Introduction
Global health interventions should align with population needs and the health issues that resonate from resource constraints in health systems, poor access to health services in the population and governance of programmes that address the burden of childhood illnesses. Programmes that manage resource constraints, integrate lessons learnt and adapt to changing infectious disease conditions can offer resiliency and extended capabilities when facing emerging threats such as novel coronavirus (COVID-19), or other challenges that strain health systems and potentially diminish progress in combating persistent disease threats like malaria, pneumonia and diarrhoea. These diseases are leading causes of mortality in children under-5 years of age (U5) and can be better addressed through effective governance of health programmes that facilitate sustainable progress in reducing mortality by improving access to essential health services and implementation of evidence-based interventions with dedicated investment schemes.
Persistent inequities in maternal and child health are enabled by barriers to health coverage, including access to care in urban centres and rural environments. In addition, on access to care, many are not afforded good quality, or face direct and indirect costs for health services that render treatment for preventable diseases improbable. Child health encompasses the nurturing care needed for a child to both ‘survive and thrive’ to their greatest potential and well-being. The ‘good health’ that ensues must be facilitated by equitable access to care.1 2 Many communities face persistent poverty due to socioeconomic disparities that require interference through high-level policy development and governmental influence. In these instances, limitations to health intervention impact and low uptake of available health services, then contributes to increased risk for illness, disease-associated morbidity and mortality.3 Given the leading causes of mortality U5 can be attributed to three infectious diseases, programmes targeting these diseases can have considerable impact in reducing morbidity and mortality, provided the programmes are governed effectively and offer reach to the underserved communities with the highest burden of disease. As a primary indicator for concern, reductions in mortality would denote progress for goals in child health. The United Nations’ Children’s Fund (UNICEF) global child survival call to action asked countries to strive for 20 or fewer deaths per 1000 live births by 2035,4 and their Strategy to Health 2016–2030 emphasises the necessary shift towards a health system strengthening approach that places a focus on equitable access through integrated, and community-based care.2 Providing equitable access however requires that the primary health system has the infrastructure and resources to drive successful programme implementation. Moreover, governance, including the coordination, partnerships and management of programmes that sit within broader health systems’ strengthening and global health strategies is intimately linked with sustainability, and anticipated success. From this stance, this project sought to understand governance attributes linked to success of integrated community case management (iCCM) programmes to identify thematic challenges in programme adaptation to national health system (NHS) structures.
Health systems’ strengthening and governance in iCCM
A strong health system connotes multisectoral engagement and hosts a community-based system for accessing health services at a local level.3 ICCM is evidence-based and focuses on improving access to effective case management for malaria, diarrhoea and pneumonia through deployment of community health workers (CHW) to increase reach to underserved populations.5 6 The concept of CHW programmes in public health systems is not novel;7–11 however, the community-based government-led strategies that utilise them are varied by country with differing levels of success.12 13 While evidence has mounted showing the potential impact on child mortality through increased coverage of quality treatment services, challenges remain in achieving the greatest impact from iCCM.6 14 15
Since 2010, the iCCM strategy has complemented the WHO Integrated Management of Childhood Illnesses (IMCI) strategy that was initiated in 1999 to focus on delivery of treatment interventions through an integrated case management approach at the health facility level. A joint statement on iCCM by the WHO and the UNICEF, in 2012, stated that delivery of health services is often weak with low coverage for populations that have the greatest need.5 While IMCI had many successes, there were clear inefficiencies in reach to the most vulnerable populations, and needed strategic adaptation to extend its reach to address insufficient coverage and capture underserved populations in rural communities with high burden of illness and low utilisation and access to care. In estimates of the potential impact for community case management, significant reductions in morbidity and mortality made an integrated approach plausible.5 16 Prompt and effective community management of pneumonia, malaria and diarrhoea has been found to reduce mortality by 70%, 60% and 70%–90%, respectively.5 The iCCM programmes use CHWs based in their respective communities to deliver diagnostic and treatment services for multiple childhood illnesses.10 11 This includes training, equipping and supporting CHWs to assess, classify and (1) treat uncomplicated diarrhoea, pneumonia and malaria using oral rehydration salts (ORS)/zinc, oral antibiotics and artemisinin-based combination therapy respectively; and, (2) refer children with signs of severe illness and acute malnutrition to an appropriate referral facility.5 17
In the context of health system strengthening, iCCM fits as a programmatic contribution to overall goals set forth by WHO and UNICEF. The WHO framework for action towards strengthening health systems to improve health outcomes, addresses challenges to ensuring essential public health functions exist in an effective system that meets population needs.5 Similarly, UNICEF includes community health, national investments and governance as core aspects of their solutions for challenges to improving health systems.3 ICCM as an intervention begins to fill key gaps in reach and coverage identified in the implementation of the IMCI programme. In that regard, it is imperative to understand what is needed for successful implementation and sustainability of iCCM, as well as lessons learnt from the past implementation failures or scale ups that did not achieve maximum impact.
Governance, country leadership and management in global health strategies for child health have notable impact on programme success. Commitment to corresponding policies has also contributed to the greatest reductions in child mortality.18 Approximately, one-third of countries participating in global strategies have developed multisectoral policies related to social determinants of child health;6 however, the strategic approaches to meet national goals related to child health needs are often not normalised, lack leadership and the prioritisation that is required to achieve effectiveness and sustainability.6 19 For example, in a review of IMCI, 72 of 92 participating countries had an IMCI community health component where CHWs provided treatment for children. Of those 72 programmes, only 52 countries had provisions for iCCM.20 Governance is not prescriptive or normative; rather, it is relative to the society, culture, politics and systems at play. Decision-making processes, alongside political systems and social structures exist and influence adoption of global strategies, such as iCCM. Despite global consensus and awareness for the need to apply iCCM for achievement of national child health goals,5 14 21 establishment of country-level policy varies.22 Where supportive policies do exist, challenges remain, extending from policy to programme implementation and expansion.23 24 Understanding the process of policy development, strategic management through programme initiation and implementation is necessary to gauge programme potential for success and sustainability in a country.