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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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Olaniran A, Briggs J, Pradhan A, Bogue E, Schreiber B, Dini HS, Hurkchand H, Ballard M. Stock-outs of essential medicines among community health workers (CHWs) in low- and middle-income countries (LMICs): a systematic literature review of the extent, reasons, and consequences. HUMAN RESOURCES FOR HEALTH 2022; 20:58. [PMID: 35840965 PMCID: PMC9287964 DOI: 10.1186/s12960-022-00755-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 06/25/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND This paper explores the extent of community-level stock-out of essential medicines among community health workers (CHWs) in low- and middle-income countries (LMICs) and identifies the reasons for and consequences of essential medicine stock-outs. METHODS A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five electronic databases were searched with a prespecified strategy and the grey literature examined, January 2006-March 2021. Papers containing information on (1) the percentage of CHWs stocked out or (2) reasons for stock-outs along the supply chain and consequences of stock-out were included and appraised for risk of bias. Outcomes were quantitative data on the extent of stock-out, summarized using descriptive statistics, and qualitative data regarding reasons for and consequences of stock-outs, analyzed using thematic content analysis and narrative synthesis. RESULTS Two reviewers screened 1083 records; 78 evaluations were included. Over the last 15 years, CHWs experienced stock-outs of essential medicines nearly one third of the time and at a significantly (p < 0.01) higher rate than the health centers to which they are affiliated (28.93% [CI 95%: 28.79-29.07] vs 9.17% [CI 95%: 8.64-9.70], respectively). A comparison of the period 2006-2015 and 2016-2021 showed a significant (p < 0.01) increase in CHW stock-out level from 26.36% [CI 95%: 26.22-26.50] to 48.65% [CI 95%: 48.02-49.28] while that of health centers increased from 7.79% [95% CI 7.16-8.42] to 14.28% [95% CI 11.22-17.34]. Distribution barriers were the most cited reasons for stock-outs. Ultimately, patients were the most affected: stock-outs resulted in out-of-pocket expenses to buy unavailable medicines, poor adherence to medicine regimes, dissatisfaction, and low service utilization. CONCLUSIONS Community-level stock-out of essential medicines constitutes a serious threat to achieving universal health coverage and equitable improvement of health outcomes. This paper suggests stock-outs are getting worse, and that there are particular barriers at the last mile. There is an urgent need to address the health and non-health system constraints that prevent the essential medicines procured for LMICs by international and national stakeholders from reaching the people who need them the most.
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Affiliation(s)
| | - Jane Briggs
- Management Sciences for Health, Washington, DC, United States of America
| | - Ami Pradhan
- New York University, New York, NY, United States of America
| | - Erin Bogue
- UNICEF, New York, NY, United States of America
| | | | | | | | - Madeleine Ballard
- Department of Global Health and Health System Design, Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, 1216 5th Ave, New York, NY, 10029, United States of America.
- Community Health Impact Coalition, London, UK.
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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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4
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Miller JS, Mulogo EM, Wesuta AC, Mumbere N, Mbaju J, Matte M, Ntaro M, Guiles DA, Patel PR, Bwambale S, Kenney J, Reyes R, Stone GS. Long-term quality of integrated community case management care for children in Bugoye Subcounty, Uganda: a retrospective observational study. BMJ Open 2022; 12:e051015. [PMID: 35459661 PMCID: PMC9036460 DOI: 10.1136/bmjopen-2021-051015] [Citation(s) in RCA: 5] [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: 11/25/2022] Open
Abstract
OBJECTIVE Integrated community case management (iCCM) of childhood illness in Uganda involves protocol-based care of malaria, pneumonia and diarrhoea for children under 5 years old. This study assessed volunteer village health workers' (VHW) ability to provide correct iCCM care according to the national protocol and change in their performance over time since initial training. SETTING VHWs affiliated with the Ugandan national programme provide community-based care in eight villages in Bugoye Subcounty, a rural area in Kasese District. The first cohort of VHWs began providing iCCM care in March 2013, the second cohort in July 2016. PARTICIPANTS All children receiving iCCM care in 18 430 clinical encounters occurring between April 2014 and December 2018. PRIMARY AND SECONDARY OUTCOME MEASURES The descriptive primary outcome measure was the proportion of patients receiving overall correct care, defined as adherence to the iCCM protocol for the presenting condition (hereafter quality of care). The analytic primary outcome was change in the odds of receiving correct care over time, assessed using logistic regression models with generalised estimating equations. Secondary outcome measures included a set of binary measures of adherence to specific elements of the iCCM protocol. Preplanned and final measures were the same. RESULTS Overall, VHWs provided correct care in 74% of clinical encounters. For the first cohort of VHWs, regression modelling demonstrated a modest increase in quality of care until approximately 3 years after their initial iCCM training (OR 1.022 per month elapsed, 95% CI 1.005 to 1.038), followed by a modest decrease thereafter (OR 0.978 per month, 95% CI 0.970 to 0.986). For the second cohort, quality of care was essentially constant over time (OR 1.007 per month, 95% CI 0.989 to 1.025). CONCLUSION Quality of care was relatively constant over time, though the trend towards decreasing quality of care after 3 years of providing iCCM care requires further monitoring.
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Affiliation(s)
- James S Miller
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Edgar Mugema Mulogo
- Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
- Bugoye Community Health Collaboration, Bugoye, Uganda
| | - Andrew Christopher Wesuta
- Bugoye Community Health Collaboration, Bugoye, Uganda
- Global Health Collaborative-MUST Uganda, Mbarara, Uganda
| | - Nobert Mumbere
- Bugoye Community Health Collaboration, Bugoye, Uganda
- Global Health Collaborative-MUST Uganda, Mbarara, Uganda
| | - Jackson Mbaju
- Bugoye Community Health Collaboration, Bugoye, Uganda
- Global Health Collaborative-MUST Uganda, Mbarara, Uganda
| | - Michael Matte
- Bugoye Community Health Collaboration, Bugoye, Uganda
- Global Health Collaborative-MUST Uganda, Mbarara, Uganda
| | - Moses Ntaro
- Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
- Bugoye Community Health Collaboration, Bugoye, Uganda
| | - Daniel A Guiles
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Palka R Patel
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Shem Bwambale
- Bugoye Community Health Collaboration, Bugoye, Uganda
- Bugoye Health Center, Bugoye, Uganda
| | - Jessica Kenney
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Bugoye Community Health Collaboration, Bugoye, Uganda
| | - Raquel Reyes
- Division of General Medicine and Clinical Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Geren S Stone
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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5
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Kannan A, Tsoi D, Xie Y, Horst C, Collins J, Flaxman A. Cost-effectiveness of Vitamin A supplementation among children in three sub-Saharan African countries: An individual-based simulation model using estimates from Global Burden of Disease 2019. PLoS One 2022; 17:e0266495. [PMID: 35390077 PMCID: PMC8989187 DOI: 10.1371/journal.pone.0266495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 03/21/2022] [Indexed: 11/19/2022] Open
Abstract
Background Vitamin A Supplementation (VAS) is a cost-effective intervention to decrease mortality associated with measles and diarrheal diseases among children aged 6–59 months in low-income countries. Recently, experts have suggested that other interventions like large-scale food fortification and increasing the coverage of measles vaccination might provide greater impact than VAS. In this study, we conducted a cost-effectiveness analysis of a VAS scale-up in three sub-Saharan African countries. Methods We developed an individual-based microsimulation using the Vivarium simulation framework to estimate the cost and effect of scaling up VAS from 2019 to 2023 in Nigeria, Kenya, and Burkina Faso, three countries with different levels of baseline coverage. We calibrated the model with disease and risk factor estimates from the Global Burden of Disease 2019 (GBD 2019). We obtained baseline coverage, intervention effects, and costs from a systematic review. After the model was validated against GBD inputs, we modeled an alternative scenario where we scaled-up VAS coverage from 2019 to a level that halved the exposure to lack of VAS in 2023. Based on the simulation outputs for DALYs averted and intervention cost, we determined estimates for the incremental cost-effectiveness ratio (ICER) in USD/DALY. Findings Our estimates for ICER are as follows: $860/DALY [95% UI; 320, 3530] in Nigeria, $550/DALY [240, 2230] in Kenya, and $220/DALY [80, 2470] in Burkina Faso. Examining the data for DALYs averted for the three countries over the time span, we found that the scale-up led to 21 [5, 56] DALYs averted per 100,000 person-years in Nigeria, 21 [5, 47] DALYs averted per 100,000 person-years in Kenya, and 14 [0, 37] DALYs averted per 100,000 person-years in Burkina Faso. Conclusions VAS may no longer be as cost-effective in low-income regions as it has been previously. Updated estimates in GBD 2019 for the effect of Vitamin A Deficiency on causes of death are an additional driver of this lower estimate of cost-effectiveness.
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Affiliation(s)
- Aditya Kannan
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - Derrick Tsoi
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | - Yongquan Xie
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | - Cody Horst
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | - James Collins
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
| | - Abraham Flaxman
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America
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6
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Yang JE, Lassala D, Liu JX, Whidden C, Holeman I, Keita Y, Djiguiba Y, N'Diaye SI, Fall F, Kayentao K, Johnson AD. Effect of mobile application user interface improvements on minimum expected home visit coverage by community health workers in Mali: a randomised controlled trial. BMJ Glob Health 2021; 6:bmjgh-2021-007205. [PMID: 34815242 PMCID: PMC8609935 DOI: 10.1136/bmjgh-2021-007205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/18/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Proactive community case management (ProCCM) has shown promise to advance goals of universal health coverage (UHC). ProCCM community health workers (CHWs) face operational challenges when pursuing their goal of visiting every household in their service area at least twice monthly to proactively find sick patients. We developed a software extension (UHC Mode) to an existing CHW mobile application featuring user interface design improvements to support CHWs in planning daily home visits. We evaluated the effect of UHC Mode on minimum expected home visit coverage. METHODS We conducted a parallel-group, two-arm randomised controlled trial of ProCCM CHWs in two separate regions in Mali. CHWs were randomly assigned to UHC Mode or the standard mobile application (control) with a 1:1 allocation. Randomisation was stratified by health catchment area. CHWs and other programme personnel were not masked to arm allocation. CHWs used their assigned intervention for 4 months. Using a difference-in-differences analysis, we estimated the mean change in minimum expected home visit coverage from preintervention to postintervention between arms. RESULTS Enrolment occurred in January 2019. Of 199 eligible CHWs randomised to the intervention or control arm, 196 were enrolled and 195 were included in the analysis. Households whose CHW used UHC Mode had 2.41 times higher odds of minimum expected home visit coverage compared with households whose CHW used the control (95% CI 1.68 to 3.47; p<0.0005). Minimum expected home visit coverage in the UHC Mode arm increased 13.6 percentage points (95% CI 8.1 to 19.0) compared with the control arm. CONCLUSION Our findings suggest UHC Mode is an effective tool that can improve home visit coverage and promote progress towards UHC when implemented in the ProCCM context. User interface design of health information systems that supports health workers' daily practices and meets their requirements can have a positive impact on health worker performance and home visit coverage. TRIAL REGISTRATION NUMBER NCT04106921.
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Affiliation(s)
| | | | - Jenny X Liu
- Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, California, USA
| | | | - Isaac Holeman
- Medic, San Francisco, California, USA.,Department of Human Centered Design & Engineering, University of Washington, Seattle, Washington, USA.,Department of Global Health, University of Washington, Seattle, Washington, USA
| | | | | | | | | | - Kassoum Kayentao
- Muso, Bamako, Mali.,Malaria Research & Training Centre, University of Sciences Techniques and Technologies, Bamako, Mali
| | - Ari D Johnson
- Muso, San Francisco, California, USA.,Department of Medicine, Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
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7
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Story WT, Pritchard S, Hejna E, Olivas E, Sarriot E. The role of integrated community case management projects in strengthening health systems: case study analysis in Ethiopia, Malawi and Mozambique. Health Policy Plan 2021; 36:900-912. [PMID: 33930137 DOI: 10.1093/heapol/czaa177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 11/14/2022] Open
Abstract
Integrated community case management (iCCM) has now been implemented at scale globally. Literature to-date has focused primarily on the effectiveness of iCCM and the systems conditions required to sustain iCCM. In this study, we sought to explore opportunities taken and lost for strengthening health systems through successive iCCM programmes. We employed a systematic, embedded, multiple case study design for three countries-Ethiopia, Malawi and Mozambique-where Save the Children implemented iCCM programmes between 2009 and 2017. We used textual analysis to code 62 project documents on nine categories of functions of health systems using NVivo 11.0. The document review was supplemented by four key informant interviews. This study makes important contributions to the theoretical understanding of the role of projects in health systems strengthening by not only documenting evidence of systems strengthening in multi-year iCCM projects, but also emphasizing important deficiencies in systems strengthening efforts. Projects operated on a spectrum, ranging from gap-filling interventions, to support, to actual strengthening. While there were natural limits to the influence of a project on the health system, all successive projects found constructive opportunities to try to strengthen systems. Alignment with the Ministry of Health was not always static and simple, and ministries themselves have shown pluralism in their perspectives and orientations. We conclude that systems strengthening remains 'everybody's business' and places demands for realism and transparency on government and the development architecture. While mid-size projects have limited decision space, there is value in better defining where systems strengthening contributions can actually be made. Furthermore, systems strengthening is not solely about macro-level changes, as operational and efficiency gains at meso and micro levels can have value to the system. Claims of 'systems strengthening' are, however, bounded within the quality of evaluation and learning investments.
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Affiliation(s)
- William T Story
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Susannah Pritchard
- Formerly Save the Children, Health Department, 1 St. John's Lane, London EC1M 4AR, UK
| | - Emily Hejna
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Elijah Olivas
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Eric Sarriot
- Formerly Save the Children, Department of Global Health, 899 North Capitol St NE #900, Washington, DC 20002, USA
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8
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Kuunibe N, Lohmann J, Hillebrecht M, Nguyen HT, Tougri G, De Allegri M. What happens when performance-based financing meets free healthcare? Evidence from an interrupted time-series analysis. Health Policy Plan 2021; 35:906-917. [PMID: 32601671 DOI: 10.1093/heapol/czaa062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2020] [Indexed: 11/12/2022] Open
Abstract
In spite of the wide attention performance-based financing (PBF) has received over the past decade, no evidence is available on its impacts on quantity and mix of service provision nor on its interaction with parallel health financing interventions. Our study aimed to examine the PBF impact on quantity and mix of service provision in Burkina Faso, while accounting for the parallel introduction of a free healthcare policy. We used Health Management Information System data from 838 primary-level health facilities across 24 districts and relied on an interrupted time-series analysis with independent controls. We placed two interruptions, one to account for PBF and one to account for the free healthcare policy. In the period before the free healthcare policy, PBF produced significant but modest increases across a wide range of maternal and child services, but a significant decrease in child immunization coverage. In the period after the introduction of the free healthcare policy, PBF did not affect service provision in intervention compared with control facilities, possibly indicating a saturation effect. Our findings indicate that PBF can produce modest increases in service provision, without altering the overall service mix. Our findings, however, also indicate that the introduction of other health financing reforms can quickly crowd out the effects produced by PBF. Further qualitative research is required to understand what factors allow healthcare providers to increase the provision of some, but not all services and how they react to the joint implementation of PBF and free health care.
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Affiliation(s)
- Naasegnibe Kuunibe
- IHeidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany.,Department of Economics and Entrepreneurship Development, Faculty of Integrated development Studies, University for Development Studies, Wa Campus, Box 520, Wa, Upper West Region, Ghana
| | - Julia Lohmann
- IHeidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany.,Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Michael Hillebrecht
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Sectoral Department, Dag-Hammarskjöld-Weg 1-5, 65760 Eschborn, Germany
| | - Hoa Thi Nguyen
- IHeidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany
| | | | - Manuela De Allegri
- IHeidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Im Neuenheimer Feld 365, 69120 Heidelberg, Germany
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9
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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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10
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Miller JS, Mbusa RK, Baguma S, Patel P, Matte M, Ntaro M, Wesuta AC, Mumbere N, Bwambale S, Mian-McCarthy S, Kenney J, Guiles D, Mulogo EM, Stone GS. A cross-sectional study comparing case scenarios and record review to measure quality of Integrated Community Case Management care in western Uganda. Trans R Soc Trop Med Hyg 2021; 115:627-633. [PMID: 33002128 DOI: 10.1093/trstmh/traa097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/28/2020] [Accepted: 09/12/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In Integrated Community Case Management (iCCM), village health workers (VHW) assess and treat malaria, pneumonia and diarrhea using a clinical algorithm. Study objectives included: 1) Compare VHWs' performance on case scenario exercises to record review data; 2) assess impact of formal education on performance in the case scenario exercises. METHODS 36 VHWs in Bugoye Subcounty, Uganda completed the case scenarios exercise, which included video case scenarios and brief oral case vignettes, between July 2017 and February 2018. We obtained clinical records for all iCCM encounters in the same time period. RESULTS In the video case scenarios, 45% of mock patients received all correct management steps (including all recommended education), while 94% received all critical management steps. Based on the level of data available from record review, 74% of patients in the record review dataset received overall correct management compared to 94% in the video case scenarios. In the case scenarios, VHWs with primary school education performed similarly to those with some or all secondary school education. CONCLUSIONS The case scenarios produced higher estimates of quality of care than record review. VHWs often omitted recommended health education topics in the case scenarios. Level of formal education did not appear to influence performance in the case scenarios.
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Affiliation(s)
- James S Miller
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Global Health Collaborative, Mbarara, Uganda
| | | | | | - Palka Patel
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Global Health Collaborative, Mbarara, Uganda
| | | | - Moses Ntaro
- Global Health Collaborative, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | | | - Sara Mian-McCarthy
- Massachusetts General Hospital, Boston, MA, USA.,Global Health Collaborative, Mbarara, Uganda
| | - Jessica Kenney
- Massachusetts General Hospital, Boston, MA, USA.,Global Health Collaborative, Mbarara, Uganda
| | - Daniel Guiles
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Global Health Collaborative, Mbarara, Uganda
| | - Edgar Mugema Mulogo
- Global Health Collaborative, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Geren S Stone
- Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Global Health Collaborative, Mbarara, Uganda
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11
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Burke D, Tiendrebeogo J, Emerson C, Youll S, Gutman J, Badolo O, Savadogo Y, Vibbert K, Wolf K, Brieger W. Community-based delivery of intermittent preventive treatment of malaria in pregnancy in Burkina Faso: a qualitative study. Malar J 2021; 20:277. [PMID: 34162384 PMCID: PMC8220751 DOI: 10.1186/s12936-021-03814-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/12/2021] [Indexed: 11/12/2022] Open
Abstract
Background Burkina Faso is among ten countries with the highest rates of malaria cases and deaths in the world. Delivery and coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) is insufficient in Burkina Faso; In a 2016 survey, only 22% of eligible women had received their third dose of IPTp. It is also an extremely rural country and one with an established cadre of community healthcare workers (CHWs). To better meet the needs of pregnant women, an enhanced programme was established to facilitate distribution of IPTp at the community level by CHWs. Methods In order to assess the perceptions of CHWs and facility healthcare workers (HCWs) involved in this programme rollout, semi-structured interviews were conducted at three high malaria burden health districts in Burkina Faso. Interviews were conducted at baseline with 104 CHWs and 35 HCWs prior to the introduction of community based IPTp (c-IPTp) to assess capacity and any areas of concern. At endline, interviews were conducted with 29 CHWs and 21 HCWs to identify key facilitators and suggestions for further implementation of the c-IPTp programme. Results CHWs reported feeling capable of supporting c-IPTp delivery and facilitating linkage to antenatal care (ANC). They noted that the opportunity for enhanced training and close and ongoing connections with facility HCWs and supportive supervision were imperative. Both CHWs and HCWs perceived this approach as acceptable to community members and noted the importance of close community engagement, monthly meetings between CHWs and facility HCWs, and maintaining regular supplies of sulfadoxine–pyrimethamine (SP). Those interviewed noted that it was beneficial to have the involvement of both female and male CHWs. Conclusions Community-based delivery of IPTp was feasible and acceptable to both facility HCWs and CHWs. This approach has the potential to strengthen delivery and uptake of IPTp and ANC both in Burkina Faso and across the region.
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Affiliation(s)
| | | | - Courtney Emerson
- US President's Malaria Initiative, Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, USA
| | - Susan Youll
- US President's Malaria Initiative, US Agency for International Development, Washington, D.C., USA
| | - Julie Gutman
- US President's Malaria Initiative, Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, USA
| | | | - Yacouba Savadogo
- National Malaria Control Programme, Ministry of Health, Ouagadougou, Burkina Faso
| | | | | | - William Brieger
- The Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
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12
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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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13
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Oliphant NP, Manda S, Daniels K, Odendaal WA, Besada D, Kinney M, White Johansson E, Doherty T. Integrated community case management of childhood illness in low- and middle-income countries. Cochrane Database Syst Rev 2021; 2:CD012882. [PMID: 33565123 PMCID: PMC8094443 DOI: 10.1002/14651858.cd012882.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The leading causes of mortality globally in children younger than five years of age (under-fives), and particularly in the regions of sub-Saharan Africa (SSA) and Southern Asia, in 2018 were infectious diseases, including pneumonia (15%), diarrhoea (8%), malaria (5%) and newborn sepsis (7%) (UNICEF 2019). Nutrition-related factors contributed to 45% of under-five deaths (UNICEF 2019). World Health Organization (WHO) and United Nations Children's Fund (UNICEF), in collaboration with other development partners, have developed an approach - now known as integrated community case management (iCCM) - to bring treatment services for children 'closer to home'. The iCCM approach provides integrated case management services for two or more illnesses - including diarrhoea, pneumonia, malaria, severe acute malnutrition or neonatal sepsis - among under-fives at community level (i.e. outside of healthcare facilities) by lay health workers where there is limited access to health facility-based case management services (WHO/UNICEF 2012). OBJECTIVES To assess the effects of the integrated community case management (iCCM) strategy on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for children younger than five years of age in low- and middle-income countries. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2019, Virtual Health Library on 8 November 2019, and Popline on 5 December 2018, three other databases on 22 March 2019 and two trial registers on 8 November 2019. We performed reference checking, and citation searching, and contacted study authors to identify additional studies. SELECTION CRITERIA Randomized controlled trials (RCTs), cluster-RCTs, controlled before-after studies (CBAs), interrupted time series (ITS) studies and repeated measures studies comparing generic WHO/UNICEF iCCM (or local adaptation thereof) for at least two iCCM diseases with usual facility services (facility treatment services) with or without single disease community case management (CCM). We included studies reporting on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for under-fives in low- and middle-income countries. DATA COLLECTION AND ANALYSIS At least two review authors independently screened abstracts, screened full texts and extracted data using a standardised data collection form adapted from the EPOC Good Practice Data Collection Form. We resolved any disagreements through discussion or, if required, we consulted a third review author not involved in the original screening. We contacted study authors for clarification or additional details when necessary. We reported risk ratios (RR) for dichotomous outcomes and hazard ratios (HR) for time to event outcomes, with 95% confidence intervals (CI), adjusted for clustering, where possible. We used estimates of effect from the primary analysis reported by the investigators, where possible. We analysed the effects of randomized trials and other study types separately. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included seven studies, of which three were cluster RCTs and four were CBAs. Six of the seven studies were in SSA and one study was in Southern Asia. The iCCM components and inputs were fairly consistent across the seven studies with notable variation for the training and deployment component (e.g. on payment of iCCM providers) and the system component (e.g. on improving information systems). When compared to usual facility services, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (RR 0.96, 95% CI 0.77 to 1.19; 2 CBA studies, 5898 children; very low-certainty evidence). iCCM may have little to no effect on neonatal mortality (HR 1.01, 95% 0.73 to 1.28; 2 trials, 65,209 children; low-certainty evidence). We are uncertain of the effect of iCCM on infant mortality (HR 1.02, 95% CI 0.83 to 1.26; 2 trials, 60,480 children; very low-certainty evidence) and under-five mortality (HR 1.18, 95% CI 1.01 to 1.37; 1 trial, 4729 children; very low-certainty evidence). iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness by 68% (RR 1.68, 95% CI 1.24 to 2.27; 2 trials, 9853 children; moderate-certainty evidence). None of the studies reported quality of care, severity of illness or adverse events for this comparison. When compared to usual facility services plus CCM for malaria, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (very low-certainty evidence) and iCCM may have little or no effect on careseeking to an appropriate provider for any iCCM illness (RR 1.06, 95% CI 0.97 to 1.17; 1 trial, 811 children; low-certainty evidence). None of the studies reported quality of care, case load or severity of illness at health facilities, mortality or adverse events for this comparison. AUTHORS' CONCLUSIONS iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness. However, the evidence presented here underscores the importance of moving beyond training and deployment to valuing iCCM providers, strengthening health systems and engaging community systems.
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Affiliation(s)
- Nicholas P Oliphant
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
- School of Public Health, University of the Western Cape, Belleville, South Africa
| | - Samuel Manda
- Biostatistics Unit, South African Medical Research Council, Hatfield, South Africa
- Department of Statistics, University of Pretoria, Hatfield, South Africa
| | - Karen Daniels
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Donela Besada
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Mary Kinney
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
| | - Emily White Johansson
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
- School of Public Health, University of the Western Cape, Belleville, South Africa
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Dwomoh D, Agyabeng K, Agbeshie K, Incoom G, Nortey P, Yawson A, Bosomprah S. Impact evaluation of the free maternal healthcare policy on the risk of neonatal and infant deaths in four sub-Saharan African countries: a quasi-experimental design with propensity score Kernel matching and difference in differences analysis. BMJ Open 2020; 10:e033356. [PMID: 32414818 PMCID: PMC7232624 DOI: 10.1136/bmjopen-2019-033356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 01/29/2020] [Accepted: 03/19/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Despite the huge financial investment in the free maternal healthcare policy (FMHCP) by the Governments of Ghana and Burkina Faso, no study has quantified the impact of FMHCP on the relative reduction in neonatal and infant mortality rates using a more rigorous matching procedure with the difference in differences (DID) analysis. This study used several rounds of publicly available population-based complex survey data to determine the impact of FMHCP on neonatal and infant mortality rates in these two countries. DESIGN A quasi-experimental study to evaluate the FMHCP implemented in Burkina Faso and Ghana between 2007 and 2014. SETTING Demographic and health surveys and maternal health surveys conducted between 2000 and 2014 in Ghana, Burkina Faso, Nigeria and Zambia. PARTICIPANTS Children born 5 years preceding the survey in Ghana, Burkina Faso, Nigeria and Zambia. PRIMARY OUTCOME MEASURES Neonatal and infant mortality rates. RESULTS The Propensity Score Kernel Matching coupled with DID analysis with modified Poisson showed that the FMHCP was associated with a 45% reduction in the risk of neonatal mortality rate in Ghana and Burkina Faso compared with Nigeria and Zambia (adjusted relative risk (aRR)=0.55, 95% CI: 0.40 to 0.76, p<0.001). In addition, infant mortality rate has reduced significantly in both Ghana and Burkina Faso by approximately 54% after full implementation of FMHCP compared with Nigeria and Zambia (aRR=0.46, 95% CI: 0.36 to 0.59, p<0.001). CONCLUSION The FMHCP had a significant impact and still remains relevant in achieving Sustainable Development Goal 3 and could provide lessons for other sub-Saharan countries in the design and implementation of a similar policy.
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Affiliation(s)
- Duah Dwomoh
- Biostatistics, School of Public Health, University of Ghana College of Health Sciences, Accra, Greater Accra, Ghana
| | - Kofi Agyabeng
- Biostatistics, School of Public Health, University of Ghana College of Health Sciences, Accra, Greater Accra, Ghana
| | - Kwame Agbeshie
- Municipal Health Directorate, Ghana Health Service, Eastern Region, Somanya, Ghana
| | - Gabriel Incoom
- Department of Management Science, School of Business, Ghana Institute of Management and Public Administration, Accra, Ghana
| | - Priscilla Nortey
- Epidemiology, University of Ghana School of Public Health, Accra, Greater Accra, Ghana
| | - Alfred Yawson
- Community Health, School of Public, College of Health Sciences, University of Ghana, Legon, Greater Accra, Ghana
| | - Samuel Bosomprah
- Biostatistics, School of Public Health, University of Ghana College of Health Sciences, Accra, Greater Accra, Ghana
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15
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Nanyonjo A, Counihan H, Siduda SG, Belay K, Sebikaari G, Tibenderana J. Institutionalization of integrated community case management into national health systems in low- and middle-income countries: a scoping review of the literature. Glob Health Action 2020; 12:1678283. [PMID: 31694498 PMCID: PMC6844392 DOI: 10.1080/16549716.2019.1678283] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background: Integrated community case management (iCCM) for malaria, pneumonia and diarrhea continues to be a recommended strategy to address child mortality in areas where access to health facilities is limited. Objective: To identify models of, and gaps in, institutionalization of benchmark components of iCCM into national health systems of low-and-middle-income countries, in order to draw lessons for future iCCM implementation and sustainability. Methods: A scoping review of relevant searchable policy documents and publications available in English literature was undertaken. Data were selected, collated and characterized by three reviewers using the Arksey and O’Malley framework. Results: Overall 19 countries were reviewed. Despite the existence of discrete policies, most iCCM programs relied heavily on implementing partners and donor financing. Parallel implementing partner-run systems were often used to procure and supply iCCM medicines. These modes of implementation occasionally violated some health system strengthening principles. Drug stock-outs were still prominent in several countries, and iCCM indicators were sometimes not integrated into the national health management information system. There were no clearly defined motivation packages for both salaried and unsalaried workers, and there were several supervision challenges. Community-based performance-financing, use of technology with mobile devices (mHealth), small procedural improvements, and provision of targeted rather than universal services, were some of the promising interventions for improved iCCM institutionalization. Conclusion: Sustainable iCCM will require improved ownership by the benefiting communities and the local and central governments. Government commitment should be evident in budgeting processes and implementation strategies.
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Affiliation(s)
- Agnes Nanyonjo
- Technical Department, Malaria Consortium Uganda, Kampala, Uganda
| | | | - Sam Gudoi Siduda
- Management Department, USAID's Malaria Action Program for Districts, Kampala, Uganda
| | - Kassahun Belay
- Technical Department, US President's Malaria Initiative, US Agency for International Development, Kampala, Uganda
| | - Gloria Sebikaari
- Technical Department, US President's Malaria Initiative, US Agency for International Development, Kampala, Uganda
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16
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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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18
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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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Langston A, Wittcoff A, Ngoy P, O'Keefe J, Kozuki N, Taylor H, Barbera Lainez Y, Bacary S. Testing a simplified tool and training package to improve integrated Community Case Management in Tanganyika Province, Democratic Republic of Congo: a quasi-experimental study. J Glob Health 2019; 9:010810. [PMID: 31263553 PMCID: PMC6594717 DOI: 10.7189/jogh.09.010810] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Integrated community case management (iCCM) is a strategy to train community health workers (relais communautaires or RECOs in French) in low-resource settings to provide treatment for uncomplicated malaria, pneumonia, and diarrhea for children 2-59 months of age. The package of Ministry of Public Health tools for RECOs in the Democratic Republic of Congo that was being used in 2013 included seven data collection tools and job aids which were redundant and difficult to use. As part of the WHO-supported iCCM program, the International Rescue Committee developed and evaluated a simplified set of pictorial tools and curriculum adapted for low-literate RECOs. Methods The revised training curriculum and tools were tested in a quasi-experimental study, with 74 RECOs enrolled in the control group and 78 RECOs in the intervention group. Three outcomes were assessed during the study period from Sept. 2015-July 2016: 1) quality of care, measured by direct observation and reexamination; 2) workload, measured as the time required for each assessment – including documentation; and 3) costs of rolling out each package. Logistic regression was used to calculate odds ratios for correct treatment by the intervention group compared to the control group, controlling for characteristics of the RECOs, the child, and the catchment area. Results Children seen by the RECOs in the intervention group had nearly three times higher odds of receiving correct treatment (adjusted odds ratio aOR = 2.9, 95% confidence interval CI = 1.3-6.3, P = 0.010). On average, the time spent by the intervention group was 10.6 minutes less (95% CI = 6.6-14.7, P < 0.001), representing 6.2 hours of time saved per month for a RECO seeing 35 children. The estimated cost savings amounts to over US$ 300 000 for a four-year program supporting 1500 RECOs. Conclusion This study demonstrates that, at scale, simplified tools and a training package adapted for low-literate RECOs could substantially improve health outcomes for under-five children while reducing implementation costs and decreasing their workload. The training curriculum and simplified tools have been adopted nationally based on the results from this study.
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Affiliation(s)
- Anne Langston
- International Rescue Committee, New York, New York, USA
| | | | - Pascal Ngoy
- International Rescue Committee, Kinshasa, DR Congo
| | | | - Naoko Kozuki
- International Rescue Committee, New York, New York, USA
| | - Hannah Taylor
- International Rescue Committee, New York, New York, USA
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Millogo O, Doamba JEO, Sié A, Utzinger J, Vounatsou P. Geographical variation in the association of child, maternal and household health interventions with under-five mortality in Burkina Faso. PLoS One 2019; 14:e0218163. [PMID: 31260473 PMCID: PMC6602179 DOI: 10.1371/journal.pone.0218163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 05/28/2019] [Indexed: 11/18/2022] Open
Abstract
Background Over the past 15 years, scaling up of cost effective interventions resulted in a remarkable decline of under-five mortality rates (U5MR) in sub-Saharan Africa. However, the reduction shows considerable heterogeneity. We estimated the association of child, maternal, and household interventions with U5MR in Burkina Faso at national and subnational levels and identified the regions with least effective interventions. Methods Data on health-related interventions and U5MR were extracted from the Burkina Faso Demographic and Health Survey (DHS) 2010. Bayesian geostatistical proportional hazards models with a Weibull baseline hazard were fitted on the mortality outcome. Spatially varying coefficients were considered to assess the geographical variation in the association of the health interventions with U5MR. The analyses were adjusted for child, maternal, and household characteristics, as well as climatic and environmental factors. Findings The average U5MR was as high as 128 per 1000 ranging from 81 (region of Centre-Est) to 223 (region of Sahel). At national level, DPT3 immunization and baby post-natal check within 24 hours after birth had the most important association with U5MR (hazard rates ratio (HRR) = 0.89, 95% Bayesian credible interval (BCI): 0.86–0.98 and HRR = 0.89, 95% BCI: 0.86–0.92, respectively). At sub-national level, the most effective interventions are the skilled birth attendance, and improved drinking water, followed by baby post-natal check within 24 hours after birth, vitamin A supplementation, antenatal care visit and all-antigens immunization (including BCG, Polio3, DPT3, and measles immunization). Centre-Est, Sahel, and Sud-Ouest were the regions with the highest number of effective interventions. There was no intervention that had a statistically important association with child survival in the region of Hauts Bassins. Interpretation The geographical variation in the magnitude and statistical importance of the association between health interventions and U5MR raises the need to deliver and reinforce health interventions at a more granular level. Priority interventions are DPT3 immunization, skilled birth attendance, baby post-natal visits in the regions of Sud-Ouest, Sahel, and Hauts Bassins, respectively. Our methodology could be applied to other national surveys, as it allows an incisive, data-driven and specific decision-making approach to optimize the allocation of health interventions at subnational level.
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Affiliation(s)
- Ourohiré Millogo
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | - Jürg Utzinger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Penelope Vounatsou
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- * E-mail:
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Hategeka C, Tuyisenge G, Bayingana C, Tuyisenge L. Effects of scaling up various community-level interventions on child mortality in Burundi, Kenya, Rwanda, Uganda and Tanzania: a modeling study. Glob Health Res Policy 2019; 4:1. [PMID: 31168481 PMCID: PMC6545006 DOI: 10.1186/s41256-019-0106-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 05/13/2019] [Indexed: 12/03/2022] Open
Abstract
Background Improving child health remains one of the most significant health challenges in sub-Saharan Africa, a region that accounts for half of the global burden of under-five mortality despite having approximately 13% of the world population and 25% of births globally. Improving access to evidence-based community-level interventions has increasingly been advocated to contribute to reducing child mortality and, thus, help low-and middle-income countries (LMICs) achieve the child health related Sustainable Development Goal (SDG) target. Nevertheless, the coverage of community-level interventions remains suboptimal. In this study, we estimated the potential impact of scaling up various community-level interventions on child mortality in five East African Community (EAC) countries (i.e., Burundi, Kenya, Rwanda, Uganda and the United Republic of Tanzania). Methods We identified ten preventive and curative community-level interventions that have been reported to reduce child mortality: Breastfeeding promotion, complementary feeding, vitamin A supplementation, Zinc for treatment of diarrhea, hand washing with soap, hygienic disposal of children’s stools, oral rehydration solution (ORS), oral antibiotics for treatment of pneumonia, treatment for moderate acute malnutrition (MAM), and prevention of malaria using insecticide-treated nets and indoor residual spraying (ITN/IRS). Using the Lives Saved Tool, we modeled the impact on child mortality of scaling up these 10 interventions from baseline coverage (2016) to ideal coverage (99%) by 2030 (ideal scale-up scenario) relative to business as usual (BAU) scenario (forecasted coverage based on prior coverage trends). Our outcome measures include number of child deaths prevented. Results Compared to BAU scenario, ideal scale-up of the 10 interventions could prevent approximately 74,200 (sensitivity bounds 59,068–88,611) child deaths by 2030 including 10,100 (8210–11,870) deaths in Burundi, 10,300 (7831–12,619) deaths in Kenya, 4350 (3678–4958) deaths in Rwanda, 20,600 (16049–25,162) deaths in Uganda, and 28,900 (23300–34,002) deaths in the United Republic of Tanzania. The top four interventions (oral antibiotics for pneumonia, ORS, hand washing with soap, and treatment for MAM) account for over 75.0% of all deaths prevented in each EAC country: 78.4% in Burundi, 76.0% in Kenya, 81.8% in Rwanda, 91.0% in Uganda and 88.5% in the United Republic of Tanzania. Conclusions Scaling up interventions that can be delivered at community level by community health workers could contribute to substantial reduction of child mortality in EAC and could help the EAC region achieve child health-related SDG target. Our findings suggest that the top four community-level interventions could account for more than three-quarters of all deaths prevented across EAC countries. Going forward, costs of scaling up each intervention will be estimated to guide policy decisions including health resource allocations in EAC countries.
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Affiliation(s)
- Celestin Hategeka
- 1Centre for Health Services and Policy Research, School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC Canada.,2Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC Canada
| | | | - Christian Bayingana
- 4Bloomberg School of Public Health, Johns Hopkins Hospital, Baltimore, MD USA
| | - Lisine Tuyisenge
- 5Department of Paediatrics and Child Health, University Teaching Hospital of Kigali, Kigali, Rwanda
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22
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Kuunibe N, Lohmann J, Schleicher M, Koulidiati JL, Robyn PJ, Zigani Z, Sanon A, De Allegri M. Factors associated with misreporting in performance-based financing in Burkina Faso: Implications for risk-based verification. Int J Health Plann Manage 2019; 34:1217-1237. [PMID: 30994207 DOI: 10.1002/hpm.2786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 03/13/2019] [Indexed: 11/06/2022] Open
Abstract
Performance-based financing (PBF) has been piloted in many low- and middle-income countries (LMICs) as a strategy to improve access to and quality of health services. As a key component of PBF, quantity verification is carried out to ensure that reported data matches the actual number of services provided. However, cost concerns have led to a call for risk-based verification. Existing evidence suggests misreporting is associated with factors such as complexity of indicators, high service volume, and accepted error margin. In contrast, evidence on the association of key facility characteristics with misreporting in PBF is scarce. We contributed to filling this gap in knowledge by combining administrative data from a large-scale pilot PBF program in Burkina Faso with data from a health facility assessment in the context of an impact evaluation of the intervention. Our results showed the coexistence of both overreporting and underreporting and that misreporting varied by service indicator and health district. We also found that the number of clinical staff at the facility, the population size in the facility catchment area, and the distance between the facility and the district administration were associated with the probability of misreporting. We recommend further research of these factors in the move towards risk-based verification. In addition, given that our analysis identified relevant associations, but could not explain them, we recommend further qualitative inquiry into verification processes.
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Affiliation(s)
- Naasegnibe Kuunibe
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Germany
| | - Julia Lohmann
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Germany
| | - Michael Schleicher
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Germany
| | - Jean-Louis Koulidiati
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Germany
| | - Paul Jacob Robyn
- Health, Nutrition and Population Unit, World Bank, Washington, DC, USA
| | | | - Adama Sanon
- Ministère de la santé, Ouagadougou, Burkina Faso
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Faculty of Medicine, Heidelberg University, Germany
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Witvorapong N, Yakubu KY. Effectiveness of antimalarial interventions in Nigeria: Evidence from facility-level longitudinal data. Health Serv Res 2019; 54:669-677. [PMID: 30740696 DOI: 10.1111/1475-6773.13122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate the effectiveness of a program of antimalarial interventions implemented in 2010-2013 in Niger State, Nigeria. DATA SOURCES Utilization reports from 99 intervention and 51 non-intervention health facilities from the Niger State Malaria Elimination Program, supplemented by data on facility-level characteristics from the Niger State Primary Health Care Development Agency and Local Government Malaria Control units. STUDY DESIGN Estimated with mixed-effects negative binomial modeling, a difference-in-differences method was used to quantify the impact of the program on the number of febrile illness cases and confirmed malaria cases. Potential confounding factors, non-stationarity, seasonality, and autocorrelation were explicitly accounted for. DATA EXTRACTION METHODS Data were retrieved from hard copies of utilization reports and manually inputted to create a panel of 5550 facility-month observations. PRINCIPAL FINDINGS The program was implemented in two phases. The first phase (August 2010-June 2012) involved the provision of free artemisinin-based combination therapies, long-lasting insecticidal nets, and intermittent preventive treatments. In the second phase (July 2012-March 2013), the program introduced an additional intervention: free parasite-based rapid diagnostic tests. Compared to the pre-intervention period, the average number of monthly febrile illness and malaria cases increased by 20.876 (P < 0.01) and 22.835 (P < 0.01) in the first phase, and by 19.007 (P < 0.05) and 19.681 (P < 0.05) in the second phase, respectively. The results are consistent across different evaluation methods. CONCLUSIONS This study suggests that user-fee removal leads to increased utilization of antimalarial services. It motivates future studies to cautiously select their investigative methods.
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Affiliation(s)
- Nopphol Witvorapong
- Center for Health Economics, Faculty of Economics, Chulalongkorn University, Pathumwan, Bangkok, Thailand
| | - Kolo Yaro Yakubu
- Strengthening Accountability and Quality Improvement for Maternal, Newborn and Child Health Project, Pact Nigeria, Gombe, Nigeria
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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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Chirambo GB, Hardy VE, Heavin C, O'Connor Y, O'Donoghue J, Mastellos N, Tran T, Hsieh J, Wu JTS, Carlsson S, Andersson B, Muula AS, Thompson M. Perceptions of a mobile health intervention for Community Case Management in Malawi: Opportunities and challenges for Health Surveillance Assistants in a community setting. Malawi Med J 2018; 30:6-12. [PMID: 29868152 PMCID: PMC5974379 DOI: 10.4314/mmj.v30i1.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Improved availability of mobile phones in low- and middle-income countries (LMICs) offer an opportunity to improve delivery of Community Case Management (CCM). Despite enthusiasm for introducing mHealth into healthcare across LMICs, end-user attitudes towards mHealth solutions for CCM are limited. We aimed to explore Health Surveillance Assistants' (HSAs) perceptions of the Supporting LIFE electronic CCM Application (SL eCCM App) and their experiences incorporating it as part of their clinical practice. Methods This exploratory qualitative study was part of a mixed methods feasibility study investigating whether children under-5 presenting to village clinics could be followed-up to collect patient outcome data. The convenience sample of 12 HSAs enrolled into the feasibility study participated in semi-structured interviews, which were conducted at village clinics after HSAs had field-tested the SL eCCM App over a 10-day period. Interviews explored HSAs perceptions of the SL eCCM App and their experiences in using the App in addition to paper CCM to assess and treat acutely unwell children. Open coding was used to label emerging concepts, which were iteratively defined and developed into six key themes. Results HSAs' perceived enhanced clinical decision-making, quality of CCM delivery, and work efficiency as opportunities associated with using the SL eCCM App. HSAs believed the inability to retrieve patient records,, cumbersome duplicate assessments/data entry study procedures, and inconsistencies between the SL eCCM App and paper-based CCM guidelines as challenges to implementation. Adding features to the App, such as, permitting communication between colleagues/supervisors, drug stock-out reporting, and community assessments, were identified as potentially supporting HSAs' many roles in the community. Conclusion This study identified opportunities and challenges associated with using the SL eCCM App in Malawi. This information can be used to inform future development and evaluation of the SL eCCM App, and similar mHealth solutions for CCM in Malawi and other developing countries.
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Affiliation(s)
- Griphin Baxter Chirambo
- Faculty of Health Sciences, Mzuzu University, Private Bag 201, Luwinga, Mzuzu, Malawi.,School of Public Health and Family Medicine, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Victoria E Hardy
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Ciara Heavin
- Health Information Systems Research Centre, University College Cork, Cork, Ireland
| | - Yvonne O'Connor
- Health Information Systems Research Centre, University College Cork, Cork, Ireland
| | - John O'Donoghue
- Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Nikolaos Mastellos
- Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Tammy Tran
- Global eHealth Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Jenny Hsieh
- Luke International (LIN), Malawi Office, P.O. Box 1088, Mzuzu, Malawi
| | | | - Sven Carlsson
- Department of Informatics, Lund University School of Economics and Management, Lund, Sweden
| | - Bo Andersson
- Department of Informatics, Lund University School of Economics and Management, Lund, Sweden
| | - Adamson S Muula
- School of Public Health and Family Medicine, University of Malawi, College of Medicine, Blantyre, Malawi.,Africa Center of Excellence in Public Health and Herbal Medicine, University of Malawi, Blantyre, Malawi
| | - Matthew Thompson
- Department of Family Medicine, University of Washington, Seattle, WA, USA
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Murray J, Head R, Sarrassat S, Hollowell J, Remes P, Lavoie M, Borghi J, Kasteng F, Meda N, Badolo H, Ouedraogo M, Bambara R, Cousens S. Modelling the effect of a mass radio campaign on child mortality using facility utilisation data and the Lives Saved Tool (LiST): findings from a cluster randomised trial in Burkina Faso. BMJ Glob Health 2018; 3:e000808. [PMID: 30057797 PMCID: PMC6058176 DOI: 10.1136/bmjgh-2018-000808] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/25/2018] [Accepted: 05/28/2018] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND A cluster randomised trial (CRT) in Burkina Faso was the first to demonstrate that a radio campaign increased health-seeking behaviours, specifically antenatal care attendance, health facility deliveries and primary care consultations for children under 5 years. METHODS Under-five consultation data by diagnosis was obtained from primary health facilities in trial clusters, from January 2011 to December 2014. Interrupted time-series analyses were conducted to assess the intervention effect by time period on under-five consultations for separate diagnosis categories that were targeted by the media campaign. The Lives Saved Tool was used to estimate the number of under-five lives saved and the per cent reduction in child mortality that might have resulted from increased health service utilisation. Scenarios were generated to estimate the effect of the intervention in the CRT study areas, as well as a national scale-up in Burkina Faso and future scale-up scenarios for national media campaigns in five African countries from 2018 to 2020. RESULTS Consultations for malaria symptoms increased by 56% in the first year (95% CI 30% to 88%; p<0.001) of the campaign, 37% in the second year (95% CI 12% to 69%; p=0.003) and 35% in the third year (95% CI 9% to 67%; p=0.006) relative to the increase in the control arm. Consultations for lower respiratory infections increased by 39% in the first year of the campaign (95% CI 22% to 58%; p<0.001), 25% in the second (95% CI 5% to 49%; p=0.010) and 11% in the third year (95% CI -20% to 54%; p=0.525). Diarrhoea consultations increased by 73% in the first year (95% CI 42% to 110%; p<0.001), 60% in the second (95% CI 12% to 129%; p=0.010) and 107% in the third year (95% CI 43% to 200%; p<0.001). Consultations for other diagnoses that were not targeted by the radio campaign did not differ between intervention and control arms. The estimated reduction in under-five mortality attributable to the radio intervention was 9.7% in the first year (uncertainty range: 5.1%-15.1%), 5.7% in the second year and 5.5% in the third year. The estimated number of under-five lives saved in the intervention zones during the trial was 2967 (range: 1110-5741). If scaled up nationally, the estimated reduction in under-five mortality would have been similar (9.2% in year 1, 5.6% in year 2 and 5.5% in year 3), equating to 14 888 under-five lives saved (range: 4832-30 432). The estimated number of lives that could be saved by implementing national media campaigns in other low-income settings ranged from 7205 in Burundi to 21 443 in Mozambique. CONCLUSION Evidence from a CRT shows that a child health radio campaign increased under-five consultations at primary health centres for malaria, pneumonia and diarrhoea (the leading causes of postneonatal child mortality in Burkina Faso) and resulted in an estimated 7.1% average reduction in under-five mortality per year. These findings suggest important reductions in under-five mortality can be achieved by mass media alone, particularly when conducted at national scale.
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Affiliation(s)
| | - Roy Head
- Development Media International, London, UK
| | - Sophie Sarrassat
- Centre for Maternal Adolescent Reproductive and Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Josephine Borghi
- Department of Global Health and Development, Health Economics and Systems Analysis Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Frida Kasteng
- Department of Global Health and Development, Health Economics and Systems Analysis Group, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | | | - Robert Bambara
- Direction Générale des Études et des Statistiques Sectorielles (DGESS), Ministère de la Santé, Ouagadougou, Burkina Faso
| | - Simon Cousens
- Centre for Maternal Adolescent Reproductive and Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
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Winn LK, Lesser A, Menya D, Baumgartner JN, Kipkoech Kirui J, Saran I, Prudhomme-O’Meara W. Motivation and satisfaction among community health workers administering rapid diagnostic tests for malaria in Western Kenya. J Glob Health 2018. [DOI: 10.7189/jogh.06.0207028.010401] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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28
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Winn LK, Lesser A, Menya D, Baumgartner JN, Kipkoech Kirui J, Saran I, Prudhomme-O'Meara W. Motivation and satisfaction among community health workers administering rapid diagnostic tests for malaria in Western Kenya. J Glob Health 2018; 8:010401. [PMID: 29497500 PMCID: PMC5823030 DOI: 10.7189/jogh.08.010401] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background The continued success of community case management (CCM) programs in low-resource settings depends on the ability of these programs to retain the community health workers (CHWs), many of whom are volunteers, and maintain their high-quality performance. This study aims to identify factors related to the motivation and satisfaction of CHWs working in a malaria CCM program in two sub-counties in Western Kenya. Methods We interviewed 70 CHWs who were trained to administer malaria rapid diagnostic tests as part of a broader study evaluating a malaria CCM program. We identified factors related to CHWs' motivation and their satisfaction with participation in the program, as well as the feasibility of program scale-up. We used principal components analysis to develop an overall CHW satisfaction score and assessed associations between this score and individual CHW characteristics as well as their experiences in the program. Results The majority of CHWs reported that they were motivated to perform their role in this malaria CCM program by a personal desire to help their community (69%). The most common challenge CHWs reported was a lack of community understanding about malaria diagnostic testing and CHWs' role in the program (39%). Most CHWs (89%) reported that their involvement in the diagnostic testing intervention had either a neutral or a net positive effect on their other CHW activities, including improving skills applicable to other tasks. CHWs who said they strongly agreed with the statement that their work with the malaria program was appreciated by the community had a 0.76 standard deviation (SD) increase in their overall satisfaction score (95% confidence interval CI = 0.10-1.24, P = 0.03). Almost all CHWs (99%) strongly agreed that they wanted to continue their role in the malaria program. Conclusions Overall, CHWs reported high satisfaction with their role in community-based malaria diagnosis, though they faced challenges primarily related to community understanding and appreciation of the services they provided. CHWs' perceptions that the malaria program generally did not interfere with their other activities is encouraging for the sustainability and scale-up of similar CHW programs.
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Affiliation(s)
| | - Adriane Lesser
- Duke University, Duke Global Health Institute, Durham, North Carolina, USA
| | - Diana Menya
- Moi University, School of Public Health, Eldoret, Kenya
| | - Joy N Baumgartner
- Duke University, Duke Global Health Institute, Durham, North Carolina, USA
| | | | - Indrani Saran
- Duke University, Duke Global Health Institute, Durham, North Carolina, USA
| | - Wendy Prudhomme-O'Meara
- Duke University, Durham, North Carolina, USA.,Duke University, Duke Global Health Institute, Durham, North Carolina, USA.,Moi University, School of Public Health, Eldoret, Kenya
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Freeman PA, Schleiff M, Sacks E, Rassekh BM, Gupta S, Perry HB. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 4. child health findings. J Glob Health 2018; 7:010904. [PMID: 28685042 PMCID: PMC5491948 DOI: 10.7189/jogh.07.010904] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background This paper assesses the effectiveness of community–based primary health care (CBPHC) in improving child health beyond the neonatal period. Although there has been an accelerated decline in global under–5 mortality since 2000, mortality rates remain high in much of sub–Saharan Africa and in some south Asian countries where under–5 mortality is also decreasing more slowly. Essential interventions for child health at the community level have been identified. Our review aims to contribute further to this knowledge by examining how strong the evidence is and exploring in greater detail what specific interventions and implementation strategies appear to be effective. Methods We reviewed relevant documents from 1950 onwards using a detailed protocol. Peer reviewed documents, reports and books assessing the impact of one or more CBPHC interventions on child health (defined as changes in population coverage of one or more key child survival interventions, nutritional status, serious morbidity or mortality) among children in a geographically defined population was examined for inclusion. Two separate reviews took place of each document followed by an independent consolidated summative review. Data from the latter review were transferred to electronic database for analysis. Results The findings provide strong evidence that the major causes of child mortality in resource–constrained settings can be addressed at the community level largely by engaging communities and supporting community–level workers. For all major categories of interventions (nutritional interventions; control of pneumonia, diarrheal disease and malaria; HIV prevention and treatment; immunizations; integrated management of childhood diseases; and comprehensive primary health care) we have presented randomized controlled trials that have consistently produced statistically significant and operationally important effects. Conclusions This review shows that there is strong evidence of effectiveness for CBPHC implementation of an extensive range of interventions to improve child health and that four major strategies for delivering these interventions are effective.
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Affiliation(s)
- Paul A Freeman
- Independent consultant, Seattle, Washington, USA.,University of Washington School of Public Health, Seattle, Washington, USA
| | - Meike Schleiff
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Emma Sacks
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | - Henry B Perry
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Johnson AD, Thiero O, Whidden C, Poudiougou B, Diakité D, Traoré F, Samaké S, Koné D, Cissé I, Kayentao K. Proactive community case management and child survival in periurban Mali. BMJ Glob Health 2018; 3:e000634. [PMID: 29607100 PMCID: PMC5873643 DOI: 10.1136/bmjgh-2017-000634] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/07/2018] [Accepted: 02/08/2018] [Indexed: 11/12/2022] Open
Abstract
The majority of the world's population lives in urban areas, and regions with the highest under-five mortality rates are urbanising rapidly. This 7-year interrupted time series study measured early access to care and under-five mortality over the course of a proactive community case management (ProCCM) intervention in periurban Mali. Using a cluster-based, population-weighted sampling methodology, we conducted independent cross-sectional household surveys at baseline and at 12, 24, 36, 48, 60, 72 and 84 months later in the intervention area. The ProCCM intervention had five key components: (1) active case detection by community health workers (CHWs), (2) CHW doorstep care, (3) monthly dedicated supervision for CHWs, (4) removal of user fees and (5) primary care infrastructure improvements and staff capacity building. Under-five mortality rate was calculated using a Cox proportional hazard survival regression. We measured the percentage of children initiating effective antimalarial treatment within 24 hours of symptom onset and the percentage of children reported to be febrile within the previous 2 weeks. During the intervention, the rate of early effective antimalarial treatment of children 0-59 months more than doubled, from 14.7% in 2008 to 35.3% in 2015 (OR 3.198, P<0.0001). The prevalence of febrile illness among children under 5 years declined after 7 years of the intervention from 39.7% at baseline to 22.6% in 2015 (OR 0.448, P<0.0001). Communities where ProCCM was implemented have achieved an under-five mortality rate at or below 28/1000 for the past 6 years. In 2015, under-five mortality was 7/1000 (HR 0.039, P<0.0001). Further research is needed to elucidate the mechanisms of action and generalizability of ProCCM.
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Affiliation(s)
- Ari D Johnson
- Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California, USA
- Muso, Bamako, Mali, San Francisco, California, USA
| | - Oumar Thiero
- Tulane University, School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
- Malaria Research and Training Centre, Faculty of Medicine and Odontostomatology, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
| | | | | | | | | | - Salif Samaké
- Ministry of Public Health and Hygiene, Bamako, Mali
| | | | | | - Kassoum Kayentao
- Muso, Bamako, Mali, San Francisco, California, USA
- Malaria Research and Training Centre, Faculty of Medicine and Odontostomatology, University of Sciences, Techniques and Technologies of Bamako, Bamako, Mali
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31
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Sarrassat S, Meda N, Badolo H, Ouedraogo M, Some H, Bambara R, Murray J, Remes P, Lavoie M, Cousens S, Head R. Effect of a mass radio campaign on family behaviours and child survival in Burkina Faso: a repeated cross-sectional, cluster-randomised trial. Lancet Glob Health 2018; 6:e330-e341. [PMID: 29433668 PMCID: PMC5817351 DOI: 10.1016/s2214-109x(18)30004-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 12/08/2017] [Accepted: 12/08/2017] [Indexed: 10/31/2022]
Abstract
BACKGROUND Media campaigns can potentially reach a large audience at relatively low cost but, to our knowledge, no randomised controlled trials have assessed their effect on a health outcome in a low-income country. We aimed to assess the effect of a radio campaign addressing family behaviours on all-cause post-neonatal under-5 child mortality in rural Burkina Faso. METHODS In this repeated cross-sectional, cluster randomised trial, clusters (distinct geographical areas in rural Burkina Faso with at least 40 000 inhabitants) were selected by Development Media International based on their high radio listenership (>60% of women listening to the radio in the past week) and minimum distances between radio stations to exclude population-level contamination. Clusters were randomly allocated to receive the intervention (a comprehensive radio campaign) or control group (no radio media campaign). Household surveys were performed at baseline (from December, 2011, to February, 2012), midline (in November, 2013, and after 20 months of campaigning), and endline (from November, 2014, to March, 2015, after 32 months of campaigning). Primary analyses were done on an intention-to-treat basis, based on cluster-level summaries and adjusted for imbalances between groups at baseline. The primary outcome was all-cause post-neonatal under-5 child mortality. The trial was designed to detect a 20% reduction in the primary outcome with a power of 80%. Routine data from health facilities were also analysed for evidence of changes in use and these data had high statistical power. The indicators measured were new antenatal care attendances, facility deliveries, and under-5 consultations. This trial is registered with ClinicalTrial.gov, number NCT01517230. FINDINGS The intervention ran from March, 2012, to January, 2015. 14 clusters were selected and randomly assigned to the intervention group (n=7) or the control group (n=7). The average number of villages included per cluster was 34 in the control group and 29 in the intervention group. 2269 (82%) of 2784 women in the intervention group reported recognising the campaign's radio spots at endline. Post-neonatal under-5 child mortality decreased from 93·3 to 58·5 per 1000 livebirths in the control group and from 125·1 to 85·1 per 1000 livebirths in the intervention group. There was no evidence of an intervention effect (risk ratio 1·00, 95% CI 0·82-1·22; p>0·999). In the first year of the intervention, under-5 consultations increased from 68 681 to 83 022 in the control group and from 79 852 to 111 758 in the intervention group. The intervention effect using interrupted time-series analysis was 35% (95% CI 20-51; p<0·0001). New antenatal care attendances decreased from 13 129 to 12 997 in the control group and increased from 19 658 to 20 202 in the intervention group in the first year (intervention effect 6%, 95% CI 2-10; p=0·004). Deliveries in health facilities decreased from 10 598 to 10 533 in the control group and increased from 12 155 to 12 902 in the intervention group in the first year (intervention effect 7%, 95% CI 2-11; p=0·004). INTERPRETATION A comprehensive radio campaign had no detectable effect on child mortality. Substantial decreases in child mortality were observed in both groups over the intervention period, reducing our ability to detect an effect. This, nevertheless, represents the first randomised controlled trial to show that mass media alone can change health-seeking behaviours. FUNDING Wellcome Trust and Planet Wheeler Foundation.
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Affiliation(s)
- Sophie Sarrassat
- Centre for Maternal, Adolescent, Reproductive and Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK.
| | | | | | | | - Henri Some
- Africsanté, Bobo Dioulasso, Burkina Faso
| | - Robert Bambara
- Direction Générale des Études et des Statistiques Sectorielles (DGESS), Ministère de la Santé, Ouagadougou, Burkina Faso
| | | | - Pieter Remes
- Development Media International, Ouagadougou, Burkina Faso
| | | | - Simon Cousens
- Centre for Maternal, Adolescent, Reproductive and Child Health (MARCH), London School of Hygiene & Tropical Medicine, London, UK
| | - Roy Head
- Development Media International, London, UK
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Ben Charif A, Zomahoun HTV, LeBlanc A, Langlois L, Wolfenden L, Yoong SL, Williams CM, Lépine R, Légaré F. Effective strategies for scaling up evidence-based practices in primary care: a systematic review. Implement Sci 2017; 12:139. [PMID: 29166911 PMCID: PMC5700621 DOI: 10.1186/s13012-017-0672-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 11/13/2017] [Indexed: 01/04/2023] Open
Abstract
Background While an extensive array of existing evidence-based practices (EBPs) have the potential to improve patient outcomes, little is known about how to implement EBPs on a larger scale. Therefore, we sought to identify effective strategies for scaling up EBPs in primary care. Methods We conducted a systematic review with the following inclusion criteria: (i) study design: randomized and non-randomized controlled trials, before-and-after (with/without control), and interrupted time series; (ii) participants: primary care-related units (e.g., clinical sites, patients); (iii) intervention: any strategy used to scale up an EBP; (iv) comparator: no restrictions; and (v) outcomes: no restrictions. We searched MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and the Cochrane Library from database inception to August 2016 and consulted clinical trial registries and gray literature. Two reviewers independently selected eligible studies, then extracted and analyzed data following the Cochrane methodology. We extracted components of scaling-up strategies and classified them into five categories: infrastructure, policy/regulation, financial, human resources-related, and patient involvement. We extracted scaling-up process outcomes, such as coverage, and provider/patient outcomes. We validated data extraction with study authors. Results We included 14 studies. They were published since 2003 and primarily conducted in low-/middle-income countries (n = 11). Most were funded by governmental organizations (n = 8). The clinical area most represented was infectious diseases (HIV, tuberculosis, and malaria, n = 8), followed by newborn/child care (n = 4), depression (n = 1), and preventing seniors’ falls (n = 1). Study designs were mostly before-and-after (without control, n = 8). The most frequently targeted unit of scaling up was the clinical site (n = 11). The component of a scaling-up strategy most frequently mentioned was human resource-related (n = 12). All studies reported patient/provider outcomes. Three studies reported scaling-up coverage, but no study quantitatively reported achieving a coverage of 80% in combination with a favorable impact. Conclusions We found few studies assessing strategies for scaling up EBPs in primary care settings. It is uncertain whether any strategies were effective as most studies focused more on patient/provider outcomes and less on scaling-up process outcomes. Minimal consensus on the metrics of scaling up are needed for assessing the scaling up of EBPs in primary care. Trial registration This review is registered as PROSPERO CRD42016041461. Electronic supplementary material The online version of this article (10.1186/s13012-017-0672-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ali Ben Charif
- Health and Social Services Systems, Knowledge Translation and Implementation component of the Quebec SPOR-SUPPORT Unit, Université Laval, Quebec, QC, Canada.,Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Université Laval, Quebec, QC, Canada.,Centre de recherche sur les soins et les services de première ligne (CERSSPL), Université Laval, Quebec, QC, Canada.,Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC, Canada.,Population Health and Practice-Changing Research Group, CHU de Québec Research Centre, Quebec, QC, Canada
| | - Hervé Tchala Vignon Zomahoun
- Health and Social Services Systems, Knowledge Translation and Implementation component of the Quebec SPOR-SUPPORT Unit, Université Laval, Quebec, QC, Canada.,Centre de recherche sur les soins et les services de première ligne (CERSSPL), Université Laval, Quebec, QC, Canada
| | - Annie LeBlanc
- Health and Social Services Systems, Knowledge Translation and Implementation component of the Quebec SPOR-SUPPORT Unit, Université Laval, Quebec, QC, Canada.,Centre de recherche sur les soins et les services de première ligne (CERSSPL), Université Laval, Quebec, QC, Canada.,Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC, Canada.,Population Health and Practice-Changing Research Group, CHU de Québec Research Centre, Quebec, QC, Canada
| | - Léa Langlois
- Health and Social Services Systems, Knowledge Translation and Implementation component of the Quebec SPOR-SUPPORT Unit, Université Laval, Quebec, QC, Canada.,Centre de recherche sur les soins et les services de première ligne (CERSSPL), Université Laval, Quebec, QC, Canada
| | - Luke Wolfenden
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.,Hunter New England Population Health, Wallsend, NSW, 2287, Australia
| | - Sze Lin Yoong
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.,Hunter New England Population Health, Wallsend, NSW, 2287, Australia
| | - Christopher M Williams
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Roxanne Lépine
- Health and Social Services Systems, Knowledge Translation and Implementation component of the Quebec SPOR-SUPPORT Unit, Université Laval, Quebec, QC, Canada.,Centre de recherche sur les soins et les services de première ligne (CERSSPL), Université Laval, Quebec, QC, Canada
| | - France Légaré
- Health and Social Services Systems, Knowledge Translation and Implementation component of the Quebec SPOR-SUPPORT Unit, Université Laval, Quebec, QC, Canada. .,Tier 1 Canada Research Chair in Shared Decision Making and Knowledge Translation, Université Laval, Quebec, QC, Canada. .,Centre de recherche sur les soins et les services de première ligne (CERSSPL), Université Laval, Quebec, QC, Canada. .,Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, QC, Canada. .,Population Health and Practice-Changing Research Group, CHU de Québec Research Centre, Quebec, QC, Canada. .,Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Pavillon Landry-Poulin - 2525 Chemin de la Canardière, Quebec City, QC, G1J 0A4, Canada.
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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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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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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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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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Daelmans B, Seck A, Nsona H, Wilson S, Young M. Integrated Community Case Management of Childhood Illness: What Have We Learned? Am J Trop Med Hyg 2016; 94:571-573. [PMID: 26936992 PMCID: PMC4775893 DOI: 10.4269/ajtmh.94-3intro2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Bernadette Daelmans
- *Address correspondence to Bernadette Daelmans, Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland. E-mail:
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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 2016; 94:574-583. [PMID: 26787158 PMCID: PMC4775894 DOI: 10.4269/ajtmh.15-0584] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/03/2015] [Indexed: 12/03/2022] Open
Abstract
We evaluated the impact of integrated community case management of childhood illness (iCCM) on careseeking for childhood illness and child mortality in Malawi, using a National Evaluation Platform dose-response design with 27 districts as units of analysis. “Dose” variables included density of iCCM providers, drug availability, and supervision, measured through a cross-sectional cellular telephone survey of all iCCM-trained providers. “Response” variables were changes between 2010 and 2014 in careseeking and mortality in children aged 2–59 months, measured through household surveys. iCCM implementation strength was not associated with changes in careseeking or mortality. There were fewer than one iCCM-ready provider per 1,000 under-five children per district. About 70% of sick children were taken outside the home for care in both 2010 and 2014. Careseeking from iCCM providers increased over time from about 2% to 10%; careseeking from other providers fell by a similar amount. Likely contributors to the failure to find impact include low density of iCCM providers, geographic targeting of iCCM to “hard-to-reach” areas although women did not identify distance from a provider as a barrier to health care, and displacement of facility careseeking by iCCM careseeking. This suggests that targeting iCCM solely based on geographic barriers may need to be reconsidered.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jennifer Bryce
- *Address correspondence to Jennifer Bryce, Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205. E-mail:
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