This summary provides an overview of 3 implementation research studies on integrated community case management (iCCM) conducted by the University Research Co., LLC.
The first study analyzed iCCM policies in 6 countries to understand how policy context, actors, and processes influence iCCM implementation. It found that policies often did not explicitly mention iCCM and were developed with technical staff but lacked engagement from key stakeholders. External funding was critical for policy development. The second study developed an iCCM costing and financing tool to help countries estimate costs and plan long-term financing. It was tested in Malawi and Senegal. The third study examined an iCCM monitoring improvement project in an unnamed country. Overall, the studies provide insights into real-
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ICCM_Sara Riese_10.16.13
1. iCCM in action
Results from 3 implementation research
studies
Sara Riese, Research Advisor
October 16, 2013
UNIVERSITY RESEARCH CO.,
LLC
1a
2. Translating Research into Action (TRAction) Project Overview
TRAction is a USAID-funded project that awards grants to research
organizations to develop, test, and compare approaches to more
effectively deliver, increase, and scale-up evidence-based interventions
that address priority public health challenges. Through implementation
research, TRAction addresses “know-do” gaps, or delays, in the
discovery of effective interventions and their wide-scale application.
TRAction emphasizes local ownership and partnerships in order to
scale up equitable and sustainable efforts.
3. What is implementation research?
Public Health
Knowledge
(what we know)
Implemen
tation
Research
Public Health
Practice
(what we do)
• IR seeks to determine the best ways to implement
evidence-based interventions in real world settings
• IR seeks to optimize programs that are currently not
achieving adequate coverage or quality
3
4. Unique features of implementation
research
• Done in real world rather than controlled settings
– Real world settings with existing staff, facilities, and budgets
– Real world populations rather than select sub-groups
• Focus on context
– Political, social, economic, cultural
– Existing health care system and network of stakeholders
• Central role of stakeholders and end-users
– Health managers, policy makers
– Involved closely in setting agenda
– Goal of efforts is to help them, not publish papers
5. Intervention Spectrum
What is the goal of the intervention?
Real-life
effectiveness
Equitabili
ty
Program
integratio
n
Replicati
on
Sustainability
Common
practice
at scale
Consider where the intervention falls on the
intervention “spectrum”
6. Real-life
Effectiveness
1.) Under what conditions does
the program work?
Replication
Sustainability
Common
practice at
scale
2.) Is the tool, intervention, or
strategy worth it? Is it costeffective?
1.) Why don‟t tested programs
work when transferred to new
settings or work in some new
settings and not others?
3.) Does the program achieve the
intended public health impact?
2.) How can implementation be
improved to assure reliability?
7. Why iCCM?
• There are many gaps in our understanding of the
optimal approaches to the implementation, scale-up,
and sustainability of iCCM Programs. (Hamer, et al, Am
J Trop Med Hyg, 2012)
7
8. Real-life
Effectiveness
Equitability
1.) Cost and
Finance : Is iCCM
cost-effective?
Program
Integration
Replication
1.) Policy: How is iCCM policy
developed in different
settings?
2.) Policy: How does iCCM
policy impact and does it
improve implementation?
3.) Embedded: How can iCCM
monitoring be improved to
Sustainability
Common
Practice
at Scale
1.) Cost and
Finance : What are
the financial
considerations for a
country to sustain
their iCCM
program?
9. iCCM Policy Analysis
PI: Sara Bennett
Research team: Asha George,
Daniela C. Rodríguez, Jessica Shearer
9
10. Study Aims
• To document and analyze the specific expressions of policy
(policy, plans, directives, guidelines etc.) that support or inhibit
implementation of iCCM of childhood and neonatal conditions.
• To identify facilitators or barriers to policy and program change
in the area of iCCM, related to policy context, policy content, the
process of policy change, and the actors involved in policy-making.
• To assess the role of ideas and evidence (comprising research
evidence, country data, learning from other countries, international
guidelines and tacit knowledge) in supporting policy and program
development.
• To identify policy elements that enable the eventual
implementation and/or improvement of integrated community case
management programs.
11. Study Design & Methods
• Document review
• Semi-structured interviews:
– Stakeholders in iCCM policy: Government officials, development
partners and multilateral organizations, bilateral donors, civil
society organizations, research institutions, etc.
– Start with respondents identified in document review, and
snowball until saturation
• Fieldwork undertaken April – September 2012
• Thematic analysis using NVivo software by country and
JHSPH researchers
• Synthesis of country studies
13. Content of iCCM Policy
• In none of the study countries was iCCM a stand-alone
policy
– iCCM was most likely to be viewed as the community component
of IMCI with treatment services targeted at hard to reach areas.
• iCCM policies for malaria and diarrhea were supportive
across country case studies with less support shown for
pneumonia or newborn CCM.
• Integration across iCCM conditions varied with more
difficulties faced in countries with well-funded, parallel
malaria programs.
14. Content of iCCM Policy
• Higher-level policy documents varied in their mention of
CHWs or components of iCCM but program documents
and training guidelines were more consistent.
– Policies were not developed in a linear fashion
• CHW profiles varied substantially.
– In some places, iCCM is part of an upgrading of community
services (Niger, Mali, Mozambique, Malawi) while in others it
aims to build on a foundation of volunteers (Burkina Faso,
Kenya)
15. Policy Context, Actors and Process
• The history of primary health care and community health
worker programs in each country had a substantial,
albeit nuanced, impact upon the development of iCCM
policies.
• Policy change was typically led by technocrats within the
MoH.
– High level policy champions were rare, and a number of actors
who could have been supportive of the policy were not really
engaged in policy formulation.
• Despite the centrality of funding issues, Ministries of
Finance were not brought into policy discussions.
16. Policy Context, Actors and Process
• Availability of funding to support both the scale up of a
paid CHW cadre and necessary training and drugs for
iCCM was critical to successful policy formulation across
all countries.
– In all cases, countries were highly dependent upon the promise
of external funding for iCCM.
• One of the key factors that focused attention on iCCM
was political commitment to the MDGs. This was
combined with recognition that existing strategies to
achieve MDG 4 (notably IMCI) were not working as
effectively as they should.
17. Policy Process
High Level
Focus on
MDGs
FUNDING AVAILABLE
Offer of funding from
Development partner or
Funding windfall
Countries not on track to
achieve MDGs
iCCM Policy window
IMCI is not working as well
as expected
Children are dying at home
New Countryled Community
strategies
POLICY SOLUTION
Emerging evidence of
Effectiveness of iCCM
18. The Role of Evidence and Ideas
• Both scientific and experiential evidence cited during
policy development, with much of it coming from outside
the country.
– Local evidence was highly valued and the lack of local evidence
on key issues had the potential to slow the policy process.
• Country-based evidence was used most to identify the
key issues at stake while research evidence, both
international and local, was used to identify and prioritize
interventions. Evidence from other countries were seen
as “proof of concept” and learning opportunities.
• Evidence was identified and promoted by “elite actors,”
such as UNICEF, WHO, NGOs and a few key
government officials.
19. Implementation of iCCM Policy
• Implementation of iCCM is taking place in all study countries
to some extent, with the exception of Kenya.
• Ministries of Health are involved in implementation but partner
organizations are playing a significant role in carrying out
activities as well as funding them.
• Key questions remain about the long-term financing and
sustainability of iCCM policy and its implementation.
• There are a series of cross-cutting barriers to implementation
that arise from existing challenges within health systems and
related to CHWs.
• There are further country-specific challenges related to the
policy content and/or the policy development process for
iCCM that also need to be addressed.
20. Acknowledgements
Funding from
• We would like to thank all country teams for
their hard work.
• Sincere appreciation to study participants
for sharing their time with us.
21. iCCM Costing and Financing Tool
Presented by Colin Gilmartin
PI: David Collins
Research Team: Zina Jarrah,
Kate Wright
Management Sciences for Health
UNIVERSITY RESEARCH CO.,
LLC
21a
23. Project Overview
• Project Scope – Major Objective
– To develop and disseminate a simple cost and financing
model for integrated Community Case Management (iCCM)
• Project Approach & Strategies
– Develop a prototype iCCM costing tool
– Test in three research countries (Rwanda, Malawi and
Senegal)
– Refine tool after each country study
– Field testing of the tool conducted by another organization
(WorldVision in Indonesia)
– Finalize tool and disseminate results
– Support early adopters of tool
23
24. iCCM Costing and Financing Tool Description
• Excel-based, open source, user-friendly
• User guide and implementation manual
• Baseline Year Costs and Financing + 5 Projection
Years
• Automatic conversion between local currency and
USD
• Automatic generation of output graphs
• Combination of standard and actual costs
• Uses financial costs only
• Does not calculate cost-effectiveness but can be
used as cost inputs for CEA
24
25. iCCM Costing Methodology
• Data collected from two main sources:
1. Program implementing agency (i.e., MOH, NGO)
• Program assumptions, population coverage
• Standard treatment protocols
• Numbers of CHWs and cases treated in year of
analysis
• Costs of medicines and equipment
• Management, supervision and training costs
2. Interviews with CHWs and their supervisors
• “Reality check” to compare with data collection from
partners/central level
• Time spent by CHWs on iCCM activities
25
• Time spent by CHW supervisors
26. Data Requirements for iCCM Costing
• National Population, total population covered by iCCM
Program
• Breakdown of population by age (newborns, infants,
children <5, pregnant)
• Interventions in iCCM package and standard treatment
guidelines
• Source of financing and amounts of funding secured for
iCCM program
• Number of CHWs current providing iCCM services
• Number of iCCM cases treated
• Incidence rate for each iCCM service (i.e. pneumonia,
diarrhea, malaria)
26
27. Data Requirements for iCCM Costing
•
•
•
•
•
•
•
•
List of standard equipment provided to CHW and cost
List of essential medicines provided to CHW and cost
Standard CHW working hours and salary, if applicable
Management costs: list of all staff providing iCCM program
management, salaries, and time spent on iCCM
Supervision costs: list of all staff providing supervision to
CHWs, salaries, and time spent on iCCM
Meeting costs: list of all meetings required for CHWs and
supervisors, costs
Training costs: list of all trainings required for CHWs
(initial/pre-service training and refresher training), costs
Any additional iCCM Program Recurrent or Startup costs 27
35. iCCM Implementation and Potential Uses
•
•
•
•
•
Clear linkage between iCCM policy development
and costing
Developing national policies and budgets should be
a simultaneous, iterative process
Identify areas where policy decisions may be driven
by costs, and create scenarios (i.e. usage of RDTs,
payment of CHWs)
Develop concrete national targets for iCCM
coverage that can be costed
Cost implications of these policy decisions can be
calculated using the iCCM tool
35
36. Applications
• Determine cost efficiency and effectiveness of iCCM
programs
• Provide detailed analysis of start-up and implementing
costs
• Develop multi-year projections of program costs
• Develop line item budgets
• Determine the cost to achieve impact (cost per DALY,
cost per life saved, etc.)
• Conduct „what-if‟ scenarios – adding new services to
the package, changing treatment protocols, etc.
• Empower national stakeholders to advocate for iCCM
program implementation and mobilize the necessary
36
resources
37. Resources
• For more information:
www.msh.org, Health Care Financing subsection
http://www.msh.org/our-work/projects/integrated-communitycase-management-cost-financing-analysis-model-development
• Download the tool: http://www.msh.org/resources/integratedcommunity-case-management-costing-financing-tool
• Please direct all questions and feedback to Zina Jarrah
(zjarrah@msh.org)
37
38. ICCM Embedded Research:
Improved data for improved programs
(CCM-IDIP)
PI: Jennifer Bryce
Research team: Elizabeth Hazel,
Tanya Guenther (StC)
UNIVERSITY RESEARCH CO.,
LLC
39. Embedded within ICCM program activities to
improve existing MOH M&E systems
– Four-country analysis of ICCM M&E systems
– Malawi as “in-depth” case study to test “innovative
approaches” for improving M&E
Objectives
1) Provide an in-depth analysis of the ICCM M&E systems
of 4 countries
a) ICCM Benchmark indicators as the framework
b) Data quality assessment snapshot
2) Describe successes/challenges of “innovative
approaches” in Malawi and how they could be adapted
to other settings.
3) Conduct a cross-country analysis of the ICCM M&E
systems with recommendations for improvements.
41. Activity timeline
Activity
Date
National level consultations
Dec 2011 & March 2012
1. Desk review
March – April 2012
2. Baseline Data quality assessment
May – June 2012
3. District level consultations
Oct 2012
Implementation of Innovative approaches:
4. Cell phone interview validation study
Oct-Nov 2012
5. Data quality and use improvement
package.
Dec 2012 – April 2013
6. Endline Data quality assessment
June 2013
7. Dissemination
July – August 2013
42. Desk review
• ICCM program is well-established and coordinated
under the IMCI/MOH
• Country focus on core implementation strength
indictors
– Developed consensus indictors and adapted routine
reporting tools to collect
• Prioritized two areas for further implementation
research
– Data management and use at district level for improved
decision‐making.
– Routine sources for quality of care
43. HSA
Form 1A
Routine monitoring
structure
Partner support
Health center
Form 1B
Partner support
District
Form 1C
National
Partner support
• Monthly reporting
forms
• Significant partner
support
• DHIS-2 being
scaled-up
44. Data quality assessment
• Objectives
– To describe data collection
availability, completeness,
quality and reporting at all
levels
– To identify any gaps in ICCM
monitoring
• Methods
– 2 districts
– Interviewed HSA,
supervisors, district health
staff
– Results verification:
comparing reporting forms
with HSA registers
45. Results verification ratio: HSA forms
Dowa
Kasungu
Av. (range)
Av. (range)
Fever cases
0.89 (0.14-1.0)
0.77 (0.22-1.20)
Diarrhea cases
0.88 (0.25-1.18)
0.99 (0.57-5.00)
Fast breathing cases 0.95 (0.32-1.0)
0.59 (0.06-1.29)
Stocks dispensed:
LA 6x1 0.93 (0.23-1.01)
0.84 (0.17-1.89)
LA 6x2 0.96 (0.14-3.2)
1.36 (0.71-2.73)
Cotrim 0.88 (0.13-1.04)
0.90 (0.39-1.27)
ORS 0.88 (0.33-1.12)
0.85 (0.04-1.43)
RVR = Count from HSA Register/Reported by HSA in MRF
46. Major findings: strengths
• Well-defined structure for reporting with clear deadlines
& expectations
• High reported ease-of-use with reporting forms
• System of quality checks in place
• Good levels of reporting and completeness
• Reasonable levels of consistency with a few
exceptions.
• HSAs meet regularly with health center staff/community
leaders
47. Major findings: weaknesses
• ICCM data not kept at health center or HSA level
• Concerns with data quality reported by participants – drug
stock & caseload
• Very limited training on data use, processing and
interpretation.
• Data use in decision making is low, mostly top-down
approach.
48. “Innovative” approach – cell phone validation
study
• Collect IS indicators via mobile telephone interviews with
HSAs
• Main objective: to determine whether telephone
interviews with HSAs is a reliable approach for
measuring ICCM implementation strength
49. Methods
• Interviewed ICCM-trained HSAs on national
consensus implementation strength indicators:
– Training, supervision/mentoring, utilization,
current/minimum drug stocks, previous stock-outs
• Validated responses by comparing responses to
health center reporting forms and direct observation
at the HSA village clinics
• Interviewed HSAs to determine the reason for any
discrepancies
• Sampled 241 ICCM-trained HSAs in 2 districts
50. Preliminary Data:
Supervision and current drug stocks
Implementation
strength indicator
Validation
Method
Reported
% (n/N)
Observe
d
% (n/N)
Sensitivity/
specificity
No. HSAs supervised
in CCM in the last 3
months
Supervisor
records &
routine forms
26.5%
(53/200)
26.5%
(53/200)
81.1%/93.2%
No. HSAs mentored in
CCM in the last 3
months
Supervisor
records &
routine forms
26.0%
(52/200)
17.5%
(35/200)
82.9%/86.1%
No. of HSAs with all
key CCM drugs at the
time of assessment
Observation
at village
clinics
56.6%
(112/198)
55.6%
(110/198)
100%/97.7%
51. Conclusions
• This method is feasible; HSAs reachable by cell phone.
18% not available by cell phone but available for face-toface interviews.
• Produces accurate results
– Less accurate for drug stockouts and supervision/mentorship
– However, given DQ issues with routine forms, interviewing HSAs
may be the most reliable method for collecting this information
short-term.
• Good method for scale-up
52. “Innovative” approach – Data use and quality
improvement package
• Objectives
– To improve the MOH ICCM monthly reporting
data quality
– To increase data use at the district, health
center and HSA levels.
– To document feasibility and costs of package
implementation
53. Specific package components
• General training on data management, use and
interpretation;
• Refresher training for HSAs and senior HSAs on
completing the monthly reporting forms;
• Simple templates for displaying the monthly ICCM
data;
• Calculators for HSAs and senior HSAs to assist
with completing monitoring forms;
• Training for senior HSAs to identify poor-reporting
HSAs for targeted supervision;
• Working with district IMCI coordinator to identify
reporting “benchmarks” and „action thresholds‟
54. Update
• Implementing in 2 districts
(Dowa and Kasungu) with
46 health facilities and 320
HSAs
• Evaluate with endline DQA
• Interim supervisory visits
show that
HSAs/supervisors are
using the graphs and
feedback is positive.
• Partners are considering
incorporating the data use
templates/training in the
ICCM package
56. IR seeks to determine the best ways to implement
evidence-based interventions in real world settings
Based on what you’ve seen today:
- What are the lessons learned?
- What are the key messages for uptake
into policy and practice?
56
Editor's Notes
In spite of iCCM successes and potential, some low income countries have not implemented iCCM or have delayed starting or expanding programs.
The integrated delivery for children under 5 of: Treatment for pneumonia with antibiotics,Treatment for diarrhea with zinc and low osmolarity ORS, Treatment for malaria with artemisinin combination therapy (ACTs), and Home visits of newborns with treatment of neonatal sepsis with antibiotics…by community or lay health workers at household and/or community levels.
Policies were not developed in a linear fashion whereby higher level policy frameworks preceded lower level implementation guidelines.
In-country pilots and programs provided local implementation evidenceTo convince policy makers (pneumonia pilots in Kenya and Burkina)To demonstrate feasibility (APEs in Mozambique, newborn CCM in Malawi)As project roll-out (Niger)
Barriers to implementation:Health system barriers: supervision of CHWs, data management, poor coordination, drug dispensing guidelines, shortages, weak community ownershipCHW related barriers: recruitment, motivation and retention, weak ties with the communityFacilitators to implementation:Relationships and support from donorsCommunity support, where presentExisting CHW cadre and health system infrastructure
NOTE: RWANDA RESULTS CURRENTLY UNDER REVIEW OF MOH
Note – RDTs in Senegal and Rwanda, presumptive malaria treatment in Malawi at the time of this analysis