Nationwide implementation of integrated community case management of childhood illness in Rwanda

Perceptions towards management of acute malnutrition by community health volunteers in northern Kenya

Child undernutrition is a persistent challenge in arid and semi-arid areas due to low and erratic rainfall, recurrent droughts and food insecurity. In these settings, caregivers face several challenges in accessing health services for sick and/or malnourished children, including long distances to health facilities, harsh terrain, and lack of money to pay for transportation costs to the health facilities, leading to low service coverage and sub-optimal treatment outcomes. To address these challenges and optimize treatment outcomes, the World Health Organization recommends utilizing community health volunteers (CHVs) to manage acute malnutrition in the community. This study explored the perceptions of community members regarding acute malnutrition treatment by CHVs in Turkana and Isiolo counties in Kenya. The study utilized a cross-sectional study design and included a purposive sample of caregivers of children, CHVs, officers who trained and supervised CHVs and community leaders in the intervention area. Focus group discussions and key informant interviews were used to explore perceptions towards the management of acute malnutrition by CHVs. Generally, caregivers and CHVs perceived the intervention to be beneficial as it readily addressed acute malnutrition treatment needs in the community. The intervention was perceived to be acceptable, effective, and easily accessible. The community health structure provided a platform for commodity supply and management and CHV support supervision. This was a major enabler in implementing the intervention. The intervention faced operational and systemic challenges that should be considered before scale-up.

mHealth-community health worker telemedicine intervention for surgical site infection diagnosis: a prospective study among women delivering via caesarean section in rural Rwanda

Background

Surgical site infections (SSIs) cause a significant global public health burden in low and middle-income countries. Most SSIs develop after patient discharge and may go undetected. We assessed the feasibility and diagnostic accuracy of an mHealth-community health worker (CHW) home-based telemedicine intervention to diagnose SSIs in women who delivered via caesarean section in rural Rwanda.

Methods

This prospective cohort study included women who underwent a caesarean section at Kirehe District Hospital between September 2019 and March 2020. At postoperative day 10 (±3 days), a trained CHW visited the woman at home, provided wound care and transmitted a photo of the wound to a remote general practitioner (GP) via WhatsApp. The GP reviewed the photo and made an SSI diagnosis. The next day, the woman returned to the hospital for physical examination by an independent GP, whose SSI diagnosis was considered the gold standard for our analysis. We describe the intervention process indicators and report the sensitivity and specificity of the telemedicine-based diagnosis.

Results

Of 787 women included in the study, 91.4% (n=719) were located at their home by the CHW and all of them (n=719, 100%) accepted the intervention. The full intervention was completed, including receipt of GP telemedicine diagnosis within 1 hour, for 79.0% (n=623). The GPs diagnosed 30 SSIs (4.2%) through telemedicine and 38 SSIs (5.4%) through physical examination. The telemedicine sensitivity was 36.8% and specificity was 97.6%. The negative predictive value was 96.4%.

Conclusions

Implementation of an mHealth-CHW home-based intervention in rural Rwanda and similar settings is feasible. Patients’ acceptance of the intervention was key to its success. The telemedicine-based SSI diagnosis had a high negative predictive value but a low sensitivity. Further studies must explore strategies to improve accuracy, such as accompanying wound images with clinical data or developing algorithms using machine learning.

The Effect and Feasibility of mHealth-Supported Surgical Site Infection Diagnosis by Community Health Workers After Cesarean Section in Rural Rwanda: Randomized Controlled Trial

Background

The development of a surgical site infection (SSI) after cesarean section (c-section) is a significant cause of morbidity and mortality in low- and middle-income countries, including Rwanda. Rwanda relies on a robust community health worker (CHW)–led, home-based paradigm for delivering follow-up care for women after childbirth. However, this program does not currently include postoperative care for women after c-section, such as SSI screenings.

Objective

This trial assesses whether CHW’s use of a mobile health (mHealth)–facilitated checklist administered in person or via phone call improved rates of return to care among women who develop an SSI following c-section at a rural Rwandan district hospital. A secondary objective was to assess the feasibility of implementing the CHW-led mHealth intervention in this rural district.

Methods

A total of 1025 women aged ≥18 years who underwent a c-section between November 2017 and September 2018 at Kirehe District Hospital were randomized into the three following postoperative care arms: (1) home visit intervention (n=335, 32.7%), (2) phone call intervention (n=334, 32.6%), and (3) standard of care (n=356, 34.7%). A CHW-led, mHealth-supported SSI diagnostic protocol was delivered in the two intervention arms, while patients in the standard of care arm were instructed to adhere to routine health center follow-up. We assessed intervention completion in each intervention arm and used logistic regression to assess the odds of returning to care.

Results

The majority of women in Arm 1 (n=295, 88.1%) and Arm 2 (n=226, 67.7%) returned to care and were assessed for an SSI at their local health clinic. There were no significant differences in the rates of returning to clinic within 30 days (P=.21), with high rates found consistently across all three arms (Arm 1: 99.7%, Arm 2: 98.4%, and Arm 3: 99.7%, respectively).

Conclusions

Home-based post–c-section follow-up is feasible in rural Africa when performed by mHealth-supported CHWs. In this study, we found no difference in return to care rates between the intervention arms and standard of care. However, given our previous study findings describing the significant patient-incurred financial burden posed by traveling to a health center, we believe this intervention has the potential to reduce this burden by limiting patient travel to the health center when an SSI is ruled out at home. Further studies are needed (1) to determine the acceptability of this intervention by CHWs and patients as a new standard of care after c-section and (2) to assess whether an app supplementing the mHealth screening checklist with image-based machine learning could improve CHW diagnostic accuracy.

Trial Registration

ClinicalTrials.gov NCT03311399; https://clinicaltrials.gov/ct2/show/NCT03311399

Enablers and barriers to post-discharge follow-up among women who have undergone a caesarean section: experiences from a prospective cohort in rural Rwanda

Background

Caesarean sections account for roughly one third of all surgical procedures performed in low-income countries. Due to lack of standardised post-discharge follow-up protocols and practices, most of available data are extracted from clinical charts during hospitalization and are thus sub-optimal for answering post-discharge outcomes questions. This study aims to determine enablers and barriers to returning to the hospital after discharge among women who have undergone a c-section at a rural district hospital in Rwanda.

Methods

Women aged ≥ 18 years who underwent c-section at Kirehe District Hospital in rural Rwanda in the period March to October 2017 were prospectively followed. A structured questionnaire was administered to participants and clinical data were extracted from medical files between March and October 2017. At discharge, consenting women were given an appointment to return for follow-up on postoperative day 10 (POD 10) (± 3 days) and provided a voucher to cover transport and compensation for participation to be redeemed on their return. Study participants received a reminder call on the eve of their scheduled appointment. We used a backward stepwise logistic regression, at an α = 0.05 significance level, to identify enablers and barriers associated with post-discharge follow-up return.

Results

Of 586 study participants, the majority (62.6%) were between 21–30 years old and 86.4% had a phone contact number. Of those eligible, 90.4% returned for follow-up. The predictors of return were counselling by a female data collector (OR = 9.85, 95%CI:1.43–37.59) and receiving a reminder call (OR = 16.47, 95%CI:7.07–38.38). Having no insurance reduced the odds of returning to follow-up (OR = 0.03, 95%CI:0.03–0.23), and those who spent more than 10.6 Euro for transport to and from the hospital were less likely to return to follow-up (OR = 0.14, 95%CI:0.04- 0.50).

Conclusion

mHealh interventions using calls or notifications can increase the post-discharge follow-up uptake. The reminder calls to patients and discharge counselling by a gender-matching provider had a positive effect on return to care. Further interventions are needed targeting the uninsured and patients facing transportation hardship. Additionally, association between counselling of women patients by a female data collector and greater return to follow-up needs further exploration to optimize counselling procedures.

Supplementary information

The online version contains supplementary material available at 10.1186/s12913-022-08137-5.

A cost analysis of the diagnosis and treatment of malaria at public health facilities and communities in three districts in Rwanda

Background

Malaria is a potentially fatal disease spread by the bites of Plasmodium-infected Anopheles mosquitoes. Despite long-term efforts to control malaria in Rwanda, malaria incidence increased from 48 to 403 cases/1000 individuals between 2012 and 2016. The diagnosis and treatment of malaria occurs at multiple levels, but the costs of these activities are not well understood. This research was conducted to estimate the direct medical costs incurred by the Ministry of Health in diagnosing and treating malaria in three districts of Rwanda in 2018.

Methods

A cross-sectional and retrospective costing analysis was conducted in three districts that represented low (5–200 cases per 1000 individuals), moderate (> 200–400 cases per 1000 individuals), and high (> 400 cases per 1000 individuals) endemicity regions. Data on malaria cases managed at three healthcare levels (community, health centre, district hospital) was obtained from national databases. The direct medical costs of cases per malaria severity (‘simple malaria’, ‘simple malaria with minor digestive symptoms’, and ‘severe malaria’) were calculated based on the minimum package of health services provided. Total costs for each of the three districts were also calculated.

Results

A total of 298,381 malaria cases were recorded in Burera, Kirehe, and Southern Kayonza districts in 2018. The average unit cost per case ranged from USD 1.36 (for simple malaria at the community level) to USD 92.80 (for severe malaria with cerebral complications at district hospitals). Simple malaria cases managed at health centres and district hospitals were more than two-fold (USD 2.99–USD 3.00) and more than eight-fold (USD 12.10–USD 12.12) higher, respectively, than those managed in the community (USD 1.36). Overall, the Ministry of Health incurred USD 645,647.68 in direct medical costs related to malaria management across the three districts in 2018. Changes in disease rates from different endemicity regions and costs of anti-malarial oral medications significantly impacted the study results.

Conclusion

In Rwanda, severe malaria results in much higher expenses compared to other malaria types. Prompt diagnosis and appropriate treatment are crucial to prevent the progression of simple malaria to severe malaria, to reduce Ministry of Health malaria expenditures, and to reduce community transmission.

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.

Factors associated with the referral of children with severe illnesses at primary care level in Ethiopia: a cross-sectional study

CONTEXT AND OBJECTIVE

Ethiopia's primary care has a weak referral system for sick children. We aimed to identify health post and child factors associated with referrals of sick children 0-59 months of age and evaluate the healthcare providers' adherence to referral guidelines.

DESIGN

A cross-sectional facility-based survey.

SETTING

This study included data from 165 health posts in 52 districts in four Ethiopian regions collected from December 2018 to February 2019. The data included interviews with health extension workers, assessment of health post preparedness, recording of global positioning system (GPS)-coordinates of the health post and the referral health centre, and reviewing registers of sick children treated during the last 3 months at the health posts. We analysed the association between the sick child's characteristics, health post preparedness and distance to the health centre with referral of sick children by multivariable logistic regressions.

OUTCOME MEASURE

Referral to the nearest health centre of sick young infants aged 0-59 days and sick children 2-59 months.

RESULTS

The health extension workers referred 39/229 (17%) of the sick young infants and 78/1123 (7%) of the older children to the next level of care. Only 18 (37%) sick young infants and 22 (50%) 2-59 months children that deserved urgent referral according to guidelines were referred. The leading causes of referral were possible serious bacterial infection and pneumonia. Those being classified as a severe disease were referred more frequently. The availability of basic amenities (adjusted OR, AOR=0.38, 95% CI 0.15 to 0.96), amoxicillin (AOR=0.41, 95% CI 0.19 to 0.88) and rapid diagnostic test (AOR=0.18, 95% CI 0.07 to 0.46) were associated with less referral in the older age group.

CONCLUSION

Few children with severe illness were referred from health posts to health centres. Improving the health posts' medicine and diagnostic supplies may enhance adherence to referral guidelines and ultimately reduce child mortality.

Caregivers' and Health Extension Workers' Perceptions and Experiences of Outreach Management of Childhood Illnesses in Ethiopia: A Qualitative Study

INTRODUCTION

Ethiopian Health Extension Workers provide facility-based and outreach services, including home visits to manage sick children, aiming to increase equity in service coverage. Little is known about the scope of the outreach services and caregivers' and health workers' perceptions of these services. We aimed at exploring mothers' and health extension workers' perceptions and experiences of the outreach services provided for the management of childhood illnesses.

METHODS

Four focus groups and eight key informant interviews were conducted. A total of 45 community members participated. Interviews were recorded, transcribed verbatim, and translated into English. We applied thematic content analysis, identified challenges in providing outreach services, and suggestions for improvement. We balanced the data collection by selecting half of the participants for interview and focus group discussions from remote areas and the other half from areas closer to the health posts.

RESULTS

Mothers reported that health extension workers visited their homes for preventive services but not for managing childhood illnesses. They showed lack of trust in the health workers' ability to treat children at home. The health extension workers reported that they provide sick children treatment during outreach services but also stated that in most cases, mothers visit the health posts when their child is sick. On the other hand, mothers considered distance from home to health post not to be a problem if the quality of services improved. Workload, long distances, and lack of incentives were perceived as demotivating factors for outreach services. The health workers called for support, incentives, and capacity development activities.

CONCLUSIONS

Mothers and health extension workers had partly divergent perceptions of whether outreach curative services for children were available. Mothers wanted improvements in the quality of services while health workers requested capacity development and more support for providing effective community-based child health services.

Is patient navigation a solution to the problem of "leaving no one behind"? A scoping review of evidence from low-income countries

Patient navigation interventions, which are designed to enable patients excluded from health systems to overcome the barriers they face in accessing care, have multiplied in high-income countries since the 1990s. However, in low-income countries (LICs), indigents are generally excluded from health policies despite the international paradigm of universal health coverage (UHC). Fee exemption interventions have demonstrated their limits and it is now necessary to act on other dimensions of access to healthcare. However, there is a lack of knowledge about the interventions implemented in LICs to support the indigents throughout their care pathway. The aim of this paper is to synthesize what is known about patient navigation interventions to facilitate access to modern health systems for vulnerable populations in LICs. We therefore conducted a scoping review to identify all patient navigation interventions in LICs. We found 60 articles employing a total of 48 interventions. Most of these interventions targeted traditional beneficiaries such as people living with HIV, pregnant women and children. We utilized the framework developed by Levesque et al. (Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health 2013;12:18) to analyse the interventions. All acted on the ability to perceive, 34 interventions on the ability to reach, 30 on the ability to engage, 8 on the ability to pay and 6 on the ability to seek. Evaluations of these interventions were encouraging, as they often appeared to lead to improved health indicators and service utilization rates and reduced attrition in care. However, no intervention specifically targeted indigents and very few evaluations differentiated the impact of the intervention on the poorest populations. It is therefore necessary to test navigation interventions to enable those who are worst off to overcome the barriers they face. It is a major ethical issue that health policies leave no one behind and that UHC does not benefit everyone except the poorest.

Integrated community case management of childhood illness in low- and middle-income countries

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.

History of malaria control in Rwanda: implications for future elimination in Rwanda and other malaria-endemic countries

BACKGROUND

Malaria was first reported in Rwanda in the early 1900s with significant heterogeneity and volatility in transmission over subsequent decades. Here, a comprehensive literature review of malaria transmission patterns and control strategies in Rwanda between 1900 and 2018 is presented to provide insight into successes and challenges in the country and to inform the future of malaria control in Rwanda.

METHODS

A systematic literature search of peer-reviewed publications (Web of Knowledge, PubMed, Google Scholar, and the World Health Organization Library (WHOLIS) and grey literature on malaria control in Rwanda between 1900 and 2019 was conducted with the following search terms: "malaria"", "Rwanda", "epidemiology", "control", "treatment", and/or "prevention." Reports and other relevant documents were also obtained from the Rwanda National Malaria Control Programme (NMCP). To inform this literature review and evidence synthesis, epidemiologic and intervention data were collated from NMCP and partner reports, the national routine surveillance system, and population surveys.

RESULTS

Two hundred sixty-eight peer-reviewed publications and 56 grey literature items were reviewed, and information was extracted. The history of malaria control in Rwanda is thematically described here according to five phases: 1900 to 1954 before the launch of the Global Malaria Eradication Programme (GMEP); (2) Implementation of the GMEP from 1955 to 1969; (3) Post- GMEP to 1994 Genocide; (4) the re-establishment of malaria control from 1995 to 2005, and (5) current malaria control efforts from 2006 to 2018. The review shows that Rwanda was an early adopter of tools and approaches in the early 2000s, putting the country ahead of the curve and health systems reforms created an enabling environment for an effective malaria control programme. The last two decades have seen unprecedented investments in malaria in Rwanda, resulting in significant declines in disease burden from 2000 to 2011. However, in recent years, these gains appear to have reversed with increasing cases since 2012 although the country is starting to make progress again.

CONCLUSION

The review shows the impact and fragility of gains against malaria, even in the context of sustained health system development. Also, as shown in Rwanda, country malaria control programmes should be dynamic and adaptive to respond and address changing settings.

Using routine health information data for research in low- and middle-income countries: a systematic review

BACKGROUND

Routine health information systems (RHISs) support resource allocation and management decisions at all levels of the health system, as well as strategy development and policy-making in many low- and middle-income countries (LMICs). Although RHIS data represent a rich source of information, such data are currently underused for research purposes, largely due to concerns over data quality. Given that substantial investments have been made in strengthening RHISs in LMICs in recent years, and that there is a growing demand for more real-time data from researchers, this systematic review builds upon the existing literature to summarize the extent to which RHIS data have been used in peer-reviewed research publications.

METHODS

Using terms 'routine health information system', 'health information system', or 'health management information system' and a list of LMICs, four electronic peer-review literature databases were searched from inception to February 202,019: PubMed, Scopus, EMBASE, and EconLit. Articles were assessed for inclusion based on pre-determined eligibility criteria and study characteristics were extracted from included articles using a piloted data extraction form.

RESULTS

We identified 132 studies that met our inclusion criteria, originating in 37 different countries. Overall, the majority of the studies identified were from Sub-Saharan Africa and were published within the last 5 years. Malaria and maternal health were the most commonly studied health conditions, although a number of other health conditions and health services were also explored.

CONCLUSIONS

Our study identified an increasing use of RHIS data for research purposes, with many studies applying rigorous study designs and analytic methods to advance program evaluation, monitoring and assessing services, and epidemiological studies in LMICs. RHIS data represent an underused source of data and should be made more available and further embraced by the research community in LMIC health systems.

Institutionalization of integrated community case management into national health systems in low- and middle-income countries: a scoping review of the literature

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.

Achievements and challenges of implementation in a mature iCCM programme: Malawi case study

Background

Malawi has a mature integrated community case management (iCCM) programme that is led by the Ministry of Health (MOH) but that still relies on donor support. From 2013 until 2017, under the Rapid Access Expansion (RAcE) programme, the World Health Organization supported the MOH to expand and strengthen iCCM services in four districts. This paper examines Malawi’s iCCM programme performance and implementation strength in RAcE districts to further strengthen the broader programme.

Methods

Baseline and endline household surveys were conducted in iCCM-eligible areas of RAcE districts. Primary caregivers of recently-sick children under five were interviewed to assess changes in care-seeking and treatment over the project period. Health surveillance assistants (HSAs) were surveyed at endline to assess iCCM implementation strength.

Results

Care-seeking from HSAs and treatment of fever improved over the project period. At endline, however, less than half of sick children were brought to an HSA, many caregivers reported a preference for providers other than HSAs, and perceptions of HSAs as trusted providers of high-quality, convenient care had decreased. HSA supervision and mentorship were below MOH targets. Stockouts of malaria medicines were associated with decreased care-seeking from HSAs. Thirty percent of clusters had limited or no access to iCCM (no HSA or an HSA providing iCCM services less than 2 days per week); 50% had moderate access (an HSA providing iCCM services 2 to 4 days per week; and 20% had high access (a resident HSA providing iCCM services 5 or more days per week). Moderate access to iCCM was associated with increased care-seeking from HSAs, increased treatment by HSAs, and more positive perceptions of HSAs compared to areas with limited or no access. Areas with high access to iCCM did not show further improvements above areas with moderate access.

Conclusions

Availability of well-equipped and supported HSAs is critical to the provision of iCCM services. Additional qualitative research is needed to examine challenges and to inform potential solutions. Malawi’s mature iCCM programme has a strong foundation but can be improved to strengthen the continuity of care from communities to facilities and to ultimately improve child health outcomes.

Beyond the building blocks: integrating community roles into health systems frameworks to achieve health for all

Achieving ambitious health goals-from the Every Woman Every Child strategy to the health targets of the sustainable development goals to the renewed promise of Alma-Ata of 'health for all'-necessitates strong, functional and inclusive health systems. Improving and sustaining community health is integral to overall health systems strengthening efforts. However, while health systems and community health are conceptually and operationally related, the guidance informing health systems policymakers and financiers-particularly the well-known WHO 'building blocks' framework-only indirectly addresses the foundational elements necessary for effective community health. Although community-inclusive and community-led strategies may be more difficult, complex, and require more widespread resources than facility-based strategies, their exclusion from health systems frameworks leads to insufficient attention to elements that need ex-ante efforts and investments to set community health effectively within systems. This paper suggests an expansion of the WHO building blocks, starting with the recognition of the essential determinants of the production of health. It presents an expanded framework that articulates the need for dedicated human resources and quality services at the community level; it places strategies for organising and mobilising social resources in communities in the context of systems for health; it situates health information as one ingredient of a larger block dedicated to information, learning and accountability; and it recognises societal partnerships as critical links to the public health sector. This framework makes explicit the oft-neglected investment needs for community health and aims to inform efforts to situate community health within national health systems and global guidance to achieve health for all.

Effect of community-based intervention on improving access to treatment for sick under-five children in hard-to-reach communities in Niger State, Nigeria

BACKGROUND

Access to prompt and appropriate treatment is key to survival for children with malaria, pneumonia and diarrhoea. Community-based services are vital to extending care to remote populations. Malaria Consortium supported Niger state Ministry of Health, Nigeria, to introduce and implement an integrated community case management (iCCM) programme for four years in six local government areas (LGAs). The objective was to increase coverage of effective treatment for malaria, pneumonia and diarrhoea among children aged 2-59 months.

METHODS

The programme involved training, equipping, ongoing support and supervision of 1320 community volunteers (CORPs) to provide iCCM services to their communities in all six LGAs. Demand creation activities were also conducted; these included community dialogues, household mobilization, sensitization and mass media campaigns targeted at programme communities. To assess the level of changes in care seeking and treatment, baseline and endline household surveys were conducted in 2014 and 2017 respectively. For both surveys, a 30×30 multi-stage cluster sampling method was used, the sampling frame being RAcE programme communities.

RESULTS

Care-seeking from an appropriate provider increased overall and for each iCCM illness from 78% to 94% for children presenting with fever (P < 0.01), from 72% to 91% for diarrhoea cases (P < 0.01), and from 76% to 89% for cases of cough with difficult or fast breathing (P < 0.05). For diagnosis and treatment, the coverage of fevers tested for malaria increased from 34% to 77% (P < 0.001) and ACT treatments from 57% to 73% (<0.005); 56% of cases of cough or fast breathing who sought care from a CORP, had their respiratory rate counted and 61% with cough or fast breathing received amoxicillin. At endline caregivers sought care from CORPs in their communities for most cases of childhood illnesses (84%) compared to other providers at hospitals (1%) or health centres (9%).This aligns with caregivers' belief that CORPs are trusted providers (94%) who provide quality services (96%).

CONCLUSION

Implementation of iCCM with focused demand creation activities can improve access to quality lifesaving interventions from frontline community providers in Nigeria. This can contribute towards achieving SDGs if iCCM is scaled up to hard-to-reach areas of all states in the country.

Four delays of child mortality in Rwanda: a mixed methods analysis of verbal social autopsies

OBJECTIVES

We sought to understand healthcare-seeking patterns and delays in obtaining effective treatment for rural Rwandan children aged 1-5 years by analysing verbal and social autopsies (VSA). Factors in the home, related to transport and to quality of care in the formal health sector (FHS) were thought to contribute to delays.

DESIGN

We collected quantitative and qualitative cross-sectional data using the validated 2012 WHO VSA tool. Descriptive statistics were performed. We inductively and deductively coded narratives using the three delays model, conducted thematic content analysis and used convergent mixed methods to synthesise findings.

SETTING

The study took place in the catchment areas of two rural district hospitals in Rwanda-Kirehe and Southern Kayonza. Participants were caregivers of children aged 1-5 years who died in our study area between March 2013 and February 2014.

RESULTS

We analysed 77 VSAs. Although 74% of children (n=57) had contact with the FHS before dying, most (59%, n=45) died at home. Many caregivers (44%, n=34) considered using traditional medicine and 23 (33%) actually did. Qualitative themes reflected difficulty recognising the need for care, the importance of traditional medicine, especially for 'poisoning' and poor perceived quality of care. We identified an additional delay-phase IV-which occurred after leaving formal healthcare facilities. These delays were associated with caregiver dissatisfaction or inability to adhere to care plans.

CONCLUSION

Delays in deciding to seek care (phase I) and receiving quality care in FHS (phase III) dominated these narratives; delays in reaching a facility (phase II) were rarely discussed. An unwillingness or inability toadhere to treatment plans after leaving facilities (phase IV) were an important additional delay. Improving quality of care, especially provider capacity to communicate danger signs/treatment plans and promote adherence in the presence of alternative explanatory models informed by traditional medicine, could help prevent childhood deaths.

Modified systemic inflammatory response syndrome and provider gestalt predicting adverse outcomes in children under 5 years presenting to an urban emergency department of a tertiary hospital in Tanzania

BACKGROUND

Modified systemic inflammatory response syndrome (mSIRS) criteria for the pediatric population together with the provider gestalt have the potential to predict clinical outcomes. However, this has not been studied in low-income countries. We investigated the ability of mSIRS and provider gestalt to predict mortality and morbidity among children presenting to the ED of a tertiary level hospital in Tanzania.

METHODS

This prospective observational study enrolled a convenience sample of children under 5 years old, presenting to the Emergency Medicine Department of Muhimbili National Hospital from September 2015 to April 2016. Trained researchers used a structured case report form to record patient demographics, clinical presentation, initial provider gestalt of severity of illness, and the mSIRS criteria. Primary outcomes were 24-h mortality and overall in-hospital mortality. Data was analyzed using simple descriptive statistics, Kruskal-Wallis, Mann-Whitney U, and chi-squared tests.

RESULTS

We enrolled 1350 patients, median age 17 months (interquartile range 8-32 months), and 58% were male. Provider gestalt estimates of illness severity were recorded for all patients and 1030 (76.3%) had complete data for mSIRS categorization. Provider gestalt classified 97 (7.2%) patients as healthy, 546 (40.4%) as mildly ill, 457 (33.9%) as moderately ill, and 250 (18.5%) as severely ill. Of the patients, classifiable by mSIRS, 411/1030 (39.9%) had ≥ 2 mSIRS criteria. In predicting 24-h mortality, the ≥ 2 mSIRS and gestalt "severely ill" had sensitivities of 82% and 81%, respectively, and specificity of 61% and 84%, respectively. In predicting overall in-hospital mortality, the ≥ 2 mSIRS and gestalt "severely ill" had sensitivities of 66% and 70% with a specificity of 62% and 86% respectively.

CONCLUSION

Both the mSIRS and provider gestalt were highly specific for predicting 24-h and overall in-hospital mortality in our patient population. The clinical utility of these assessment methods is limited by the low positive predictive value.

Causes of death and predictors of childhood mortality in Rwanda: a matched case-control study using verbal social autopsy

Background

Rwanda has dramatically reduced child mortality, but the causes and sociodemographic drivers for mortality are poorly understood.

Methods

We conducted a matched case-control study of all children who died before 5 years of age in eastern Rwanda between 1st March 2013 and 28th February 2014 to identify causes and risk factors for death. We identified deaths at the facility level and via a community health worker reporting system. We used verbal social autopsy to interview caregivers of deceased children and controls matched by area and age. We used InterVA4 to determine probable causes of death and cause-specific mortality fractions, and utilized conditional logistic regression to identify clinical, family, and household risk factors for death.

Results

We identified 618 deaths including 174 (28.2%) in neonates and 444 (71.8%) in non-neonates. The most commonly identified causes of death were pneumonia, birth asphyxia, and meningitis among neonates and malaria, acute respiratory infections, and HIV/AIDS-related death among non-neonates. Among neonates, 54 (31.0%) deaths occurred at home and for non-neonates 242 (54.5%) deaths occurred at home. Factors associated with neonatal death included home birth (aOR: 2.0; 95% CI: 1.4–2.8), multiple gestation (aOR: 2.1; 95% CI: 1.3–3.5), both parents deceased (aOR: 4.7; 95% CI: 1.5–15.3), mothers non-use of family planning (aOR: 0.8; 95% CI: 0.6–1.0), lack of accompanying person (aOR: 1.6; 95% CI: 1.1–2.1), and a caregiver who assessed the medical services they received as moderate to poor (aOR: 1.5; 95% CI: 1.2–1.9). Factors associated with non-neonatal deaths included multiple gestation (aOR: 2.8; 95% CI: 1.7–4.8), lack of adequate vaccinations (aOR: 1.7; 95% CI: 1.2–2.3), household size (aOR: 1.2; 95% CI: 1.0–1.4), maternal education levels (aOR: 1.9; 95% CI: 1.2–3.1), mothers non-use of family planning (aOR: 1.6; 95% CI: 1.4–1.8), and lack of household electricity (aOR: 1.4; 95% CI: 1.0–1.8).

Conclusion

In the context of rapidly declining childhood mortality in Rwanda and increased access to health care, we found a large proportion of remaining deaths occur at home, with home deliveries still representing a significant risk factor for neonatal death. The major causes of death at a population level remain largely avoidable communicable diseases. Household characteristics associated with death included well-established socioeconomic and care-seeking risk factors.

Operationalising integrated community case management of childhood illnesses by community health workers in rural Haryana

AIM

To conduct implementation research in integrated community case management (ICCM) of childhood pneumonia, diarrhoea and fever by promoting accredited social health activists as treatment providers and generate lessons for upscaling this approach.

METHODS

In this one-sample study, 49 Accredited Social Health Activists were trained in ICCM. Community awareness and demand generation activities undertaken included announcements, pamphlets and posters. Supplies of medicines and supervision of activists were maintained throughout the 10-month implementation period. Three cross-sectional surveys were conducted in households with children aged 2-59 months for documenting two-week prevalence of illnesses and care-seeking practices. Focus group discussions and in-depth interviews were carried out with mothers/grandmothers and activists for documenting perceptions about health activists as treatment providers.

RESULTS

One third of pneumonia (113/334) and one quarter of diarrhoea (102/408) cases at end-line were treated by Accredited Social Health Activists. Proportion of households seeking care from private providers (mostly unqualified) reduced significantly from baseline to endline (81-56% for diarrhoea, p < 0.01; 78-48% for pneumonia, p < 0.01). At endline, activists were considered an acceptable and attractive source for treatment near home.

CONCLUSION

Trained Accredited Social Health Activists can treat uncomplicated childhood illnesses and are accepted by the community in this role.

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda

BACKGROUND

The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda.

METHODS

The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors.

RESULTS

In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions.

CONCLUSION

The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.

A Comparison of Health Achievements in Rwanda and Burundi

Strong primary health care systems are essential for implementing universal health coverage and fulfilling health rights entitlements, but disagreement exists over how best to create them. Comparing countries with similar histories, lifestyle practices, and geography but divergent health outcomes can yield insights into possible mechanisms for improvement. Rwanda and Burundi are two such countries. Both faced protracted periods of violence in the 1990s, leading to significant societal upheaval. In subsequent years, Rwanda's improvement in health has been far greater than Burundi's. To understand how this divergence occurred, we studied trends in life expectancy following the periods of instability in both countries, as well as the health policies implemented after these conflicts. We used the World Bank's World Development Indicators to assess trends in life expectancy in the two countries and then evaluated health policy reforms using Walt and Gilson's framework. Following both countries' implementation of health sector policies in 2005, we found a statistically significant increase in life expectancy in Rwanda after adjusting for GDP per capita (14.7 years, 95% CI: 11.4-18.0), relative to Burundi (4.6 years, 95% CI: 1.8-7.5). Strong public sector leadership, investments in health information systems, equity-driven policies, and the use of foreign aid to invest in local capacity helped Rwanda achieve greater health gains compared to Burundi.

Contribution of community health workers to improving access to timely and appropriate case management of childhood fever in Mozambique

Background

Large scale evaluations in several settings have demonstrated that lay community health workers can be trained to provide quality case management of childhood illnesses. In 2010, Mozambique introduced the integrated community case management (iCCM) strategy to reach children in remote areas with care provided through Agentes Polivalentes Elementares (APEs). We assessed the contribution of the program to improved care–seeking and appropriate treatment of childhood febrile illness in Nampula Province.

Methods

We used a post–test quasi–experimental design with three intervention and one comparison districts to compare access and appropriateness of care for sick children in Nampula province. We carried out a household survey in the study districts to measure levels of care–seeking and treatment of childhood fever after approximately two years of full implementation of the iCCM program in the intervention districts. We also assessed consistency of care with standard case management protocols comparing children receiving care from (APEs) to those receiving care from first–level health facilities.

Results

A total of 773 children 6–59 months with fever in the last two weeks were included in the study. In iCCM served areas, APEs were the predominant source of care and treatment; 87.1% (95% confidence interval CI 80.8–93.4) of children 6–59 months with fever who sought care were taken first to an APE and APEs accounted for 86.2% (95% CI 79.7–92.7) of all first–line antimalarial treatments. Public health facilities were the leading source of care in comparison areas, providing care to 86.1% (95% CI 79.0–93.3) of children with fever taken for care outside the home. Timeliness of treatment was significantly better in intervention areas, where 63.9% (95% CI 54.4–73.3) of children received treatment within 24 hours of symptom onset compared to 37.5% (95% CI 31.1–43.9) in comparison areas. Children taken first to an APE were more likely to receive a rapid diagnostic test (RDT) (68.1%; 95% CI 57.2–79.0) and to have their respiratory rate assessed (60.0%; 95% CI 45.4–74.6) compared to children taken to health facilities (41.4%; 95% CI33.7–49.2 and 19.4%; 95% CI 8.4–30.5, respectively). Overall, 61.3% (95% CI 51.5–71.0) of children with fever receiving care from APEs received the correct drug within 24 hours and for the correct duration compared to 26.0% (95% CI 18.2–33.9) of those receiving care from health facilities.

Conclusion

iCCM contributed to improved timely and appropriate treatment for fever for children living far from facilities. Trained, supplied and supervised APEs provided care consistent with iCCM protocols and performed significantly better than first level facilities on most measures of adherence to case management protocols. These findings reinforce the need for comprehensive efforts to strengthen the health system in Mozambique to enable reliable support for quality of case management of childhood illness at both health facility and community levels.

Care-seeking patterns among families that experienced under-five child mortality in rural Rwanda

Background

Over half of under-five deaths occur in sub-Saharan Africa and appropriate, timely, quality care is critical for saving children’s lives. This study describes the context surrounding children’s deaths from the time the illness was first noticed, through the care-seeking patterns leading up to the child’s death, and identifies factors associated with care-seeking for these children in rural Rwanda.

Methods

Secondary analysis of a verbal and social autopsy study of caregivers who reported the death of a child between March 2013 to February 2014 that occurred after discharge from the child’s birth facility in southern Kayonza and Kirehe districts in Rwanda. Bivariate analyses using Fisher’s exact tests were conducted to identify child, caregiver, and household factors associated with care-seeking from the formal health system (i.e., community health worker or health facility). Factors significant at α = 0.10 significance level were considered for backwards stepwise multivariate logistic regression, stopping when remaining factors were significantly associated with care-seeking at α = 0.05 significance level.

Results

Among the 516 eligible deaths among children under-five, 22.7% (n = 117) did not seek care from the health system. For those who did, the most common first point of contact was community health workers (45.8%). In multivariate logistic regression, higher maternal education (OR = 3.36, 95% CI: 1.89, 5.98), having diarrhea (OR = 4.21, 95%CI: 1.95, 9.07) or fever (OR = 2.03, 95%CI: 1.11, 3.72), full household insurance coverage (3.48, 95%CI: 1.79, 6.76), and longer duration of illness (OR = 22.19, 95%CI: 8.88, 55.48) were significantly associated with formal care-seeking.

Conclusion

Interventions such as community health workers and insurance promote access to care, however a gap remains as many children had no contact with the health system prior to death and those who sought formal care still died. Further efforts are needed to respond to urgent cases in communities and further understand remaining barriers to accessing appropriate, quality care.

Exploring Drivers of Infant Deaths in Rural Rwanda Through Verbal Social Autopsy

BACKGROUND

Rwanda has been a leader in the global effort to reduce infant mortality, particularly in regions of sub-Saharan Africa. Although rates have dropped, deaths still occur.

OBJECTIVE

To explore the care pathways and barriers taken by infant caregivers before the death of their infant through a verbal social autopsy study in 2 districts in eastern Rwanda.

METHODS

We adapted the World Health Organization verbal socialautopsy tools to reflect local context and priorities. Caregivers of infants in the 2 districts were interviewed using the adapted quantitative survey and semistructured interview guide. Interviews were recorded and thematic analysis employed on a subsample (n = 133) to extract the content relevant to understanding the drivers of infant death and inform results of the quantitative data until saturation was reached (66). Results were interpreted through a driver diagram framework to explore caregiver-reported challenges in knowledge and experiences with care access and delivery.

FINDINGS

Most study participants (82%) reported accessing the formal health system at some point before the infant's death. The primary caregiver-reported drivers for infant death included challenges in accessing care in a timely manner, concerns about the technical quality of care received, and poor responsiveness of the system and providers. The 2 most commonly discussed drivers were gaps in communication between providers and patients and challenges obtaining and using the community-based health insurance. The framework of the driver diagram was modified to identify the factors where change was needed to further reduce mortality.

CONCLUSION

This study provides important information on the experiential quality of care received by infants and their caregivers within the current health care space in rural Rwanda. By listening to the individual stories of so many caregivers regarding the gaps and challenges they faced, appropriate action may be taken to bolster the existing health care system.

Impact of a district-wide health center strengthening intervention on healthcare utilization in rural Rwanda: Use of interrupted time series analysis

Background

Evaluations of health systems strengthening (HSS) interventions using observational data are rarely used for causal inference due to limited data availability. Routinely collected national data allow use of quasi-experimental designs such as interrupted time series (ITS). Rwanda has invested in a robust electronic health management information system (HMIS) that captures monthly healthcare utilization data. We used ITS to evaluate impact of an HSS intervention to improve primary health care facility readiness on health service utilization in two rural districts of Rwanda.

Methods

We used controlled ITS analysis to compare changes in healthcare utilization at health centers (HC) that received the intervention (n = 13) to propensity score matched non-intervention health centers in Rwanda (n = 86) from January 2008 to December 2012. HC support included infrastructure renovation, salary support, medical equipment, referral network strengthening, and clinical training. Baseline quarterly mean outpatient visit rates and population density were used to model propensity scores. The intervention began in May 2010 and was implemented over a twelve-month period. We used monthly healthcare utilization data from the national Rwandan HMIS to study changes in the (1) number of facility deliveries per 10,000 women, (2) number of referrals for high risk pregnancy per 100,000 women, and (3) the number of outpatient visits performed per 1,000 catchment population.

Results

PHIT HC experienced significantly higher monthly delivery rates post-HSS during the April-June season than comparison (3.19/10,000, 95% CI: [0.27, 6.10]). In 2010, this represented a 13% relative increase, and in 2011, this represented a 23% relative increase. The post-HSS change in monthly rate of high-risk pregnancies referred increased slightly in intervention compared to control HC (0.03/10,000, 95% CI: [-0.007, 0.06]). There was a small immediate post-HSS increase in outpatient visit rates in intervention compared to control HC (6.64/1,000, 95% CI: [-13.52, 26.81]).

Conclusion

We failed to find strong evidence of post-HSS increases in outpatient visit rates or referral rates at health centers, which could be explained by small sample size and high baseline nation-wide health service coverage. However, our findings demonstrate that high quality routinely collected health facility data combined with ITS can be used for rigorous policy evaluation in resource-limited settings.

A retrospective review of the Pediatric Development Clinic implementation: a model to improve medical, nutritional and developmental outcomes of at-risk under-five children in rural Rwanda

Background

As more high-risk newborns survive the neonatal period, they remain at significant medical, nutritional, and developmental risk. However, no follow-up system for early intervention exists in most developing countries. In 2014, a novel Pediatric Development Clinic (PDC) was implemented to provide comprehensive follow-up to at-risk under-five children, led by nurses and social workers in a district hospital and surrounding health centers in rural Rwanda.

Methods

At each PDC visit, children undergo clinical/nutritional assessment and caregivers participate in counseling sessions. Social assessments identify families needing additional social support. Developmental assessment is completed using Ages and Stages Questionnaires. A retrospective medical record review was conducted to evaluate the first 24 months of PDC implementation for patients enrolled between April 2014–December 2015 in rural Rwanda. Demographic and clinical characteristics of patients and their caregivers were described using frequencies and proportions. Completion of different core components of PDC visits were compared overtime using Fisher’s Exact test and p-values calculated using trend analysis.

Results

426 patients enrolled at 5 PDC sites. 54% were female, 44% were neonates and 35% were under 6 months at enrollment. Most frequent referral reasons were prematurity/low birth weight (63%) and hypoxic-ischemic encephalopathy (34%). In 24 months, 2787 PDC visits were conducted. Nurses consistently completed anthropometric measurements (age, weight, height) at all visits. Some visit components were inconsistently recorded, including adjusted age (p = 0.003), interval growth, danger sign assessment, and feeding difficulties (p < 0.001). Completion of other visit components, such as child development counseling and play/stimulation activities, were low but improved with time (p < 0.001).

Conclusions

It is feasible to implement PDCs with non-specialized providers in rural settings as we were able to enroll a diverse group of high-risk infants. We are seeing an improvement in services offered at PDCs over time and continuous quality improvement efforts are underway to strengthen current gaps. Future studies looking at the outcomes of the children benefiting from the PDC program are underway.

Institutionalizing community-focused maternal, newborn, and child health strategies to strengthen health systems: A new framework for the Sustainable Development Goal era

Background

Stronger health systems, with an emphasis on community-based primary health care, are required to help accelerate the pace of ending preventable maternal and child deaths as well as contribute to the achievement of the Sustainable Development Goals (SDGs). The success of the SDGs will require unprecedented coordination across sectors, including partnerships between public, private, and non-governmental organizations (NGOs). To date, little attention has been paid to the distinct ways in which NGOs (both international and local) can partner with existing national government health systems to institutionalize community health strategies.

Discussion

In this paper, we propose a new conceptual framework that depicts three primary pathways through which NGOs can contribute to the institutionalization of community-focused maternal, newborn, and child health (MNCH) strategies to strengthen health systems at the district, national or global level. To illustrate the practical application of these three pathways, we present six illustrative cases from multiple NGOs and discuss the primary drivers of institutional change. In the first pathway, “learning for leverage,” NGOs demonstrate the effectiveness of new innovations that can stimulate changes in the health system through adaptation of research into policy and practice. In the second pathway, “thought leadership,” NGOs disseminate lessons learned to public and private partners through training, information sharing and collaborative learning. In the third pathway, “joint venturing,” NGOs work in partnership with the government health system to demonstrate the efficacy of a project and use their collective voice to help guide decision-makers. In addition to these pathways, we present six key drivers that are critical for successful institutionalization: strategic responsiveness to national health priorities, partnership with policymakers and other stakeholders, community ownership and involvement, monitoring and use of data, diversification of financial resources, and longevity of efforts.

Conclusion

With additional research, we propose that this framework can contribute to program planning and policy making of donors, governments, and the NGO community in the institutionalization of community health strategies.

Where there is no doctor: can volunteer community health workers in rural Uganda provide integrated community case management?

INTRODUCTION

Integrated community case management (iCCM) involves assessment and treatment of common childhood illnesses by community health workers (CHWs). Evaluation of a new Ugandan iCCM program is needed.

OBJECTIVES

The objectives of this study were to assess if iCCM by lay volunteer CHWs is feasible and if iCCM would increase proportions of children treated for fever, pneumonia, and diarrhoea in rural Uganda.

METHODS

This pre/post study used a quasi-experimental design and non-intervention comparison community. CHWs were selected, trained, and equipped to assess and treat children under five years with signs of the three illnesses. Evaluation included CHW-patient encounter record review plus analysis of pre/post household surveys.

RESULTS

196 iCCM-trained CHWs reported 6,276 sick child assessments (45% fever, 46% pneumonia, 9% diarrhoea). 93% of cases were managed according to algorithm recommendations. Absolute proportions of children receiving treatment significantly increased post-intervention: antimalarial for fever (+24% intervention versus +4% control) and oral rehydration salts/zinc for diarrhoea (+14% intervention versus +1% control).

CONCLUSION

In our limited-resource, rural Ugandan setting, iCCM involving lay CHWs was feasible and significantly increased the proportion of young children treated for malaria and diarrhoea.

Mental Health and Antiretroviral Adherence Among Youth Living With HIV in Rwanda

BACKGROUND AND OBJECTIVES

In Rwanda, significant progress has been made in advancing access to antiretroviral therapy (ART) among youth. As availability of ART increases, adherence is critical for preventing poor clinical outcomes and transmission of HIV. The goals of the study are to (1) describe ART adherence and mental health problems among youth living with HIV aged 10 to 17; and (2) examine the association between these factors among this population in rural Rwanda.

METHODS

A cross-sectional analysis was conducted that examined the association of mental health status and ART adherence among youth (n = 193). ART adherence, mental health status, and related variables were examined based on caregiver and youth report. Nonadherence was defined as ever missing or refusing a dose of ART within the past month. Multivariate modeling was performed to examine the association between mental health status and ART adherence.

RESULTS

Approximately 37% of youth missed or refused ART in the past month. In addition, a high level of depressive symptoms (26%) and attempt to hurt or kill oneself (12%) was observed in this population of youth living with HIV in Rwanda. In multivariate analysis, nonadherence was significantly associated with some mental health outcomes, including conduct problems (odds ratio 2.90, 95% confidence interval 1.55-5.43) and depression (odds ratio 1.02, 95% confidence interval 1.01-1.04), according to caregiver report. A marginally significant association was observed for youth report of depressive symptoms.

CONCLUSIONS

The findings suggest that mental health should be considered among the factors related to ART nonadherence in HIV services for youth, particularly for mental health outcomes, such as conduct problems and depression.

Social, economic and environmental risk factors for acute lower respiratory infections among children under five years of age in Rwanda

Background

In low and middle-income countries, acute lower respiratory illness is responsible for roughly 1 in every 5 child deaths. Rwanda has made major health system improvements including its community health worker systems, and it is one of the few countries in Africa to meet the 2015 Millennium Development Goals, although prevalence of acute lower respiratory infections (4 %) is similar to other countries in sub-Saharan Africa. This study aims to assess social, economic, and environmental factors associated with acute lower respiratory infections among children under five to inform potential further improvements in the health system.

Methods

This is a cross-sectional study using data collected from women interviewed in the 2010 DHS about 8,484 surviving children under five. Based on a literature review, we defined 19 health, social, economic, and environmental potential risk factors, tested bivariate associations with acute lower respiratory infections, and advanced variables significant at the 0.1 confidence level to logistic regression modelling. We used manual backward stepwise regression to arrive at a final model. All analyses were performed in Stata v13 and adjusted for complex sample design.

Results

The following factors were independently associated with acute lower respiratory infections: child’s age, anemia level, and receipt of Vitamin A; household toilet type and residence, and season of interview. In multivariate regression, being in the bottom ten percent of households (OR: 1.27, 95 % CI: 0.85-1.87) or being interviewed during the rainy season (OR: 1.61, 95 % CI: 1.24-2.09) was positively associated with acute lower respiratory infections, while urban residence (OR: 0.58, 95 % CI: 0.38-0.88) and being age 24–59 months versus 0–11 months (OR: 0.53, 95 % CI: 0.40-0.69) was negatively associated with acute lower respiratory infections.

Conclusion

Potential areas for intervention including community campaigns about acute lower respiratory infections symptoms and treatment, and continued poverty reduction through rural electrification and modern stove distribution which may reduce use of dirty cooking fuel, improve living conditions, and reduce barriers to health care.

How do we know? An assessment of integrated community case management data quality in four districts of Malawi

The World Health Organization contracted annual data quality assessments of Rapid Access Expansion (RAcE) projects to review integrated community case management (iCCM) data quality and the monitoring and evaluation (M&E) system for iCCM, and to suggest ways to improve data quality. The first RAcE data quality assessment was conducted in Malawi in January 2014 and we present findings pertaining to data from the health management information system at the community, facility and other sub-national levels because RAcE grantees rely on that for most of their monitoring data. We randomly selected 10 health facilities (10% of eligible facilities) from the four RAcE project districts, and collected quantitative data with an adapted and comprehensive tool that included an assessment of Malawi's M&E system for iCCM data and a data verification exercise that traced selected indicators through the reporting system. We rated the iCCM M&E system across five function areas based on interviews and observations, and calculated verification ratios for each data reporting level. We also conducted key informant interviews with Health Surveillance Assistants and facility, district and central Ministry of Health staff. Scores show a high-functioning M&E system for iCCM with some deficiencies in data management processes. The system lacks quality controls, including data entry verification, a protocol for addressing errors, and written procedures for data collection, entry, analysis and management. Data availability was generally high except for supervision data. The data verification process identified gaps in completeness and consistency, particularly in Health Surveillance Assistants' record keeping. Staff at all levels would like more training in data management. This data quality assessment illuminates where an otherwise strong M&E system for iCCM fails to ensure some aspects of data quality. Prioritizing data management with documented protocols, additional training and approaches to create efficient supervision practices may improve iCCM data quality.

Data for Program Management: An Accuracy Assessment of Data Collected in Household Registers by Community Health Workers in Southern Kayonza, Rwanda

Community health workers (CHWs) collect data for routine services, surveys and research in their communities. However, quality of these data is largely unknown. Utilizing poor quality data can result in inefficient resource use, misinformation about system gaps, and poor program management and effectiveness. This study aims to measure CHW data accuracy, defined as agreement between household registers compared to household member interview and client records in one district in Eastern province, Rwanda. We used cluster-lot quality assurance sampling to randomly sample six CHWs per cell and six households per CHW. We classified cells as having 'poor' or 'good' accuracy for household registers for five indicators, calculating point estimates of percent of households with accurate data by health center. We evaluated 204 CHW registers and 1,224 households for accuracy across 34 cells in southern Kayonza. Point estimates across health centers ranged from 79 to 100% for individual indicators and 61 to 72% for the composite indicator. Recording error appeared random for all but the widely under-reported number of women on modern family planning method. Overall, accuracy was largely 'good' across cells, with varying results by indicator. Program managers should identify optimum thresholds for 'good' data quality and interventions to reach them according to data use. Decreasing variability and improving quality will facilitate potential of these routinely-collected data to be more meaningful for community health program management. We encourage further studies assessing CHW data quality and the impact training, supervision and other strategies have on improving it.

Perceived Quality of Care of Community Health Worker and Facility-Based Health Worker Management of Pneumonia in Children Under 5 Years in Western Kenya: A Cross-Sectional Multidimensional Study

Integrated community case management (iCCM) programs that train lay community health workers (CHWs) in the diagnosis and treatment of diarrhea, malaria, and pneumonia have been increasingly adopted throughout sub-Saharan Africa to provide services in areas where accessibility to formal public sector health services is low. One important aspect of successful iCCM programs is the acceptability and utilization of services provided by CHWs. To understand community perceptions of the quality of care in an iCCM intervention in western Kenya, we used the Primary Care Assessment Survey to compare caregiver attitudes about the diagnosis and treatment of childhood pneumonia as provided by CHWs and facility-based health workers (FBHWs). Overall, caregivers rated CHWs more highly than FBHWs across a set of 10 domains that capture multiple dimensions of the care process. Caregivers perceived CHWs to provide higher quality care in terms of accessibility and patient relationship and equal quality care on clinical aspects. These results argue for the continued implementation and scale-up of iCCM programs as an acceptable intervention for increasing access to treatment of childhood pneumonia.

First Steps in Initiating an Effective Maternal, Neonatal, and Child Health Program in Urban Slums: the BRAC Manoshi Project's Experience with Community Engagement, Social Mapping, and Census Taking in Bangladesh

The processes for implementing effective programs at scale in low-income countries have not been well-documented in the peer-reviewed literature. This article describes the initial steps taken by one such program--the BRAC Manoshi Project, which now reaches a population of 6.9 million. The project has achieved notable increases in facility births and reductions in maternal and neonatal mortality. The focus of the paper is on the initial steps--community engagement, social mapping, and census taking. Community engagement began with (1) engaging local leaders, (2) creating Maternal, Neonatal, and Child Health Committees for populations of approximately 10,000 people, (3) responding to advice from the community, (4) social mapping of the community, and (5) census taking. Social mapping involved community members working with BRAC staff to map all important physical features that affect how the community carries out its daily functions--such as alleys, lanes and roads, schools, mosques, markets, pharmacies, health facilities, latrine sites, and ponds. As the social mapping progressed, it became possible to conduct household censuses with maps identifying every household and listing family members by household. Again, this was a process of collaboration between BRAC staff and community members. Thus, social mapping and census taking were also instrumental for advancing community engagement. These three processes-community engagement, social mapping, and census taking--can be valuable strategies for strengthening health programs in urban slum settings of low-income countries.

Clinical effects of integrated health care in patients undergoing cesarean section

AIM: To evaluate the clinical effects of integrated health care in patients undergoing cesarean section.

METHODS: Two hundred and forty-eight mothers who underwent cesarean section at our hospital from June 2013 to June 2014 were divided into two groups based on the time of admission: a control group (June 2013 to December 2013, n = 124) and an observation group (January 2014 to June 2014, n = 124). The control group was treated using the traditional care model, and the observation group was treated using the integrated health care model. The nursing care quality score, incidence of adhesions, gastrointestinal motility recovery and patient satisfaction were compared between the two groups.

RESULTS: The scores of disease cognition, implementation of doctors' orders, emergency drug use, condition observation, ward management, document management, and overall quality of care were significantly higher in the observation group than in the control group (P < 0.05). The incidence rates of adhesions, bloating, constipation, and intestinal obstruction were significantly lower in the observation group than in the control group (P < 0.05). The times to bloating disappearance, anal exhaust, recovery of bowel sounds, defecation, and first meal, as well as the average length of hospital stay were significantly shorter in the observation group than in the control group (P < 0.05), and patient satisfaction score in the observation group was significantly higher than that in the control group (P < 0.05).

CONCLUSION: Integrated health care can effectively improve health care quality, reduce the incidence of postoperative adhesions, and improve the recovery of gastrointestinal function in patients undergoing cesarean section.

The Potential for Community-Directed Interventions: Reaching Underserved Populations in Africa

Community-directed interventions (CDIs) have the potential for fulfilling the promise of primary health care by reaching underserved populations in various settings. CDI has been successfully tested by expanding access to additional health services like malaria case management through local effort in communities where ivermectin distribution is ongoing. The question remains whether the CDI approach has potential in communities that do not have a foundation of community-directed treatment with ivermectin. The UNICEF/UNDP/World Bank/WHO Special Program of Research and Training in Tropical Diseases commissioned three sets of formative studies to explore the potential for introducing CDI among nomads, urban poor, and rural areas with no community-directed treatment with ivermectin. This article reviews their findings. Community and health system respondents identified a set of mainly communicable diseases that could be adapted to CDI as well as participatory mechanisms like community-based organizations and leaders that could form a foundation for local organizing and participation. It is hoped that the results of these formative studies will spur further research on CDI among peoples with poor health-care access.

Delays in Breast Cancer Presentation and Diagnosis at Two Rural Cancer Referral Centers in Rwanda

BACKGROUND

Breast cancer incidence is increasing in low- and middle-income countries (LMICs). Mortality/incidence ratios in LMICs are higher than in high-income countries, likely at least in part because of delayed diagnoses leading to advanced-stage presentations. In the present study, we investigated the magnitude, impact of, and risk factors for, patient and system delays in breast cancer diagnosis in Rwanda.

MATERIALS AND METHODS

We interviewed patients with breast complaints at two rural Rwandan hospitals providing cancer care and reviewed their medical records to determine the diagnosis, diagnosis date, and breast cancer stage.

RESULTS

A total of 144 patients were included in our analysis. Median total delay was 15 months, and median patient and system delays were both 5 months. In multivariate analyses, patient and system delays of ≥6 months were significantly associated with more advanced-stage disease. Adjusting for other social, demographic, and clinical characteristics, a low level of education and seeing a traditional healer first were significantly associated with a longer patient delay. Having made ≥5 health facility visits before the diagnosis was significantly associated with a longer system delay. However, being from the same district as one of the two hospitals was associated with a decreased likelihood of system delay.

CONCLUSION

Patients with breast cancer in Rwanda experience long patient and system delays before diagnosis; these delays increase the likelihood of more advanced-stage presentations. Educating communities and healthcare providers about breast cancer and facilitating expedited referrals could potentially reduce delays and hence mortality from breast cancer in Rwanda and similar settings.

IMPLICATIONS FOR PRACTICE

Breast cancer rates are increasing in low- and middle-income countries, and case fatality rates are high, in part because of delayed diagnosis and treatment. This study examined the delays experienced by patients with breast cancer at two rural Rwandan cancer facilities. Both patient delays (the interval between symptom development and the patient's first presentation to a healthcare provider) and system delays (the interval between the first presentation and diagnosis) were long. The total delays were the longest reported in published studies. Longer delays were associated with more advanced-stage disease. These findings suggest that an opportunity exists to reduce breast cancer mortality in Rwanda by addressing barriers in the community and healthcare system to promote earlier detection.

Community case management of childhood illness in sub-Saharan Africa - findings from a cross-sectional survey on policy and implementation

BACKGROUND

Community case management (CCM) involves training, supporting, and supplying community health workers (CHWs) to assess, classify and manage sick children with limited access to care at health facilities, in their communities. This paper aims to provide an overview of the status in 2013 of CCM policy and implementation in sub-Saharan African countries.

METHODS

We undertook a cross-sectional, descriptive, quantitative survey amongst technical officers in Ministries of Health and UNICEF offices in 2013. The survey aim was to describe CCM policy and implementation in 45 countries in sub-Saharan Africa, focusing on: CHW profile, CHW activities, and financing.

RESULTS

42 countries responded. 35 countries in sub-Saharan Africa reported implementing CCM for diarrhoea, 33 for malaria, 28 for pneumonia, 6 for neonatal sepsis, 31 for malnutrition and 28 for integrated CCM (treatment of 3 conditions: diarrhoea, malaria and pneumonia) - an increase since 2010. In 27 countries, volunteers were providing CCM, compared to 14 countries with paid CHWs. User fees persisted for CCM in 6 countries and mark-ups on commodities in 10 countries. Most countries had a national policy, memo or written guidelines for CCM implementation for diarrhoea, malaria and pneumonia, with 20 countries having this for neonatal sepsis. Most countries plan gradual expansion of CCM but many countries' plans were dependent on development partners. A large group of countries had no plans for CCM for neonatal sepsis.

CONCLUSION

28 countries in sub-Saharan Africa now report implementing CCM for pneumonia, diarrhoea and malaria, or "iCCM". Most countries have developed some sort of written basis for CCM activities, yet the scale of implementation varies widely, so a focus on implementation is now required, including monitoring and evaluation of performance, quality and impact. There is also scope for expansion for newborn care. Key issues include financing and sustainability (with development partners still providing most funding), gaps in data on CCM activities, and the persistence of user fees and mark-ups in several countries. National health management information systems should also incorporate CCM activities.

Multi-country analysis of routine data from integrated community case management (iCCM) programs in sub-Saharan Africa

Aim

To identify better performing iCCM programs in sub–Saharan Africa (SSA) and identify factors associated with better performance using routine data.

Methods

We examined 15 evaluations or studies of integrated community case management (iCCM) programs in SSA conducted between 2008 and 2013 and with information about the program; routine data on treatments, supervision, and stockouts; and, where available, data from community health worker (CHW) surveys on supervision and stockouts. Analyses included descriptive statistics, Fisher exact test for differences in median treatment rates, the Kruskal-Wallis test for differences in the distribution of treatment rates, and Spearman’s correlation by program factors.

Results

The median percent of annual expected cases treated was 27% (1–74%) for total iCCM, 37% (1–80%) for malaria, 155% (7–552%) for pneumonia, and 27% (1–74%) for diarrhoea. Seven programs had above median total iCCM treatments rates. Four programs had above median treatment rates, above median treatments per active CHW per month, and above median percent of expected cases treated. Larger populations under–five targeted were negatively associated with treatment rates for fever, malaria, diarrhea, and total iCCM. The ratio of CHWs per population was positively associated with diarrhoea treatment rates. Use of rapid diagnostic tests (RDTs) was negatively associated with treatment rates for pneumonia. Treatment rates and percent of annual expected cases treated were equivalent between programs with volunteer CHWs and programs with salaried CHWs.

Conclusions

There is large variation in iCCM program performance in SSA. Four programs appear to be higher performing in terms of treatment rates, treatments per CHW per month, and percent of expected cases treated. Treatment rates for diarrhoea are lower than expected across most programmes. CHWs in many programmes are overtreating pneumonia. Programs targeting larger populations under–five tend to have lower treatment rates. The reasons for lower pneumonia treatment rates where CHWs use RDTs need to be explored. Programs with volunteer CHWs and those with salaried CHWs can achieve similar treatment rates and percent of annual expected cases treated but to do so volunteer programs must manage more CHWs per population and salaried CHWs must provide more treatments per CHW per month.

Systematic literature review of integrated community case management and the private sector in Africa: Relevant experiences and potential next steps

Background

Despite substantial investments made over the past 40 years in low income countries, governments cannot be viewed as the principal health care provider in many countries. Evidence on the role of the private sector in the delivery of health services is becoming increasingly available. In this study, we set out to determine the extent to which the private sector has been utilized in providing integrated care for sick children under 5 years of age with community–acquired malaria, pneumonia or diarrhoea.

Methods

We reviewed the published literature for integrated community case management (iCCM) related experiences within both the public and private sector. We searched PubMed and Google/Google Scholar for all relevant literature until July 2014. The search terms used were “malaria”, “pneumonia”, “diarrhoea”, “private sector” and “community case management”.

Results

A total of 383 articles referred to malaria, pneumonia or diarrhoea in the private sector. The large majority of these studies (290) were only malaria related. Most of the iCCM–related studies evaluated introduction of only malaria drugs and/or diagnostics into the private sector. Only one study evaluated the introduction of drugs and diagnostics for malaria, pneumonia and diarrhoea in the private sector. In contrast, most iCCM–related studies in the public sector directly reported on community case management of 2 or more of the illnesses.

Conclusions

While the private sector is an important source of care for children in low income countries, little has been done to harness the potential of this sector in improving access to care for non–malaria–associated fever in children within the community. It would be logical for iCCM programs to expand their activities to include the private sector to achieve higher population coverage. An implementation research agenda for private sector integrated care of febrile childhood illness needs to be developed and implemented in conjunction with private sector intervention programs.

Toward utilization of data for program management and evaluation: quality assessment of five years of health management information system data in Rwanda

BACKGROUND

Health data can be useful for effective service delivery, decision making, and evaluating existing programs in order to maintain high quality of healthcare. Studies have shown variability in data quality from national health management information systems (HMISs) in sub-Saharan Africa which threatens utility of these data as a tool to improve health systems. The purpose of this study is to assess the quality of Rwanda's HMIS data over a 5-year period.

METHODS

The World Health Organization (WHO) data quality report card framework was used to assess the quality of HMIS data captured from 2008 to 2012 and is a census of all 495 publicly funded health facilities in Rwanda. Factors assessed included completeness and internal consistency of 10 indicators selected based on WHO recommendations and priority areas for the Rwanda national health sector. Completeness was measured as percentage of non-missing reports. Consistency was measured as the absence of extreme outliers, internal consistency between related indicators, and consistency of indicators over time. These assessments were done at the district and national level.

RESULTS

Nationally, the average monthly district reporting completeness rate was 98% across 10 key indicators from 2008 to 2012. Completeness of indicator data increased over time: 2008, 88%; 2009, 91%; 2010, 89%; 2011, 90%; and 2012, 95% (p<0.0001). Comparing 2011 and 2012 health events to the mean of the three preceding years, service output increased from 3% (2011) to 9% (2012). Eighty-three percent of districts reported ratios between related indicators (ANC/DTP1, DTP1/DTP3) consistent with HMIS national ratios. Conclusion and policy implications: Our findings suggest that HMIS data quality in Rwanda has been improving over time. We recommend maintaining these assessments to identify remaining gaps in data quality and that results are shared publicly to support increased use of HMIS data.