Evaluation and lessons learned for the BASICS project : intervention in Niger, 1993-1996

CCM is a form of integrated case management. The evaluation covers the period 1993-1996. The project has worked with the Niger Ministry of Health (MOH) to combine training, supervision, and management efforts for three programs in the health districts of Boboye and Say: the control of diarrheal diseases, acute respiratory infections, and malaria control. In addition, the project emphasized the verification of children's vaccination status and nutritional condition. The principal project activities included planning and conceptualization; a baseline survey of health workers' case management practices conducted in January 1995; the development of training and supervision materials; training of trainers and health workers; supervision and problem resolution; and a follow-up survey in December 1996. BASICS collaborated with the Quality Assurance Project (under 9375992) to develop and use appropriate supervision and problem resolution tools. BASICS' intervention was perceived positively by the project's main partners in Niger. At the central level, the national disease control program directors and other MOH staff have been active participants in the development and use of training and supervision materials. This experience should prove helpful, since it is clear that the integrated (or combined) case management approach can be effective in treating childhood diseases and associated problems in Niger, where 65-92% of children have more than one pathology and problems of malnutrition are common. In general, the results of the case management surveys show that health workers' practices have notably improved from the baseline survey, with the exception of the assessment of diarrhea and dehydration cases. Other aspects of integrated (or combined) case management that still need improvement include advice to parents and assessment of management of malnutrition. Some aspects of the combined approach, such as weighing children consistently and the emphasis on interpersonal communication, are relatively new to health workers. Making these practices part of their routine will take more time than the 2-year time period of this intervention and will require steady reinforcement by the health system. Project activities, lessons learned, and recommendations are presented for each of the main project components and for combined case management in general. The quality assurance approach to problem resolution and supervision, including an emphasis on the client's viewpoint, teamwork, analysis of available data, and causal analysis, appears to be an effective tool to prioritize problems and to enable health workers to solve practical case management and communication problems. Problems encountered by the pilot project include issues of compatibility between the treatment guidelines used for the BASICS intervention and the treatment protocols that were used in the two districts, and throughout Niger, before the intervention. In addition, health workers say that the new, more comprehensive approach to assessing and treating children takes more time and requires reorganization of their work. Possible solutions for these issues are discussed in this report. The overall advantages and disadvantages of the integrated case management approach are discussed and the prerequisites and resources needed at each level of the health system are described. The report concludes with recommendations for next steps for the MOH and for BASICS/Niger. A summary of all recommendations is included at the end of the report. As the MOH and donors move to implement the integrated management of childhood illnesses (IMCI) strategy, the experience of BASICS' pilot project provides important and helpful lessons. The BASICS' experience will also help to guide the implementation of IMCI in other countries of the West African region. (Author abstract)