Does integrated community case management (iCCM) target health inequities and treatment delays? Evidence from an analysis of Demographic and Health Surveys data from 21 countries in the period 2010 to 2018

Know-do gap for sick child care and drivers of knowledge and practice among health extension workers in four regions of Ethiopia: a cross-sectional study

OBJECTIVE

Though efforts were made to expand community-based sick child healthcare in Ethiopia, the quality of care provided remained low. Improving quality of care requires understanding providers' knowledge of appropriate care and their actual execution of tasks. This study examined gap between what health extension workers (HEWs) knew and did during the management of sick children in Ethiopia.

DESIGN

Facility-based cross-sectional study was conducted.

SETTING

The study was carried out in 52 districts across 4 regions in Ethiopia.

PARTICIPANTS

We interviewed 274 HEWs and performed observations of consultations done by 150 HEWs supplemented with facility assessment from December 2018 to February 2019.

OUTCOME

We compared providers' knowledge and performance in the management of childhood pneumonia and diarrhoea. Know-do gap implies the difference in proportion between knowledge and actual practice of HEWs. Logistic regression was used to identify predictors of knowledge and actual practice.

RESULTS

Providers' correct knowledge ranged from 27.8% to 76.0% for signs and symptoms of pneumonia, and 32.0% to 84% for dehydration signs. Their actual practices ranged from 15.1% to 47.3% for pneumonia and 27.0% to 42.6% for dehydration. The correct knowledge and actual practices for pneumonia and dehydration management were 88.3% vs 15.6% and 93.9% vs 51.3%, respectively. There was significant know-do gap in assessments (16.7%, p=0.002) and management of childhood conditions (68.5%, p<0.0001). Mentorships were associated with providers' knowledge of clinical management, while medicines availability was associated with their actual management practice.

CONCLUSIONS

While knowledge and actual practice for assessment and management of pneumonia and dehydration ranged from very low to high, what is more concerning is the huge know-do gap among HEWs. Our findings suggest that knowledge-based training is necessary but not sufficient for ensuring correct assessment and management of sick children by HEWs. Continuous support through mentorships and the supply of commodities are critically needed.

Effectiveness of community case management of malaria on severe malaria and inpatient malaria deaths in Zambia: a dose-response study using routine health information system data

BACKGROUND

Community case management of malaria (CCM) has been expanded in many settings, but there are limited data describing the impact of these services in routine implementation settings or at large scale. Zambia has intensively expanded CCM since 2013, whereby trained volunteer community health workers (CHW) use rapid diagnostic tests and artemether-lumefantrine to diagnose and treat uncomplicated malaria.

METHODS

This retrospective, observational study explored associations between changing malaria service point (health facility or CHW) density per 1000 people and severe malaria admissions or malaria inpatient deaths by district and month in a dose-response approach, using existing routine and programmatic data. Negative binomial generalized linear mixed-effect models were used to assess the impact of increasing one additional malaria service point per 1000 population, and of achieving Zambia's interim target of 1 service point per 750 population. Access to insecticide-treated nets, indoor-residual spraying, and rainfall anomaly were included in models to reduce potential confounding.

RESULTS

The study captured 310,855 malaria admissions and 7158 inpatient malaria deaths over 83 districts (seven provinces) from January 2015 to May 2020. Total CHWs increased from 43 to 4503 during the study period, while health facilities increased from 1263 to 1765. After accounting for covariates, an increase of one malaria service point per 1000 was associated with a 19% reduction in severe malaria admissions among children under five (incidence rate ratio [IRR] 0.81, 95% confidence interval [CI] 0.75-0.87, p < 0.001) and 23% reduction in malaria deaths among under-fives (IRR 0.77, 95% CI 0.66-0.91). After categorizing the exposure of population per malaria service point, there was evidence for an effect on malaria admissions and inpatient malaria deaths among children under five only when reaching the target of one malaria service point per 750 population.

CONCLUSIONS

CCM is an effective strategy for preventing severe malaria and deaths in areas such as Zambia where malaria diagnosis and treatment access remains challenging. These results support the continued investment in CCM scale-up in similar settings, to improve access to malaria diagnosis and treatment.

Improving access to care and community health in Haiti with optimized community health worker placement

The national deployment of polyvalent community health workers (CHWs) is a constitutive part of the strategy initiated by the Ministry of Health to accelerate efforts towards universal health coverage in Haiti. Its implementation requires the planning of future recruitment and deployment activities for which mathematical modelling tools can provide useful support by exploring optimised placement scenarios based on access to care and population distribution. We combined existing gridded estimates of population and travel times with optimisation methods to derive theoretical CHW geographical placement scenarios including constraints on walking time and the number of people served per CHW. Four national-scale scenarios that align with total numbers of existing CHWs and that ensure that the walking time for each CHW does not exceed a predefined threshold are compared. The first scenario accounts for population distribution in rural and urban areas only, while the other three also incorporate in different ways the proximity of existing health centres. Comparing these scenarios to the current distribution, insufficient number of CHWs is systematically identified in several departments and gaps in access to health care are identified within all departments. These results highlight current suboptimal distribution of CHWs and emphasize the need to consider an optimal (re-)allocation.