If the poorest children can’t access healthcare, then healthcare must come to them
I-C-C-M. This four-letter sequence encapsulates what is fast becoming one of the developing world’s core approaches to tackling under-five mortality.
Last year alone, nearly 6 million children did not make it to their fifth birthday. The majority of these children died from preventable causes – diseases that the world knows how to prevent and treat. Nearly a third of these deaths were due to three conditions: malaria, pneumonia and diarrhoea. The vast majority of these deaths occurred in sub-Saharan Africa and South Asia, where infant and child mortality rates have decreased substantially over the past couple of decades but are still unacceptably high.
Integrated Community Case Management (ICCM) stemmed from a simple premise. Primary healthcare – whether provided by district health facilities, clinics or hospitals – is either inaccessible for, or unused by, large swathes of the poorest rural and peri-urban population in these regions. The reasons for this include: the vast distances often separating remote communities from the closest health centre; insecurity; cultural norms that are not conducive to healthy practices and behaviours; unfriendly or overcrowded clinics; and more often than not, dysfunctional health systems.
If health services are not accessible to these communities, then why not bring the most basic, but also the most vital of these services closer to home?
To achieve this, ICCM revolves around an increasingly common and important cadre of carers: community health workers (CHWs). CHWs are members of the communities they serve and are trained, supervised and empowered to detect and treat uncomplicated cases of malaria, pneumonia and diarrhoea among children under five. In some rare cases their remit also includes the management of newborn sepsis and even acute malnutrition.
CHWs are also tasked with referring the more serious cases to the closest health facility where they can receive the appropriate care, as well as with promoting healthy and hygienic practices in their communities – such as exclusive breastfeeding until a baby is six months old, regular hand-washing or the systematic use of bed nets. CHWs usually form an extension of the formal health system.
The concept of managing cases of childhood illnesses in communities is not new. Examples of programmes involving community-based health agents or para-professionals can be found as far back as the 1970s. The community case management of a specific disease – for instance, pneumonia or malaria – has also been tried, tested and taken to scale in a number of countries over the past two decades.
But what’s different about ICCM is that it recognises that most sick children suffer from more than one condition at the time. Studies have shown that a majority of children suffering from malaria, pneumonia or diarrhoea actually suffer from a combination of at least two of these conditions.
For this reason, it seemed logical to equip CHWs with the skills and supplies required to treat all three diseases directly in the community.
So, the theory is simple. But does it work? The evidence so far is unquestionably convincing. A large number of studies conducted in several countries suggest the approach is a very effective way to reduce child mortality due to common childhood illnesses (by up to 70% by some estimates) in rural areas of sub-Saharan Africa, South Asia or even Central America. UNICEF and the World Health Organization have declared in a joint statement that “ICCM is an essential strategy that can both foster equity and contribute to sustained reduction in child mortality.”
But ICCM is not a magic bullet. Examples of failed experiments abound and ICCM policies and programmes suffer from well-known challenges.
Start with the CHWs themselves: few of them have received more than five or six years of school education, and in some contexts, such as South Sudan, the majority are illiterate. Training and supervision can achieve wonders but CHWs’ capacity to take on duties previously performed by professional clinicians is inevitably limited.
Moreover – though inspirational stories of incredibly dedicated CHWs performing way beyond the call of duty are plentiful – incentives do matter. While in some contexts CHWs are salaried employees of the Ministry of Health, in many others they are volunteers and earn just modest stipends for the vital services they offer.
And CHWs can do little if the drug supply chains are so broken that stockouts of essential medicines – including oral rehydration salts and zinc for diarrhoea, antibiotics for pneumonia and antimalarials – become the rule rather than the exception. Sadly, poorly functioning supply chains are a major bottleneck for the entire health system in many of the countries where ICCM offers the greatest hope for reducing the morbidity of common childhood illnesses.
Many other barriers are also commonly found. Poor or inconsistent supervision of CHWs by their clinician supervisor is a chronic issue in a number of ICCM settings. Referral systems for severe cases of malaria, pneumonia or diarrhoea are often dysfunctional. CHWs can also find it difficult to get their diagnosis and treatment accepted by caregivers when they are not sufficiently empowered in their communities. Deeply ingrained social norms are hard to take on. Health information systems rarely capture the impact of community-based care. And so on…
In spite of all these extensively documented issues, ICCM remains a great source of hope for millions of children around the world. Recognising its effectiveness, most developing countries have adopted this approach as part of their national health policy and plans. And a few have already rolled it out on a national scale: witness Ethiopia’s mighty programme of health extension workers or Mozambique’s famous “agentes polivalentes elementares”.
Save the Children has played a key role in the story of ICCM since it first began, and has continued to drive this agenda along with dozens of partners around the world. In this pivotal year for international development which marks the start of the mightily ambitious Sustainable Development Goals, it will remain a driving force to ensure that if the poorest children cannot access healthcare, then healthcare must come to them.