Integrated community case management (ICCM) – a way forward

ccm-in-onileekaa.jpgICCM was the theme of a symposium at the MIM 5th Pan-African Malaria Conference last week. The organizers defined ICCM as a ‘strategy that delivers to the most vulnerable groups anti-malarials, antibiotics and a combination of oral rehydration therapy and zinc at the community level by trained community health workers.’ during the course of discussion CHWs were defined as people not only from the community, but also working in the community.

A little leeway has been taken with the latter definition in an ICCM study from Ghana where RDTs, ACTs, Amoxicillin and Paracetamol were availble for use by Community Health Officers posted in village health services known as Community Health Planning (CHPs) compounds.  Having both the RDTs and alternative treatment for pneumonia in the case of negative tests resulted in less overall drug use in the 8 intervention CHPs compounds compared with the 8 controls. Integration can only happen when health workers have all the materials they need to do appropriate case management.

Documentation of ICCM policy and program implementation for 68 countries was reported to the symposium. Only 55% of countries had a CCM policy for malaria, 50% for diarrhea, 30% for pneumonia and none for neonatal infections. Some countries were implementing without policies. Less than half had integration of three diseases – malaria, diarrhea and poneumonia.

Even with policies, not all countries implement CCM on a national basis, though there were examples of implementation across many or just a few pilot districts.

Potential barriers to CCM policy and implementation were identified through interviews with Ministry of Health officials from the selected countries. Common concerns were the ability to guarantee quality of care, incentives, supplies, monitoring and evaluation, training and supervision.

Ethical concerns were raised as to whether CCM really provides quality care to the poor.  In contrast, presenters working in post-conflict areas found that these situations provided opportunities for creative thinking on how to reach disenfranchised communities.

The session did not have time to get into the role of the informal private sector – especially patent medicine vendors – in CCM.  Also the focus on individual CHWs tended to divert attention away from the word ‘community.’ It is hoped that CCM can take a leaf from the Community Directed Interventions process and focus on strengthening community leadership and systems to take charge of health matters, and not rely solely on an individual CHW who may be here today and gone tomorrow.

NOTE: ICCM training materials and job aids are being consolidated by WHO/Unicef. The CORE Group also has a set of CCM training materials under development.

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