORS, – Treatment for malaria with artemisinin combination

therapy (ACTs), and – Home visits of newborns with treatment of neonatal

sepsis with antibiotics

…by community or lay health workers at household and/or community levels.

Progress in adopting & implementing iCCM

• By 2013 out of 44 Sub-Saharan African countries:-– 36 had written policies or plans for CCM of

diarrhea– 35 for malaria– 31 for pneumonia (Rasanathan 2014)

• Implementation somewhat uneven – fast progress in some countries, much slower in others

THE ICCM POLICY ANALYSIS STUDY

Policy Analysis of iCCM

• How do we explain the uneven progress in adopting and implementing iCCM?

• What are the barriers and facilitators to policy adoption and implementation? For example:-– Is there active resistance from specific stakeholders

such as clinicians?– Are there objectives to the content of the proposed

policy?– Do policy-makers feel that they have sufficient evidence

to proceed?

Study Objective• In-depth analysis of national policy change for iCCM in

six sub-Saharan African countries to understand whether, how and why iCCM policies were developed, including barriers and facilitators to policy change.

• Aims:– Document and analyze the specific expressions of policy – Identify facilitators or barriers to policy and program change – Assess the role of ideas and evidence in policy and program

development– Identify policy elements that enable the eventual

implementation

Policy Analysis Triangle

Actors- Individuals- Groups

- Organizations

Context

ProcessContent

Source: Walt & Gilson 1994

MaliBurkina FasoNiger

KenyaMalawiMozambique

Qualitative Retrospective Country Case Studies varying by -policy status-nature of CHW cadre-sub-regions

*iCCM Policy Study TeamTeam Institutional Partner Core team members

Burkina Faso Jessica Shearer (McMaster University)

Kenya Great Lakes University-Kisumu Pamela A. Juma

Malawi REACH Trust Ireen Namakhoma, Hastings Banda

Mali MARIKANI Brahima Diallo, Mamadou Konate

Mozambique Universidade Eduardo Mondlane

Baltazar Chilundo, Alda Mariano, Julie Cliff

Niger LASDEL Sarah Dalgish (JHSPH) and Aissa Diarra (LASDEL)

JHSPH Core Team

Sara Bennett, Asha George, Daniela Rodriguez, Jessica Shearer

Study Methods

• Document review• Semi-structured interviews:

– Stakeholders in iCCM policy: Government officials, development partners and multilateral organizations, bilateral donors, civil society organizations, research institutions, etc.

– Start with respondents identified in document review, and snowball until saturation

• Fieldwork undertaken April – September 2012• Thematic analysis using NVivo software by country

and JHSPH researchers

Data Collection

Country Number approached

Number interviewed

Number documents reviewed

Burkina Faso 30 25 80+

Mali 35 33 33

Niger 37 32 113

Kenya 31 19 41

Malawi 30 20 29

Mozambique 40 21 50

Acknowledgements

Funding from

• Sincere appreciation to study participants for sharing their time with us.

iCCM Policy Development in

MalawiTRAction Project Webinar

21 January 2016

Ireen Namakhoma, REACH TrustDaniela C. Rodriguez, Johns Hopkins School of Public Health

iCCM policy in Malawi• iCCM was developed in 2007 (part of larger child survival policy)

started implementation in 2009 via a cadre of paid community health workers known as HSAs (Health Surveillance Assistants)

• iCCM covers malaria, pneumonia, diarrhea, neonatal sepsis (limited) as well as conjunctivitis

• iCCM is targeted at hard-to-reach areas (e.g. beyond 8km radius from health facility)

Serious questions about implementation of iCCM were raised during policy development, how were they addressed?

Main findings

Contributing factors to iCCM policy development

Innovation characteristics• Perceived need for innovation:

• Child survival was a persistent problem, as highlighted by various sources of evidence

• Facility IMCI was not reaching children in communities• Lancet series on child survival offered plausible

interventions

• Innovation and system compatibility• The health worker shortage had led to the expansion of

the HSA cadre so HSAs seen as viable delivery mechanism for iCCM system readiness

• Earlier experiences with IMCI and other health improvement programs aimed at community level (e.g. DRF, BMHI) system antecedents

Institution characteristics• Leadership:

• Process led by MOH through consultative process that engaged Child Health TWG

• Engaged development partners to address key implementation questions

• Coordination among partners:• Despite the MOH’s leadership in policy development,

getting internal agreement within MOH was challenging• MOH coordinated across stakeholders, incl. other

Ministries, and presented plans to districts• Development partners, esp. UNICEF and WHO, played a

supportive role to policy development and acted as knowledge brokers

Institution characteristics, cont.• Organizational capacity:

• Professional organizations raised concerns about training and regulation of HSAs, but were overcome

• HSA supervision and overburdening were challenges raised during policy development***

• Planned funding was felt to be inadequate for long-term implementation of iCCM***

• Funds for iCCM are channeled through the SWAp, but with substantial external support from donors***

***Still unresolved after 3 years of implementation

Implications of findings

Implications of the findings for local country context

• Need for improved coordination of partners in iCCM implementation especially at district and sub district level

• Government should commit to funding iCCM activities e.g through raising budget allocation to health (to meet 15% Abuja declaration)

• Need for strengthened HSA supervision, monitoring and motivation.

Post-study developments

Developments contributing towards improving iCCM

• The findings contributed to development of the new Malawi Child Health Strategy 2014-2020

• Has particular section tackling strategies for strengthening iCCM

• Strategy recognizes need for sustainable funding• New supervision guideline manual developed

• REACH Trust under REACHOUT consortium with support from EU has been piloting peer and group HSA supervision approaches

• Introduction of amoxyllin- dispersible tablets for pneumonia for HSAs

THANK YOU

Re-launch of the official Community Health Worker Program in Mozambique:

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Is there a sustainable basis for iCCM policy?

Baltazar Chilundo (MD, PhD), Julie Cliff (FRCP, MScCHDC), Alda Mariano (MD, MSc), Daniela Rodriguez (DrPH), Asha George (DrPH)

Analysis of sustainability of the official CHW program and of iCCM

policy

Context

Research question

Methods

Results

Concluding remarks and implications

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Context

32

Remarkable progress of reduction of child mortality

Government and partners recognize that more gains are possible if there is more emphasis on effective interventions at the community level

DHS 1997 DHS 2003 MICS 2008 DHS 20110

50

100

150

200

250

300

57 48 4230

143.7

101 93

64

245.3

154138

97

Trends of Mozambican child mortality 1997 to 2011

Under 1 month Under 12 monthUnder 5 years

Context

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Malaria 42%

AIDS13%

Pnuemonia6%

Diarrhea6%

Undernu-trition

2%

Measles1%

Other29%

% distribution of U5 causes of mortality in Mozambique (INE,

2007)

The official CHW government Program known as Elementary Polyvalent Agents “Agentes Polivalentes Elementares” was established in 1978 and it functioned with innumerous operational challenges, being suspended in 1989, but it was relaunched in 2010 thanks to its potential impact: Majority of causes of mortality

among children are of “ easy solution” with emphasis on iCCM by CHW

Context and Research question

CHWs trained for four months to carry out promoting / preventive (80%), first aid, activities treatment of common diseases especially in children such as Malaria, Pneumonia, Diarrhea and referral of more serious cases = iCCM

Given the past history of decline, a key issue is whether the current revitalization of the CHW program allows for a more sustainable basis.

Does the current revitalization of the CHW program, which

encapsulates iCCM, exhibit characteristics that facilitate or

impede its sustainability?

Methods

Study design Qualitative: retrospective case study (Yin, 2009)

done simultaneously across 6 SSA countries (+ Burkina Faso, Kenya, Mali, Malawi, Niger)

Data collection Performed in Maputo city, in 2012 Literature review (n = 54) Key informant interviews (n=21)

Analysis Thematic analysis using an Nvivo codebook

Thematic analysis using a sustainability framework (Schell et al. 2013)

Facilitators of and barriers to CHW sustainability for the domains: Strategic Planning Organizational capacity Program adaptation M&E Communication Funding stability Political support Partnership Public Health impact

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Findings: Strategic Planning

Facilitators• CHW program developed in a consultative manner across MOH

departments and with partners• National policies and guidelines reviewed to avoid mistakes made in

the past, e.g. APE non-payment.• After consultative process with drug regulatory agencies, MOH

exercised fiat regarding drug regulations allowing APEs to prescribe certain medicines and mainstreaming medicines into the NHS and CHW kit

Barriers• Poor coordination with MOH departments• Ministry of Finance not included in consultations• APEs have short-term contracts, low pay ( not full-time salary), and no

career path, causing potential retention problems• CHWs not integrated into the civil service, due to their educational

level, despite precedence from other Ministries on how to incorporate community level agents into government structures

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Findings: Organizational Capacity

Facilitators• Operational guidelines and tools developed• APEs trained in standardized manner • APEs equipped with necessary equipment and supplies to carry

out their tasks • NGOs with programme experience willing to support

supervision and logistics

Barriers• Weak supply chain, with frequent medicine stock-outs may

demotivate APEs and the community• Weak supportive supervision systems • Dependence on NGOs/ partners and difficulties with

harmonization may weaken government health systems and oversight

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Figure 1. Heterogeneity and multiplicity of funding sources to the APE programme in Mozambique by districts, 2012

FUNDING SOURCE BY DISTRICT, 2012 Adapted from UNICEF (2013). Data from MISAU – APE Programme

UNICEF/CIDA

SAVE THE CHILDREN/UNICEF/CIDA

SAVE THE CHILDREN

MALARIA CONSORTIUM

PNG/UNICEF/USAID

UNICEF/USAID

HELP AGE

WORLD VISION

WORLD BANK

UNICEF/CIDA/WORLD BANK

WITHOUT APEs

Findings: Funding stability Barriers only

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Program is entirely dependent on external donors for salaries, drugs, supplies, supervision, etc.

Scale up is slow (36% = 2.270/6.343 APE) as government requires partners to pay for APEs comprehensively and not just for training

Funding partners targeting specific provinces and districts, leaving others without support, leading to geo-discrepancy in service delivery and unequal distribution of APEs

Weak and decreasing contribution of the state budget to the health sector

Decrease of external support to the health sector, pending response from Global Fund audit recommendations

Concluding remarks and implications

Without careful attention to finance, human resources, supply chain management, and quality assurance, the CHW program including iCCM may yield disappointing results.

To ensure sustainability, the government should commit itself to fund the program from the state budget

This study was presented to the health authorities and partners in National Health Congress in September 2015 and within the TWG of public health directorate at the MOH

Partially thanks to this study MOH/Unicef are commissioning development of the 1st strategic plan for the official CHW 2016 – 2020 which includes the need to define funding strategies taking into account a scenario of sustainability 40

Muito obrigado!Thanks

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Reactions from our discussantsRory Nefdt

Dyness Kasungami

iCCM Policy Analysis Findings from Mozambique and Malawi

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iCCM Policy Analysis Findings from Mozambique and Malawi

Thank you!

You can access the recording of this webinar and the link to the HPP

supplement at www.tractionproject.org

iCCM Policy Analysis Findings from Mozambique and Malawi