Integrated community case management and community-based health planning and services: a cross sectional study on the effectiveness of the national implementation for the treatment of malaria, diarrhoea and pneumonia
During the past 30 years, the under-five mortality rate has declined in Ghana from 145/1000 live births in 1998 to 60/1000 live births in 2014 with an infant mortality rate of 41/1000 and a neonatal mortality rate of 29/1000 live births. These mortalities are higher in the north of the country and in the rural areas. Despite this decline in under-five year mortality, the Millennium Development target of 40/1000 was not reached [1]. The main causes of under-five mortality are neonatal related causes (38 %), malaria (20 %), pneumonia (11 %) and diarrhoea (8 %) [2]. In 2012, the Child Survival Call to Action set “A Promise Renewed” with the target of decreasing under-five mortality rates to 20 or fewer deaths per 1000 live births by 2035 in all countries [2].
Access to anti-malarials within 24 h of the onset of malaria symptoms is vital to prevent progression to severe malaria or death. The Roll Back Malaria partnership recommends that 100 % of those suffering from malaria should have prompt access to affordable and appropriate treatment within 24 h of onset of symptoms [3, 4].
There are three key strategies that seek to improve physical access to quality treatment which are: extension and quality improvement of formal health care systems, improvement in the informal private sector (mainly drug shops), and the home-based care (HBC) of fevers [5]. The World Health Organization and the Roll Back Malaria partnership states that in settings with limited access to health facilities, diagnosis and treatment should be provided at community level through community case management of malaria, recommending the introduction of rapid diagnostic test (RDT) and rectal artesunate for referral, when possible [4, 6, 7]. Malaria HBC has been shown to be effective and cost effective especially in areas with high malaria transmission, and in areas with medium transmission and low coverage of health facilities [8–13]. Integrated HBC or integrated community case management (iCCM) does not reduce the quality of malaria case management if adequate training is provided and supervision is maintained [14]. Issues related to implementation (e.g., availability of CBAs, availability of drugs or access to facilities), may decrease the expected impact of the strategy. The United Nations Children’s Fund (UNICEF) and the World Health Organization officially endorsed iCCM in 2012 [15].
Ghana has developed two main community-based interventions or delivery strategies that aim to reduce barriers to physical access to quality treatment: the HBC and the community-based health planning and services (CHPS).
The HBC strategy started on a pilot basis in Ghana in 1999 to treat suspected malaria cases [16]. The pilot programme initially used chloroquine, shifting to artemisinin-based combination therapy (ACT) in 2005 [17]. In 2009 and in the context of integrated management of childhood illness (IMCI), Ghana developed the Home Management of Malaria, ARI and Diarrhoea in Ghana [16] also called iCCM. HBC (or iCCM) was defined as prevention, early case detection and prompt and appropriate treatment of fevers, ARI and diarrhoea in the community.
The HBC strategy corresponds to the lowest level of health care delivery in Ghana and it is designed to be implemented within the health system, with community-based agents (CBA) reporting their activities to care providers at the CHPS compounds (when existing) or to the next health facility level. All CBAs in the three northern regions (Northern, Upper East and Upper West Regions) provide treatment for malaria, diarrhoea and suspected pneumonia cases based on clinical symptoms and with the support of ARI timers for measuring the respiratory rate to diagnose pneumonia cases, mainly with the financial support of UNICEF. Those in the rest of the country have received the same training as the three northern regions but provide only malaria treatment with the support of the Global Fund to fight AIDS, TB and malaria (GFATM), and are supposed to refer diarrhoea and suspected pneumonia cases for further management. Other projects implemented by non-governmental organizations support integrated HBC on a smaller scale in different regions of the country. The HBC guidelines state that the service provided should be free, although some regions (such as the Northern Region) decided that users should give a small amount of money to CBAs to avoid risking lack of continuity and commitment of the strategy as experienced in other countries [8, 18, 19]. No target was set for iCCM utilization as a proportion of other delivery points for treatment of sick children.
The CHPS strategy started in 1999 after a pilot phase conducted in 1994 [20] attempting to respond to the 1978 Alma Ata Conference and the ‘Health for All’ principle. A key component of the CHPS strategy is that traditional leaders of the community must accept the CHPS concept and commit themselves to supporting it. The CHPS strategy is based upon a basic facility known as a community health compound, where health care is provided by a resident community health nurse or community health officer who also does a 90 days cycle visiting the communities she/he serves at least once within that period. The services provided include immunizations, family planning, supervising delivery (if trained staff available), antenatal/postnatal care, treatment of common diseases such as malaria, diarrhoea and acute respiratory infections (ARI) and health education. These services are free for those having a valid national health insurance card. No target was set for CHPS utilization as a proportion of other delivery points for treatment of sick children. The target for CHPS coverage is that a geographical area of a 4 km radius and between 4500 and 5000 persons should be covered by a CHPS [21, 22].
After several years of national implementation, there is the need to know how effective HBC and CHPS are at delivering care for children with fever, diarrhoea or cough. There are several studies that looked at the HBC in Ghana. However, most of these studies focused in few districts, looked particularly at malaria HBC and were conducted in a more “controlled” context [23–27]. This study aims to assess the effectiveness of the national implementation of HBC and CHPS in terms of utilization of services, appropriate treatment given and users’ satisfaction in the current context, without additional supervision, in a larger area and considering the management of fever, diarrhoea and cough for children under-five years old.