Three quarters of deaths in children under five are caused by malaria, diarrhoea and pneumonia often because access to quality health care is hardest in areas where the need is greatest. Uganda has one of the highest infant mortality rates, with 440 maternal deaths per 100,000 live births. Just over 75 percent of these are post-neonatal and the leading causes are malaria (which accounts for 19 percent), diarrhoea (14 percent) and pneumonia (11 percent). Malaria Consortium’s inSCALE project aims to increase coverage of integrated community case management (iCCM) in countries where the programme is being implemented, including Uganda, in order to reduce the number of children dying as a result of these diseases.
Integrated community case management focuses on the premise that most common childhood killers can be readily diagnosed and treated by people within the community. It brings essential health care for the most vulnerable right to their doorstep. Research has shown that the iCCM approach has the potential to decrease childhood mortality from these three diseases by 60 percent, and yet in Uganda, where there were 2,662,258 confirmed cases of malaria alone in 2012, iCCM is conducted in only 34 out of a possible 130 districts.
The strategy behind iCCM involves providing training for two community health workers - or village health team members (VHTs) in Uganda - per village to carry out diagnosis and treatment of pneumonia, diarrhoea and malaria in children under five years old, and to identify and refer sick new-born babies. The aim is to reduce childhood morbidity and mortality by increasing the correct use of life-saving treatments – making them available, ensuring quality of delivery and mobilising demand for them. Where Malaria Consortium has supported the district authorities, excellent results have been observed, including a reduction of the number of cases seen at the health facility as care givers go directly to the VHTs instead, as well as an improvement in care seeking behaviour. InSCALE aims to demonstrate that the coverage and impact of these government-led iCCM programmes can be extended further if innovative solutions can be found for limitations of the iCCM, such as the motivation and retention of community health workers.
Various advocacy efforts are being undertaken to scale up the implementation of iCCM and to promote the sustainability of the VHT structure. However, despite the government’s support for this intervention, there is still no policy for iCCM and no funding has been allocated to sustain this approach.
As part of inSCALE Malaria Consortium invited political and technical leaders from Mbale and Tororo districts for a three-day learning visit in mid-west Uganda. These two districts partner with Malaria Consortium to implement malaria control activities and have a vibrant VHT structure, but have not yet introduced iCCM. This was an opportunity for their leaders to observe first-hand the implementation of iCCM, to understand the support needed from the district authorities to implement the programme, and exchange views and experience on sustainability of VHTs.
“I am very enthusiastic about the idea of treating children in our community and am very happy about this learning opportunity,” expressed Mr Emmanuel Osuna, Chairperson of the Local Council of Tororo District.
The leaders were impressed by the impact of iCCM and by the skills of the VHTs they met. Dr Waniaye, District Health Officer in Mbale District, commented on the “confidence and professionalism” of one of the VHTs they met: “I now realise that VHTs’ capacity can be built,” he said.
The leaders from both hosting and visiting districts discussed various ways to help maintain VHTs’ motivation and agreed that more effort was required to recognise their impact on communities’ health. There was also a consensus on the importance of strengthening data reporting and the links between health facilities and VHTs.
Although many steps can be taken within their districts to create a favourable environment for VHTs and iCCM, the leaders are also aware of the efforts required to attract government attention on this programme to ensure that policies are put in place.
“We learnt a lot from this visit and we would now very much appreciate it if we were given the chance to implement iCCM,” declared Mr Bernard Mujasi, Chairperson of the Local Council of Mbale District. “We hope that we can come together, talk to the Ministry of Health and ensure that they do more for this very good programme.”
Malaria Consortium will continue to support these districts to take the appropriate measures at local level and advocate at higher level for adequate support to scale up and sustain iCCM.