Integrated Community Case Management: Findings from Senegal, the Democratic Republic of the Congo, and Malawi A Synthesis Report

In Africa, many countries are still in the early stages of their CCM strategies, focusing either on advocacy activities or on introducing the approach for a single disease at a time. However, a few countries, including the Democratic Republic of the Congo (DRC), Senegal, Malawi, Rwanda, Madagascar, and Niger have begun to implement the integrated approach on a national scale. Three such countries—Senegal, the DRC, and Malawi—have recently conducted assessments of their programs to generate key lessons. The assessments in the DRC and Senegal were conducted in 2010, while the Malawi assessment was conducted in 2011. In Senegal, an integrated CCM program had been ongoing for seven years at the time of the assessment. By 2010, the Senegalese program covered approximately 1,600 health huts in 58 (out of 69) districts. CCM began in the DRC five years before the assessment was conducted in 2010. At that point, CCM was occurring in approximately 750 community sites in 10 (out of 11) provinces. The CCM program in Malawi had three years of implementation experience when the assessment was conducted in 2011. This program involved 3,000 paid health surveillance assistants (HSAs) in village health clinics that covered 3,500 pre-determined hard-to-reach areas. In all three countries, the CCM programs included the treatment of three major childhood illnesses by CHWs: diarrheal disease, malaria, and pneumonia. Each country's CCM assessment was reviewed and findings were summarized across eight CCM Benchmarks that are accepted global components by which CCM programs can be evaluated: Coordination and Policy Setting, Financing, Human Resources, Supply Chain Management, Service Delivery and Referral, Communication and Social Mobilization, Supervision and Quality Assurance, and Monitoring and Evaluation. Based on the synthesis of findings, lessons learned that can contribute to ongoing refinement of CCM programming approaches and global learning about the policy and operational needs of these programs in each of these areas were identified. Ownership and active leadership from the national Ministry of Health is at the core of a successful CCM program. It is essential to ensure that this ownership continues down to operational levels (provincial and district) to help with successful programming. The two financial components of an effective and sustainable CCM program are a budget system that allows planning and tracking of specific CCM activities and expenditures, and a long-term implementation and financial plan for CCM. Motivating CHWs is an integral aspect of success, and a package of incentives (not necessarily financial) should be agreed upon in early design stages. This incentive package should be created with the long-term financing capacity of the host government in mind. While separate supply chains for CCM may be faster and often more convenient in addressing the stock-outs that are very common in many countries, the more sustainable approach is to strengthen the national supply chain system so it can include CCM commodities. Substantial thought should be invested in the early stages of program design to create a locally acceptable service delivery model that will work within the health system and facilitate community satisfaction. CCM programs should ensure that mechanisms are in place to collect relevant data to track frequency of compliance in cases of referral, as well as reasons for non-compliance, to assist in addressing service delivery challenges. Because information, education, and communication/behavior change communication campaigns are complex, involving local leaders and religious figures can help increase coverage and understanding of key messages. It is essential to success that CCM programs work from the early design stages to devise a local supervision strategy with clear division of roles and (well-defined) tested guidance on timing and content. Efforts should be focused on supporting health system staff to act as supervisors. Supervision by external organizations should only provide additional support as part of capacity-building in the health system.