integrated Community Case Management – one size does not fit all

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The ASTMH 60th annual meeting today featured a panel on integrated community case management (iCCM). The variety of experiences was notable. Some used volunteer CHWs, while had ones receiving a very minimal pay package. In some cases RDTs were used, while in others not. In some places national policy allowed CHWs to give antibiotics, though not in others.

A multi-country study sponsored by the Tropical Disease Research Program trained CHWs in using RDTs for malaria and recognizing high respiration rates for pneumonia. The intervention group had lower than 5% rate of inappropriate ACT provision compared to around 20% for the control CHWs. While incorrect antibiotics use was better in the intervention group, it was still 40%. This must be addressed to avoid problems like antibiotic resistance.

In Cameroon training CHWs had a very positive effect on access to malaria and diarrhea case management. Access through CHWs was especially higher among the poorest segment of the population.

A quality of care study in Malawi among community based health surveillance assistants (HSAs) found that a simplified IMCI algorithm found improvements in assessment, classification and treatment skills performance for malaria, pneumonia and diarrhea. Community satisfaction was also greater with the IMCI-trained HSAs.

While intervention studies showed improved skills of and access to CHWs for iCCM, management problems like stock-out were also documented. An MCHIP analysis of iCCM logistics issues found that variations in access may be due to whether a country practices cost recovery or has a uniform national supply and logistics system. Fortunately, even if CHWs raise the issue of material incentives, they do value the knowledge they gain, and the recognition they receive from the community.

Thirty-three years after Alma Ata we working hard to understand the basic processes and functions of CHWs. Clearly one size will not fit all, but common goal can be improving access to quality care for all.

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