In 2010, the Democratic of Congo (DRC) Ministry of Health (MoH), USAID, MCHIP undertook an exercise to document the country’s experience with integrated Community Case Management (iCCM). The purpose of the exercise was to share DRC’s iCCM experience with other countries and to strengthen the DRCs program. It is estimated that in DRC, diarrhea is responsible for 18% of under-five deaths, malaria for 17%, and pneumonia for 16%. DRC is one of six countries that together with India, Pakistan, China, Nigeria, and Ethiopia, contribute over half of all child deaths in the world each year. Its statistics for infant and under-five mortality consistently rank among the highest in the world. Since 2005, DRC has been implementing iCCM to extend access to child health to reduce significantly preventable deaths among children
Relevance of DRC’s experience
Before 2006 there was no community case management available for childhood illnesses interventions available at community level. In 2006, DRC launched its iCCM program, and immediately integrated malaria, pneumonia and diarrheal disease. By September 2010, CCM-trained relays were providing integrated services for these conditions at 716 community sites covering approximately 1.7 million people, thereby significantly extending key interventions to previously under-served communities.
What is additionally notable about the DRC iCCM program is that the extension phase was planned right from the beginning to avoid a potential gap after the pilot phase. Successive lessons learned were integrated through ongoing adjustments. The DRC program is particularly noted for having a complex partnership involved in iCCM, which includes multiple implementing partners and sources of funding. With five years of experience and well-documented lessons learned, the DRC program has a number of lessons to offer other countries interested in either implementing CCM for the first time or expanding their current programs.
By sharing its experience, DRC provides important lessons for the global community to help countries scale up their programs. Using an internationally-recognized framework of iCCM benchmarks the document presents key findings for eight programmatic components of the iCCM benchmarks, namely: 1) coordination and policy setting, 2) financing, 3) human resources, 4) supply chain management, 5) service delivery and referral, 6) communication and social mobilization, 7) supervision and performance quality assurance, and 8) monitoring and evaluation and the health information system.
Key lessons the report identifies include:
1. Coordination and policy setting: Country leadership was indispensable; the MoH introduced iCCM and led an active steering committee with a clear vision which helped prevent verticalization of the conditions addressed in iCCM. Despite the known challenges of governance in DRC, the MoH plays a strong leadership role in iCCM and was able to mobilize a large consensus and solidarity among concerned stakeholders, including exemplary support from donors coupled with strong technical assistance. This includes a clear plan with roles and responsibilities for the beginning and expansion phase. Advocacy efforts in DRC were conducted in parallel with the immediate learning and demonstration phase. At scale, particularly in a country as big as DRC, coordination with and ownership of provincial and district level should be specified in the Decentralization Plan. Written policy developed in expansion phase should regulate competing technical programs, competing priorities and resource allocation.
2. Financing: Lack of longer-term budgeted national plan amplifies dependence on donors. Given the changes in authority and resources available at provincial level, provincial administrations should play a strong role in iCCM, including provincial budget allocation. Financial motivation issues continue to be raised and non-financial motivation alternatives are not fully exploited.
3. Human resources: Training of facility staff in clinical IMCI to supervise CHWs is not a precondition for a successful community-based management initiative. Motivation of CHW remains an unanswered question, but does not impede CHW work or retention.
4. Supply-chain management: Frequent drug stock-outs are a prominent program challenge. The CCM supply recovery system is weak, this is linked to CHWs tending to use risky alternative supply network.
5. Service delivery and referral: The role of CHWs in CCM is fundamental in extending essential services to hard-to reach populations. One major challenge of the referral system between the CHWs and health facilities is the physical inaccessibility of health facilities due to the difficult terrain and security issues. CHWs are technically capable of identifying danger signs but caregivers’ compliance remains weak. Counter referral from health center is generally less systematic.
6. Communication and social mobilization: The communication component does not receive enough attention at a large scale. CCM specific messages tend to be diluted into more generic IEC activities. Supervisors and program managers tend to be highly focused on the technical complexity of case management.
7. Supervision and performance quality assurance: Through monthly monitoring meetings, health professionals provide CHWs regular support and coaching. However, on-site supervision tends to be underfunded, and quality might suffer during scale-up.
8. Monitoring & Evaluation and the Health Information System: Quarterly reviews are organized by Health Zone management teams with partners and occasionally with the provincial and national level. Data from direct observation are collected during follow-up. These, and individual records are sent to the central level for analysis. A computer database was developed for analysis.