Study: Understanding the implementation of the Integrated Community Case Management intervention, its dynamics and processes for integration and coordination.
Funder: Global Fund Through Ministry of Health Uganda
Implementing Agency: PACE
Collaborators: This study was conducted in coordination with national iCCM stakeholders including the Uganda National Malaria Control Division (NMCD), Maternal and Child Health Division and relevant district officials in the selected districts such as DHOs, iCCM District Coordinators and the In-charges of the Health Facilities.
Study Period: May 2019-December 2020
Overview of the Study
In 2010, the Uganda government in partnership with UNICEF and Malaria Consortium adopted the iCCM as a key strategic approach to the control and timely treatment of malaria, pneumonia and diarrhea among children under five years especially in vulnerable communities.
In Uganda, the iCCM is implemented through both public and private sectors. In the public sector, commodities are given free to the VHTs who in turn, offer them freely through diagnosis and treatment to the under 5 children at household level. In the private sector, VHTs acquire commodities at a cost, sell them at a subsidized price and earn a small interest. While the public sector implementing partners cover whole districts, the coverage of private sector is partial and majorly in towns.
Since its initiation, iCCM had rolled out from 15 out of 112 districts (13%) to 120 out of 135 districts (89%) in 2020, including both public and privately supported districts. iCCM is implemented by Village Health Teams (VHTs) who are community volunteers identified by their community members and are given basic training on major health programs so that they can in turn mobilize and sensitize communities to actively participate in utilizing the available health services.
Despite the progress in scale up of iCCM, the strategy has been afflicted by some challenges, including inadequate supervision, motivation and retention of VHTs, unreliable medicine and equipment supply systems, weak monitoring and evaluation systems and low uptake of services provided by VHTs in certain areas. Adaptations such as the implementation of iCCM commodity supply chain to VHTs have also been implemented. However, there remains inadequate capacity of sub-recipients and implementation partners to integrate, coordinate and evaluate the iCCM strategy. To inform iCCM implementation and performance, tailored community engagement strategies such as client satisfaction and VHT motivation approaches, a functional supply chain and factors that affect integration of the strategy into the national system were vital.
The primary goal of this study was to understand the implementation of the Integrated Community Case Management intervention, its dynamics and processes for integration and coordination.
- To map/characterize the extent of ICCM implementation within districts
- To assess the impact of the ICCM strategy on trends in U5 morbidity .
- To assess client satisfaction and rating of the VHT services to the home/family.
- To assess the appropriateness of the ICCM strategy.
- To assess the ICCM supply chain in order to identify avenues to improve it.
- To examine the factors that influence integration of the ICCM intervention in the national health system.
- To assess effectiveness of VHT motivation approaches in ICCM.
The study results are to inform the review of the iCCM implementation guidelines by the Uganda MoH National Malaria Control Division (NMCD) and partners to strengthen the iCCM implementation process
To evaluate ICCM outcomes and processes, a comparative cross-sectional evaluation design using both quantitative and qualitative methods of data collection was used. The study had three key components: a) desk review of relevant guidelines, policies, program reports, and past assessments; b) field visits to 20 districts for qualitative depth study and c) field visits to 15 districts for quantitative studies.
The desk reviews documented the country context of iCCM implementation i.e., components of iCCM implemented, implementing partners, coverage, and any documented outcomes of the implementation. Also, the review documented scalable good practices and principal challenges in the implementation of iCCM.
The desk included review of published literature of available peer-reviewed studies, national and international iCCM guidelines, national community health strategies, training and supervision materials, program reports as well as past assessments in the country.
Qualitative depth studies
Qualitative studies were conducted in 20 selected districts; 15 iCCM and 5 non-iCCM (control districts). The focus of the studies in iCCM districts was to qualitatively assess district-level implementation coverage, client satisfaction of services provided by VHTs, appropriateness of iCCM, motivation approaches of VHTs, supply chain performance, factors influencing integration of the intervention into the national system as well as documenting good practices and challenges in iCCM implementation. In each of the selected iCCM districts, the study team, in consultation with district stakeholders, purposely selected 4 health facilities and 6 VHTs from each health facility (each VHT corresponded to a village) for the on-site visits. The health facilities were purposively selected with a balance between HCII, HCIII or HCIV. Study sites within districts were purposely selected based on duration of iCCM implementation and performance (as judged by the district stakeholders). Well performing study sites were purposely selected in order to positively identify and document good practices facilitating implementation of iCCM. Studies in control districts were carried out to provide insights on how caretakers for children U5 years are coping with treatment for malaria, diarrhoea and pneumonia without the iCCM support.
Quantitative studies were carried out in 15 iCCM districts and the objectives are to quantitatively assess client satisfaction of services provided by VHTs, appropriateness of iCCM, the supply chain performance, trends in U5 morbidity and effectiveness of VHT motivation approaches. The selection procedure for study districts was similar to that followed in qualitative studies except there was an additional group of respondents i.e. caretakers of children U5 years. Following the selection of 6 VHTs from each health facility, 8 caretakers were selected from each of the VHT catchment village.
The study was undertaken in 20 districts (15 iCCM intervention and 5 non-iCCM intervention) selected from the different regions of the country namely; Acholi, Ankole, Bugisu, Bukedi, Bunyoro, Busoga, Karamoja, Kigezi, Lango, North Central, South Central, Teso, Tooro and West Nile.
The ICCM Study was concluded in 2020 and results disseminated
Principal Investigators -Nakamya Phellister (PACE)
Co- Principal Investigator – Dr. Freddy Kitutu (Makerere University), Peter Buyungo (PSI), Rebecca Babirye (PACE), Dr. Betty Bukenya Nambuusi (PACE)
Co Investigators – Kato Joel (PACE), Muhire Ivan (PACE), Stephen Wamani (PACE), Medard Wamani (PACE)