By Pamela Juma, Associate Research Scientist, APHRC
Reducing child deaths has been one of the key priorities in the health care system. Some progress had been made in addressing the child health indicators as shown in the Kenya Demographic Health Survey 2008/2009 (MOH 2009). The survey revealed that under 5 mortality rate was at 74/1000 live births, and infant mortality at 52/1000 live births. The neonatal mortality rate was estimated at 33 deaths per 1000 live births in 2003 (KDHS, 2003) and 31/1000 in 2008. Even though this was an improvement from the previously poorer indicators, the child health indicators are still unacceptable. The major diseases contributing to poor child health indicators include pneumonia, diarrhoea, malaria, malnutrition and HIV/AIDS.
Effective interventions for treatment of children at the community exist. These interventions have not been adequately implemented in Kenya. From a recent study conducted in Kenya (Pamela et al. 2013), the challenges include lack of clear overarching Integrated Community case management of childhood illness (iCCM) policy to address all the killer diseases, inadequate mechanisms for training supervision and monitoring of community health workers to ensure quality service provision, barriers to scale up and implementation of iCCM including financial allocation and sustaining effective drug supply.
This policy brief addresses these three challenges and looks at how effective implementation of iCCM can reduce child deaths in Kenya. Recommendations and options for successful policy development and implementation are provided.
In 1999, Kenya introduced integrated Management of Childhood Illnesses (IMCI) in the health care system. This was implemented with inadequate success due to various challenges including inadequate training coverage, inadequate community access, failure of health workers in using guidelines and funding for scale up (Mulei, Wafula & Goodman, 2008). Furthermore the community component of IMCI was not addressed at all by the public sector.
Recently, UNICEF and WHO developed guideline for Integrated Community Case Management for Childhood illness (iCCM) by community health workers at household and community level.
The components of iCCM as recommended by WHO/UNICEF include:
………… Generally by community health workers at household and/or community levels
Even though Kenya has recently developed community strategy to strengthen community-based services, iCCM has not been given adequate attention in the strategy. According to the recently completed multicounty study, Kenya still lags behind many countries in developing and implementing iCCM policy to reduce childhood deaths at community level (Sara et al 2013).
The following are the main reasons why iCCM has not been implemented adequately in Kenya.
Absence of clear overarching iCCM policy to address all the killer diseases
There has been slow progress in developing iCCM policy in Kenya despite the existence of international guidelines and strong support from development partners. A multi-country study of iCCM policy process showed that Kenya has lagged behind many other countries in Africa. (Bennet et a.l 2013). Even though iCCM was incorporated in recently developed CHWs training manual, policy endorsement for use of antibiotics by CHW for treatment has not been done (MOH 2012).
Inadequate training and supervision of community health workers
Whereas evidence exists to show that CHWs can deliver basic health care services to children under five in areas where communities have poor access to formal health care services (WHO 2009c) training and support to CHWs to provide these services is not adequate in Kenya. Majority of the participants in the recent Kenya policy analysis study mentioned multiple barriers related to CHWs including inadequate number of well-trained CHWs, as well as issues regarding supervision, motivation and retention. Even though there is strong support for CHWs from donors and NGOs , a strong cadre of CHWs able to deliver quality care.
Barriers to scale up and implementation of iCCM
A major barrier to implementation is lack of funds to support iCCM activities. The findings from the iCCM study showed that Kenya is highly dependent upon the promise of external funding for iCCM. There has been no long term financial commitment to sustain community based activities including iCCM. Another barrier is resistance by certain carders of health professionals to allow community health workers to dispense antibiotics.
Develop an overarching policy for iCCM.
Having an overarching policy that covers all the killer diseases to be implemented by CHWs will enhance implementation of iCCM. The participants in the completed Kenyan emphasized that having this policy would guide integration of the services in the context of improving primary health care. Given the poor access to services by community members in hard to reach areas the policy will support service provision by CHWs in these communities. The policy will also improve coordination and involvement of key departments and actors who have a role in child health.
Develop mechanism for training, supervision and motivation of CHWs
Developing a strong cadre of CHWs to implement iCCM is important in enhancing access to care in hard to reach communities. Evidence from other set ups like Malawi, Ethiopia and Pakistan show that well trained and motivated CHWs can help reduce child morbidity and deaths. To achieve this integration of iCCM training into community health workers training is critical. Mechanisms for supervision and tools to monitor quality should be developed. This would address the quality gaps identified in a pilot study conducted in Siaya in (Ref)
Address Barriers to scale up and implementation of iCCM.
Allocation of funding to support both the scale up of a payment of CHW cadre and necessary training and drugs for iCCM is critical to successful iCCM implementation. Experiences from countries like Malawi that have well trained lay workers who are on the government pay role show that retention of the workers is high and they continue to deliver quality services. This is more cost effective than waiting to train health professionals to do the same work.
Develop an overarching policy to guide development and implementation of iCCM
This should include development of an overarching policy document that addresses all the components of iCCM to guide implementation. Development partners who have been supporting community health interventions can be involved in the process. CHWs who have worked for long can be mobilized to give their views and support for iCCM policy debates. Involvement of Ministry of finance is important to ensure allocation of finance to support iCCM. Pharmacy and Dentist board as well as medical professional associations are also critical in this process. Failure to have a clear policy will lead to uncoordinated efforts among the implementing stakeholders and continue burden of death among children under fives.
Scale up training and supervision of health workers who provide community iCCM with a focus on hard to reach areas.
Successful implementation of iCCM will require adequate numbers of well trained and well-motivated CHWs . Involve NGOs who have implemented pilot iCCM projects in designing at training of CHWs. Health professional at primary health care level should be trained to provide continuous training, supervision and monitoring of CHWs to ensure quality service provision. This would ensure continuous quality of services provided by CHWs
Address Barriers to scale up and implementation of iCCM.
Ownership and financial commitment from the government is crucial to iCCM implementation process. Training, supervision of CHWs as well as supply of essential medication and other commodities will require adequate financing. Both the national and county governments should allocate a percentage of the health budget to support iCCM.