It is estimated that there are over 30 million children under the age of five in Nigeria; approximately 765,000 of these die each year contributing to 11% of the total global estimate of under five deaths. The majority of these deaths occur at home among the vulnerable and are due to preventable and treatable illnesses such as malaria, pneumonia and diarrhoea. Gaps in access to treatment services have been identified as a major factor responsible for the mortality, leading the country to adopt integrated community case management (ICCM) in order to expand access to life saving treatment interventions for the three diseases.
Nigeria has adopted the global best practices for resource limited settings to implement ICCM and has developed national implementation guidelines. Following the country’s decision to implement the ICCM strategy, a team of health officers from the Nigeria Ministry of Health (MoH) with support from the Honourable Minister of Health and the United States President’s Malaria Initiative (PMI) participated in a five day learning visit to Uganda. The aim of the visit was for the development and implementation of ICCM in Nigeria to be guided by the experience and lessons learned in Uganda where the programme has been MoH policy since 2010.
“It has been a great honour to host our esteemed colleagues who are as passionate as we are about saving the lives of children in their country,” said Dr. Godfrey Magumba, Malaria Consortium Uganda Country Director reflecting on the visit. “We hope we have been able to show some critical learning from the programme in Uganda which will support the successful implementation of ICCM in Nigeria, improving access to care for those who need it most.”
The learning visit included a team of officers at policy level and programme officers from the Federal Ministry of Health (Department of Family Health-Child Health Division, National Malaria Control Programme), National Primary Health Care Development Agency, State Ministry of Health (integrated management of childhood illnesses focal persons from Ebonyi and Zamfara States), representatives of Malaria Consortium, PMI fundedMalaria Action Program for States project and USAID-PMI. In addition, Ugandan MoH team and district health teams, community members and implementing partners also participated in the activity.
“We have learnt a lot from our one week stay in Uganda and we hope to take back to Nigeria all these in order to ensure that children in the most remote areas have improved access to good quality diagnosis and treatment of pneumonia, diarrhoea and malaria,” says Dr Kayode Afolabi, head of Child Health Division, FMOH about his trip and its impact on the implementation of ICCM in Nigeria.
During the five day trip, the Nigeria delegation was able to meet with implementers of ICCM (community health workers, health facility staff responsible for their supervision, district and national level officials) in mid-western and central Uganda and discuss their experiences, challenges faced, and lessons learned. The visiting team also observed and discussed how ICCM training and supervision were planned and implemented as well as community health workers practicing their skills. In terms of implementation and optimisation of the ICCM model, the Nigerian team was able to learn about community dialogues and other community mobilisation and sensitisation activities taking place in order to promote use and acceptability of ICCM within communities. Furthermore, by sharing learning from the implementation of the Bill & Melinda Gates Foundation supported inSCALE project in Uganda, the Nigerian delegation was able to find out about innovative approaches to motivating and retaining community health workers through the use of technology and community focused interventions.
Through meeting with stakeholders, discussions were also held around key areas that need to be addressed when implementing a sustainable ICCM programme. It was important to understand how community caregiver performance can be optimised through support supervision and incentives programmes as well as the supply chain for ICCM and how it is managed. There were many discussions around commodity security which are crucial at the early stages of planning for implementation. Furthermore, in order to understand how ICCM fits into the health system and the contribution it makes to improved health service delivery, attention focused on the referral chain and the process of and challenges associated with being referred to health facilities especially with regards to transportation and pre-referral treatment for severe malaria with rectal artesunate. Finally, it was important to understand the budgeting and long-term funding for ICCM implementation in order to plan for a sustainable programme with potential for nationwide scale-up. The importance of planning by MoH for long-term support of ICCM strategy was also highlighted.
“We are happy that USAID is able to support such in-depth and beneficial learning exchanges which we believe will have a marked influence on the life saving programme to be implemented in Nigeria” says Dr Uwem Inyang who represented USAID-PMI Nigeria on the learning trip to Uganda.
The trip was considered to be highly successful with key recommendations and lessons learned being taken back to Nigeria to inform policy and practice. The recommendations from the visit include the inauguration of ICCM task force, led by the Federal Ministry of Health (FMOH), to coordinate implementation, ensure Government support, and facilitate the development of a scale-up strategy as part of the ICCM implementation plan. In addition the Government should coordinate all activities on ICCM, allocate adequate funds at all levels and strengthen the national procurement and supply management system. It is also of crucial importance to facilitate development of the community level health management information system tools and processes to ensure community level indicators are captured by the National Health Information System as well as strengthen the referral system. Other recommendations include the need for an ICCM investment plan and establishment of an incentive system for community health workers.
“We learned a lot on our trip to Uganda about the implementation of a sustainable and scalable ICCM programme, it has been very enlightening and beneficial. There is a lot of work to be done in order to achieve our goals for improved child health in Nigeria and high quality implementation of ICCM is one of the ways forward,” concludes Ebenezer Baba, Malaria Consortium Nigeria Programme Technical Coordinator. “We have come back to Nigeria with a lot of ideas, inspiration and motivation.”