Urban Community Case Management: valuable or redundant?

Today I shared a link to a new publication on the Tropical Disease Research (TDR) website entitled, “Community case management of malaria in urban settings,” to members of our Malaria Update Listserve (see link at right).  A major conclusion from the multi-country study in Burkina Faso, Ethiopia, Ghana and Malawi was …

The use of the ACT (Artemisinin-based Combination Therapy) unit dose pre-pack is feasible and acceptable. When CMDs (Community Medicine Distributors) are properly trained, the community is properly sensitised and pre-packed drugs are provided either free or sold at an affordable cost, the quality of services delivered by CMDs and adherence by caregivers are similar to those seen in rural CCMm settings. The proportion of cases seen by CMDs, however, tended to be lower than was generally seen in rural CCMm. Urban CCMm is feasible, but it struggles against other sources of established healthcare providers.

One member of the listserve responded by raising a question about access and quality to malaria treatment services in urban settings. Jim Ricca from Jhpiego’s office in Maputo made the point that …

I’m interested to know why CCM was done in an urban setting where geographic access should not be a problem. If other access issues were a problem for people using facility-based services (e.g., cost, cultural/linguistic barriers), then I wonder why these barriers to use of facility based services were not addressed instead of moving to community-based services.

In places I’ve seen CCM implemented, the planners took great pains to do a situation analysis beforehand to see where there were geographic access problems for use of facility-based services and it was there that the CCM services were implemented. As much of an advocate as I am of community-based services, if CB services are the answer for ALL the shortcomings of the current health system, is there any sense having facility-based services at all?

TDR has led the way in operational research over the years and has been trying out community engagement strategies or community directed interventions (CDI) in a variety of settings – rural, urban, nomadic, migratory, etc. The question about the value of CDI when one could hopefully improve the quality of existing health services is certainly valid. But a basic question has been whether the willingness of rural community members to volunteer will work in urban areas where ‘community’ is much more diffuse. Even if the CDI approach does not translate culturally into diverse, anomic urban settings, access to care in urban areas, there are other challenges such as the plethora of provider types.

pmv-in-kano-sm.jpgJim is right that there have been studies about urban access that show geography is not the main issue – there may be social and financial barriers as well as perceptions of quality barriers.  To complicate the picture these issues must be addressed not only in the public sector but with private clinics and patent medicine shops.These private formal and informal sources usually provide desirable options like convenient hours, convenient locations and the ability to purchase on credit that the public sector does not.

While these private provider must be considered in any effort to improve the quality of health care in urban areas, they are also elusive. From experience in Nigerian cities, I can vouch that registries of private clinics and medicine shops are out of date and incomplete.  These entities may fail to register in the first place, move location or go out of business, and noe one seems to be responsible for updating the list.  In Kaduna, for example, an effort to study medicine shops started with a state ministry registry of 200 shops for the whole state and found by going street by street over 500 shops in one half of Kaduna alone. These providers too need to be considered as part of the total picture, and quality assurance mechanisms must be extended to them -if only we can find them.

So the answer to the basic question – is community volunteerism in the delivery of health services really necessary in urban area? – does depend not only on whether the volunteer spirit works in an urban setting, but whether quality services are already or potentially accessible thus, negating the need for community members delivering services.

A different model may be appropriate – that is the Community Navigator. Such a volunteer would help community members find the right care and get there. The Navigator could also serve as a patient advocate once she or he arrives at the point of service with their neighbors in tow.

Urban and rural settings differ dramatically in terms of culture, economy and social structure – we need to find the right community engagement model for each.

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