On Bathwater, Babies, and Designing Programs for Impact: Evaluations of the Integrated Community Case Management Strategy in Burkina Faso, Ethiopia, and Malawi

Building consensus on common features and interoperability use cases for community health information systems: a Delphi study

INTRODUCTION

Information systems for community health have become increasingly sophisticated and evidence-based in the last decade and they are now the most widely used health information systems in many low-income and middle-income countries. This study aimed to establish consensus regarding key features and interoperability priorities for community health information systems (CHISs).

METHODS

A Delphi study was conducted among a systematically selected panel of CHIS experts. This impressive pool of experts represented a range of leading global health institutions, with gender and regional balance as well as diversity in their areas of expertise. Through five rounds of iterative surveys and follow-up interviews, the experts established a high degree of consensus. We supplemented the Delphi study findings with a series of focus group discussions with 10 community health worker (CHW) leaders.

RESULTS

CHISs today are expected to adapt to a wide range of local contextual requirements and to support and improve care delivery. While once associated with a single role type (CHWs), these systems are now expected to engage other end users, including patients, supervisors, clinicians and data managers. Of 30 WHO-classified digital health interventions for care providers, experts identified 23 (77%) as being important for CHISs. Case management and care coordination features accounted for more than one-third (14 of 37, 38%) of the core features expected of CHISs today, a higher proportion than any other category. The highest priority use cases for interoperability include CHIS to health management information system monthly reporting and CHIS to electronic medical record referrals.

CONCLUSION

CHISs today are expected to be feature-rich, to support a range of user roles in community health systems, and to be highly adaptable to local contextual requirements. Future interoperability efforts, such as CHISs in general, are expected not only to move data efficiently but to strengthen community health systems in ways that measurably improve care.

Improving community health worker treatment for malaria, diarrhoea, and pneumonia in Uganda through inSCALE community and mHealth innovations: A cluster randomised controlled trial

The inSCALE cluster randomised controlled trial in Uganda evaluated two interventions, mHealth and Village Health Clubs (VHCs) which aimed to improve Community Health Worker (CHW) treatment for malaria, diarrhoea, and pneumonia within the national Integrated Community Case Management (iCCM) programme. The interventions were compared with standard care in a control arm. In a cluster randomised trial, 39 sub-counties in Midwest Uganda, covering 3167 CHWs, were randomly allocated to mHealth; VHC or usual care (control) arms. Household surveys captured parent-reported child illness, care seeking and treatment practices. Intention-to-treat analysis estimated the proportion of appropriately treated children with malaria, diarrhoea, and pneumonia according to WHO informed national guidelines. The trial was registered at ClinicalTrials.gov (NCT01972321). Between April-June 2014, 7679 households were surveyed; 2806 children were found with malaria, diarrhoea, or pneumonia symptoms in the last one month. Appropriate treatment was 11% higher in the mHealth compared to the control arm (risk ratio [RR] 1.11, 95% CI 1.02, 1.21; p = 0.018). The largest effect was on appropriate treatment for diarrhoea (RR 1.39; 95% CI 0.90, 2.15; p = 0.134). The VHC intervention increased appropriate treatment by 9% (RR 1.09; 95% CI 1.01, 1.18; p = 0.059), again with largest effect on treatment of diarrhoea (RR 1.56, 95% CI 1.04, 2.34, p = 0.030). CHWs provided the highest levels of appropriate treatment compared to other providers. However, improvements in appropriate treatment were observed at health facilities and pharmacies, with CHW appropriate treatment the same across the arms. The rate of CHW attrition in both intervention arms was less than half that of the control arm; adjusted risk difference mHealth arm -4.42% (95% CI -8.54, -0.29, p = 0.037) and VHC arm -4.75% (95% CI -8.74, -0.76, p = 0.021). Appropriate treatment by CHWs was encouragingly high across arms. The inSCALE mHealth and VHC interventions have the potential to reduce CHW attrition and improve the care quality for sick children, but not through improved CHW management as we had hypothesised. Trial Registration:ClinicalTrials.gov (NCT01972321).

Lessons from an eight-country community health data harmonization collaborative

BACKGROUND

Community health workers (CHWs) are individuals who are trained and equipped to provide essential health services to their neighbors and have increased access to healthcare in communities worldwide for more than a century. However, the World Health Organization (WHO) Guideline on Health Policy and System Support to Optimize Community Health Worker Programmes reveals important gaps in the evidentiary certainty about which health system design practices lead to quality care. Routine data collection across countries represents an important, yet often untapped, opportunity for exploratory data analysis and comparative implementation science. However, epidemiological indicators must be harmonized and data pooled to better leverage and learn from routine data collection.

METHODS

This article describes a data harmonization and pooling Collaborative led by the organizations of the Community Health Impact Coalition, a network of health practitioners delivering community-based healthcare in dozens of countries across four WHO regions.

OBJECTIVES

The goals of the Collaborative project are to; (i) enable new opportunities for cross-site learning; (ii) use positive and negative outlier analysis to identify, test, and (if helpful) propagate design practices that lead to quality care; and (iii) create a multi-country 'brain trust' to reinforce data and health information systems across sites.

RESULTS

This article outlines the rationale and methods used to establish a data harmonization and pooling Collaborative, early findings, lessons learned, and directions for future research.

Evaluating the effectiveness of Community Health Worker home visits on infant health: A quasi-experimental evaluation of Home Based Newborn Care Plus in India

Background

Home visits by community health workers are promoted to improve the coverage and uptake of evidence-based newborn services and behaviours. However, evidence on the effectiveness of these home visits delivered through government systems at scale is limited, as is evidence from the post-neonatal period. From 2013 to 2017, the Government of India piloted an intervention called Home Based Newborn Care Plus with the goal of reducing pneumonia- and diarrhoea-related morbidity and malnutrition. Village-based Accredited Social Health Activists were incentivised to make quarterly home visits to infants between three and 12 months of age. After the pilot, the intervention was adapted and scaled up nationally (with an additional visit at 15 months of age) as a new programme called Home Based Care for Young Child.

Methods

The study used a quasi-experimental, difference-in-differences method to assess the quantitative impact on key outcome indicators by comparing changes over time in treatment districts with matched control districts. This was supplemented by a quantitative health worker survey and qualitative data collected at worker and community level.

Results

The intervention led to a significant increase in the number of home visits, and their content became more aligned with Home Based Newborn Care Plus protocols. However, absolute levels of coverage remained low. The intervention had no detectable effect on the key outcomes of feeding practices, handwashing, iron and folic acid and oral rehydration solution supplementation, growth monitoring, and immunisation.

Conclusions

Given the scale up of Home-Based Care for Young Child, there is a need to identify appropriate and comprehensive support for Accredited Social Health Activists to attain high coverage and quality and deliver impact. This will require reconsidering current design elements (such as incentives) and solving the underlying demand side and system level challenges (such as workload and supply chains) constraining Accredited Social Health Activists.

Community health workers at the dawn of a new era: 11. CHWs leading the way to "Health for All"

BACKGROUND

This is the concluding paper of our 11-paper supplement, "Community health workers at the dawn of a new era".

METHODS

We relied on our collective experience, an extensive body of literature about community health workers (CHWs), and the other papers in this supplement to identify the most pressing challenges facing CHW programmes and approaches for strengthening CHW programmes.

RESULTS

CHWs are increasingly being recognized as a critical resource for achieving national and global health goals. These goals include achieving the health-related Sustainable Development Goals of Universal Health Coverage, ending preventable child and maternal deaths, and making a major contribution to the control of HIV, tuberculosis, malaria, and noncommunicable diseases. CHWs can also play a critical role in responding to current and future pandemics. For these reasons, we argue that CHWs are now at the dawn of a new era. While CHW programmes have long been an underfunded afterthought, they are now front and centre as the emerging foundation of health systems. Despite this increased attention, CHW programmes continue to face the same pressing challenges: inadequate financing, lack of supplies and commodities, low compensation of CHWs, and inadequate supervision. We outline approaches for strengthening CHW programmes, arguing that their enormous potential will only be realized when investment and health system support matches rhetoric. Rigorous monitoring, evaluation, and implementation research are also needed to enable CHW programmes to continuously improve their quality and effectiveness.

CONCLUSION

A marked increase in sustainable funding for CHW programmes is needed, and this will require increased domestic political support for prioritizing CHW programmes as economies grow and additional health-related funding becomes available. The paradigm shift called for here will be an important step in accelerating progress in achieving current global health goals and in reaching the goal of Health for All.

From direct engagement to technical support: a programmatic evolution to improve large community health worker programs in Bihar, India

INTRODUCTION

In 2011, through a multipartner Integrated Family Health Initiative (IFHI), CARE started supporting maternal and neonatal health (MNH) improvement goals in 8 of 38 districts in Bihar, India. The programme included a frontline health worker (FHW) component offering health advice through household visits and benefited from CARE's direct engagement during IFHI, which then evolved into statewide Technical Support Unit (TSU) to the Government of Bihar in 2014.

METHODS

Using eight rounds of state-representative household surveys with mothers of infants aged 0-2 months (N=73 093) linked with two facility assessments conducted during 2012-2017, we assessed changes in FHW visit coverage, intensity and quality between IFHI and TSU phases. Using logistic regression models, we ascertained associations between FHW outputs and three MNH core practices: ≥3 antenatal care check-ups (ANC3+), institutional delivery and early breastfeeding initiation.

RESULTS

Women's receipt of 1+ FHW visits declined from 60.2% (IFHI phase) to 46.3% (TSU phase) in the eight IFHI districts, being below 40% statewide during the TSU phase. Despite a parallel decline in FHW visit quality measured as the number of health advice received, all three outcomes improved during the TSU versus IFHI phase in IFHI districts. We found significant positive associations between all three outcomes and receipt of 1+ FHW visits and programme phase (TSU vs IFHI) in the eight IFHI districts. During the TSU phase, receipt of 2+ FHW visits in the third trimester increased the odds of women receiving ANC3+ (adjusted OR (aOR)=1.21; 95% CI: 1.13 to 1.31), delivering in a facility (aOR=1.64; 95% CI: 1.51 to 1.77) and initiating breast feeding early (aOR=1.18; 95% CI: 1.05 to 1.18). Independent of the number and timing of FHW visits, we also found positive associations between women reporting higher than lower quality of FHW interactions and receiving outcome-specific advice and all three MNH outcomes.

CONCLUSION

Implementation of large community-based interventions under the technical support model should be continuously and strategically evaluated and adapted.

The role of governance in implementing sustainable global health interventions: review of health system integration for integrated community case management (iCCM) of childhood illnesses

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.

Mind the Global Community Health Funding Gap

Community health workers play a critical role in providing both essential health services and pandemic response. Community health demonstrates a strong return on investment, but funding for this sector is limited and fragmented. Understanding the underlying costs of a community health system is crucial for both planning and policy; the data demonstrate a strong investment case.

Proactive case detection of common childhood illnesses by community health workers: a systematic review

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.

Proactive community case management and child survival: protocol for a cluster randomised controlled trial

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.

Who are the real community health workers in Tshopo Province, Democratic Republic of the Congo?

Recent years have seen increasing momentum towards task shifting of basic health services, including using community health workers (CHW) to diagnose and treat common childhood illnesses. Yet few studies have examined the role of traditional healers in meeting families’ and communities’ health needs and liaising with the formal health system. We examine these issues in Tshopo Province in the Democratic Republic of the Congo, a country with high rates of child mortality (104 deaths per 1000 live births). We conducted 127 in-depth interviews and eight focus group discussions with a range of community members (mothers, fathers and grandmothers of children under 5 years of age) and health providers (CHWs, traditional healers, doctors and nurses) on topics related to care seeking and case management for childhood illness and malnutrition, and analysed them iteratively using thematic content analysis. We find significant divergence between biomedical descriptions of child illness and concepts held by community members, who distinguished between local illnesses and so-called ‘white man’s diseases.’ Traditional healers were far less costly and more geographically accessible to families than were biomedical health providers, and usually served as families’ first recourse after home care. Services provided by traditional healers were also more comprehensive than services provided by CHWs, as the traditional medicine sphere recognised and encompassed care for ‘modern’ diseases (but not vice versa). Meanwhile, CHWs did not receive adequate training, supervision or supplies to provide child health services. Considering their accessibility, acceptability, affordability and ability to recognise all domains of illness (biomedical and spiritual), traditional healers can be seen as the de facto CHWs in Tshopo Province. National and international health policymakers should account for and involve this cadre of health workers when planning child health services and seeking to implement policies and programmes that genuinely engage with community health systems.

Testing a simplified tool and training package to improve integrated Community Case Management in Tanganyika Province, Democratic Republic of Congo: a quasi-experimental study

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.

Employing practitioner expertise in optimizing community healthcare systems

To harness the potential of community health workers (CHWs) to extend health services to poor and marginalized populations and avoid the pitfalls of the post-Alma-Ata period, there is an urgent need to better understand how CHW programs can be optimized. Understanding that several operational questions are unresolved by current academic evidence, this viewpoint considers the role of practitioner expertise in optimizing community health systems and highlights findings from a recently published report that captures implementation experience from 15 countries. The viewpoint considers applications of the report's suggested community health design principles and implications for implementers, philanthropists, policymakers, and academic researchers.

Expanding the population coverage of evidence-based interventions with community health workers to save the lives of mothers and children: an analysis of potential global impact using the Lives Saved Tool (LiST)

Background

Evidence has been accumulating that community health workers (CHWs) providing evidence–based interventions as part of community–based primary health care (CBPHC) can lead to reductions in maternal, neonatal and child mortality. However, investments to strengthen and scale–up CHW programs still remain modest.

Methods

We used the Lives Saved Tool (LiST) to estimate the number of maternal, neonatal and child deaths and stillbirths that could be prevented if 73 countries effectively scaled up the population coverage of 30 evidence–based interventions that CHWs can deliver in these high–burden countries. We set population coverage targets at 50%, 70%, and 90% and summed the country–level results by region and by all 73 high–burden countries combined. We also estimated which specific interventions would save the most lives.

Findings

LiST estimates that a total of 3.0 (sensitivity bounds 1.8–4.0), 4.9 (3.1–6.3) and 6.9 (3.7–8.7) million deaths would be prevented between 2016 and 2020 if CBPHC is gradually scaled up during this period and if coverage of key interventions reaches 50%, 70%, and 90% respectively. There would be 14%, 23%, and 32% fewer deaths in the final year compared to a scenario assuming no intervention coverage scale up. The Africa Region would receive the most benefit by far: 58% of the lives saved at 90% coverage would be in this region. The interventions contributing the greatest impact are nutritional interventions during pregnancy, treatment of malaria with artemisinin compounds, oral rehydration solution for childhood diarrhea, hand washing with soap, and oral antibiotics for pneumonia.

Conclusions

Scaling up CHW programming to increase population–level coverage of life–saving interventions represents a very promising strategy to achieve universal health coverage and end preventable maternal and child deaths by 2030. Numerous practical challenges must be overcome, but there is no better alternative at present. Expanding the coverage of key interventions for maternal nutrition and treatment of childhood illnesses, in particular, may produce the greatest gains. Recognizing the millions of lives of mothers and their young offspring that could be achieved by expanding coverage of evidence–based interventions provided by CHWs and strengthening the CBPHC systems that support them underscores the pressing need for commitment from governments and donors over the next 15 years to prioritize funding, so that robust CHW platforms can be refined, strengthened, and expanded.

Proactive community case management and child survival in periurban Mali

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.

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

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.