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

Abstract

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.

Figures

Figure 1

Implementation of community case management (CCM) of diarrhoea, malaria, pneumonia, neonatal sepsis and malnutrition in sub–Saharan Africa (n = 42). iCCM* refers to community case management services for diagnosis and treatment of pneumonia, diarrhoea and malaria that are provided together. There was no data for neonatal sepsis and malnutrition in the 2010 survey.

Figure 2

National policies on community case management in sub–Saharan Africa, by condition (n = 36).

Figure 3

Institutions providing primary funding for different aspects of community case management in sub–Saharan Africa (n = 27). CHW – community health worker.

Figure 4

Future plans for community case management in sub–Saharan Africa, by condition (n = 42).