Integrated community case management (iCCM) of common illnesses, as we learned at the just completed evidence review symposium on iCCM in Accra, Ghana, requires a number of key inputs ranging from adequate procurement and supply of commodities, well stated supportive policies and human resources from the district to the clinic to the community. One input, the collaboration among stakeholders needs constant reinforcement.
Although the project was not iCCM, an implementation research study in 8 sites in Africa that added a package of interventions to existing ivermectin distribution illustrates the need for stakeholder concurrence and collaboration. This 3-year community directed intervention (CDI) Tropical Disease Research Program effort (UNDP/World Bank/Unicef/WHO) was designed to add a package of interventions to the community’s ‘portfolio’ each year in a step-wise manner. These included antimalarials for community case management, insecticide treated nets, vitamin A and drugs for directly observed treatment of tuberculosis.
While ultimately the community directed approach to distributing these commodities resulted in better coverage in intervention districts than facility based service provision in the control areas, an important lesson from the project occurred in the start-up process the very first year. In fact no real commodity distribution took place that year as originally planned.
What the teams learned is that while community distribution of ivermectin had been taking place for at least 10 years in most of the districts, not all members of the district health teams (DHT) were fully aware of what the onchocerciasis focal person was doing. It had been hoped a bit naively that the DHT member in charge of immunization and vitamin A, the DHT focal point for malaria and the DHT member in charge of TB/Leprosy would gladly join their onchocerciasis colleague in making their services available through community volunteers.
In reality the advocacy process took up the whole first year before other DHT members could be convinced that it was safe and appropriate for community members to take charge of a package of basic health commodities. In some locations, the TB/Leprosy program managers were never convinced.
Even at start-up of onchocerciasis programs in the late 1990s it took much convincing of health workers to ‘allow’ communities to handle drugs like ivermectin. When introducing a larger package through CDI, it became necessary to start this process of convincing and seeking collaboration anew.
A basic iCCM package of ACTs, RDTs, ORS, Zinc and amoxicillin may not appear as complicated as the CDI package added to ivermectin distribution, but in truth a lot of stakeholder advocacy work is still needed. We learned at the Accra meeting that at minimum malaria and child health programs need to collaborate to provide the basic package and the funding that does with it. Different programs may in fact have different policies and guidelines. Different donors and different sections of the Ministry of Health must be willing to bring their efforts and resources together and share. This is as much a political as it is a technical process, and scientific evidence that health care interventions delivered in the community save lives may not be enough to overcome politics and vested program interests.
The 300+ delegates to the iCCM symposium are returning home over the next few days. Hopefully the momentum of the conference will carry them on to engage in collaboration, not only with their colleagues who also attended, but also with those who did not attend and benefit from the sharing of evidence and experience. It will take a team of people with varied interests to make iCCM a success.