1 iCCM Project Model Orientation Series July 2014

2 Overview of the iCCM Project Model

3 What is CCM / iCCM? CCM utilizes trained, supervised community members, linked to facility-based services, to deliver curative interventions in the community. These community members can be formal Ministry of Health (MOH) outreach workers, paraprofessional Community Health Workers (CHWs), or private sector workers, among others. CHWs may perform their duties from their homes, a community-constructed building, or government or private health facility. Integrated Community Case Management (iCCM) is a strategy to train, support, and supply community health workers (CHW) to provide diagnostics and treatment for multiple illnesses specifically pneumonia, diarrhea, and malaria for sick children of families with difficult access to case management at health facilities.

4 Rationale for iCCM The formal facility-based health system in most developing countries achieves only about 40% coverage. 80% of children die at home under the care of the family Many children live more than five kilometers from a health facility and are brought too late for care or not at all. Many children either do not get treatment for common treatable diseases, or they get treatment of unknown quality: Only 27% of children with suspected pneumonia would receive an antibiotic Only 39% of children with diarrhea would get proper management with ORT Only 34% of children with fever (suspected malaria) would receive antimalarial medicines I’ll go through one of the problem stories with you. This would be in the form of a flip book, with the narrative on the back. We can talk about the drawings themselves afterwards if you’d like. Clara esta embarazada. Empieza su dia molendo su maiz. Su olla esta lista para que pueda cocinar la comida para el dia. Biba is pregnant. She starts her day by grinding her maize. Her cooking pot is ready so she can begin to prepare food for the day

5 Leading causes of death

6 Why do we need iCCM? Nearly half the world’s under-five deaths were concentrated in Sub-Saharan Africa in 2012. Child mortality rates concentrated in HRH crisis countries, predominantly due to major killers; diarrhoea, pneumonia and malaria.

7 Why iCCM? CCM targets the conditions that cause the most child death in developing countries. - pneumonia, diarrhoea, malaria, and neonatal causes. CCM relies on evidence-based and one of the most cost effective child survival interventions - proven to save the lives of newborns and children under five, at a price that is affordable in developing countries. CCM brings curative health care to children in those communities that are hardest to reach. CCM is consistent with practices recommended by WHO, UNICEF, and other international health agencies. WHO, UNICEF, and other international agencies have jointly called on countries to adopt and promote policies and programs that have strong community-based components to deliver interventions for diarrhoea, malaria, pneumonia, newborn care, and acute severe malnutrition, while improving services at first-level health facilities.

8 Infectious Diseases within 7- 11 StrategyMaternal health Child health (0-24 months) Adequate diet Appropriate breastfeeding Iron-folate supplements Essential newborn care Tetanus toxoid immunisation Hand washing Malaria prevention and intermittent preventive treatment Appropriate complementary feeding (6-24 months) Healthy birth spacing and timing Adequate iron De-worming Vitamin A supplements Access to antenatal care, skilled birth attendance, prevention of mother to child transmission, HIV and STI screening Oral rehydration therapy/Zinc Care seeking for fever Full immunisation coverage for age Malaria prevention De-worming (+12 months) Direct Infectious Disease interventions are highlighted in blue and interventions which contribute to prevention and reduction of infectious disease are highlighted in grey.

9 iCCM Strategy: World Vision’s Approach

10 Target groups for iCCM interventionsPopulation living five kilometers away from health facilities in our ADPs Poor and vulnerable households (most of these are beyond five kilometers of health facilities)

11 360⁰ of support: households to health systems Family support Demand Preventive practices Community systems Supply chains Referral, transport and communication Training and supervision IMCI based facility level secondary management

12 WHAT: iCCM Programming StrategyFour building blocks Access (effective access): defined as access to trained providers and to appropriate medicines Quality: standard protocols for services delivered, a quality assurance plan based on supervision and refresher trainings Demand: CCM increases care seeking behavior by addressing common barriers to care seeking e.g. cost, transport, loss of productive time, and shortened distance National Policy: seeking to influence the formulation (and implementation) of national policies that promote ICCM integration and scale up within the health services.

13 iCCM Strategic FrameworkTo reduce mortality among children under 5 from common childhood illnesses by increasing the use of curative and preventive interventions. Demand Access Quality Systems Outcome 1. Caregivers demand for essential health services Outcome 2. Children receive treatment in a prompt and timely manner Outcome 3. Improved quality of services at the community level Outcome 4. Local health services are linked to and supportive of quality CCM. Output 1.1 Caregivers counselled on recognition and detection of symptoms of child illness Output 2.1 CCM treatment coverage by CHWs increased Output 3.1 CHWs knowledge on case management increased Output 4.1 Health systems and local partners have increased operational structures to support CCM Output 3.2 Trained CCM CHWs are routinely supervised Output 1.2 Caregivers counselled on optimal practices for home based care of the sick child Output 2.2 Caregivers enact timely and appropriate referral for severe cases (referral compliance) Output 4.2 (HMIS) Data monitoring systems include CCM indicators and are used for evidence based management and supervision Output 3.3 Community health structures provide oversight and management of CCM services Output 1.3 CHWs conduct follow up visits for counselling and treatment adherence Output 2.3 Sick children receive appropriate home-based and post referral follow up by the CHW Output 4.3 CHW supervisors utilise improved CHW management systems, tools and job aids Output 3.4 Community leaders promote awareness, uptake and quality of CCM services. Output 2.4 Children or households at high risk of child death are identified and regularly monitored. Output 4.4 Medical supply chains are functional and continuous with no stock outs at facility levels Think: Sustainable systems not interventions Output 3.5 Community medicines and stocks are well managed and are available to the CHWs

14 iCCM Technical approaches - Integration of newbornsWhere policy permits: Improved training on recognition and referral of newborn infections Integration of chlorhexidine cleaning of the cord stump Improved detection and referral of breastfeeding difficulties Antibiotic treatment of newborn sepsis Where policies are lacking Engage advocacy efforts Partner up Further research needed...

15 Integration contd Integrating nutrition, HIV & TBSupport the recognition and referral of acute malnutrition or GMP Integrate support for paediatric HIV and TB case identification and referral Improve nutrition practices for infants and children through ttC or similar Integrate nutrition treatment protcols where possible Strengthen referral and counter referral communication Ensure linkages between iCCM CHWs and HIV / CMAM facility based programmes Further research needed.....

16 Package of services CommunityPromote demand for quality services and uptake of iCCM Education on the detection of childhood infections CHWs Initial and ongoing training, on the job mentoring Equipment, resources and job aids Medicines and stock management Monitoring and supportive supervision Systems strengthening IMCI based severe case management Supply chain management COMMs support Referral support Linkage and communication with health services

17 Direct / financial supportCHW AIM Framework Community engagement Direct / financial support Advocacy role

18 Our Approach Current Technical ApproachesIntegrated rather than single disease approaches Include newborns in the iCCM model where policies allow For high hunger contexts, the integration of CMAM and iCCM Paediatric TB & HIV treatment should be integrated where possible Applying CHW PoP -Principles of practice Formal recognition and pushing up the cadre Promoting country ownership and leadership of the model and formal integration into health service Sustainable systems approach Harmonize approaches amongst partners & consortia – not ‘going it alone’ iCCM is a health systems strengthening activity rather than a project Consider grant-based programmes as ‘start-up’ with the aim to lead into integration

19 The CCM Toolkit https://www.wvcentral.org/community/health/Pages/CCM.aspx https://www.wvcentral.org/community/health/HNH%20Wiki/Community%20Case%20Management%20Toolkit.aspx

20 Preparatory tools (Deployment & Policy)CHW principles of practice CHW AIM & CHW programming standards CCM Implementation standards CCM results framework & indicators Are globally applicable Used to guide World Vision programming Set precedents and standards Not for adaptation Identify programming and policy weaknesses Identify key areas for advocacy

21 External tools CHW AIM – USAIDCCM Essentials guide - The Core Group guide for programmer managers implementing CCM. Covers all key areas of design, supervision, and implementing CCM Save the Child CCM Toolbox Tools to Introduce community case management of serious childhood infection, March 2011 Also - see CCM Central – core indicators, benchmarks (policy and planning) Supply Chain and CCM Resources

22 Operational tools (quality & access)Supervision tools Basic tools sample set (stocks & records) Referral / counter referral tools High risk household targeting Examples Can be completely contexualised to your country To take home and discuss with your MoH and National coordinating bodies.

23 CCM Toolkit Provides you with sample tools you require for iCCM roll out ICCM Quality Standards Generic results framework Generic M&E tool Commodities quantification tool Always work with local MOH to develop and introduce programming tools

24 Global Status of iCCM in World Vision

25 Where is iCCM happening?Sudan, South Sudan, Uganda, Kenya, Rwanda, Burundi, Zambia, Mozambique, DRC, Niger, Ghana, Sierra Leone, Indonesia

26 iCCM Roll Out Burundi ICCM part of Technical ApproachNational Office Level of roll out Burundi ICCM part of Technical Approach National dialogue Secured $1.2M funding from Korea Ghana National level discussions Partnering with Kenya National level engagement iCCM part of GIK policy Five ADPs prioritized for iCCM Clear scale up plan in place Mozambique Niger WHO $10M RAcE grant – not in WV operational areas

27 NOs with iCCM roll out National Office Level of roll out RwandaiCCM in Technical Approach Sierra Leone All ADPs budgeted for iCCM Sudan Received Irish Aid/Unicef grant with iCCM S. Sudan iCCM grant Uganda ICCM in Technical Approach Model adopted by ADPs National level engagement Lobbied to be included in the pilot phase of central government system iCCM – one WV district included Zambia ADP Implementation National level discussions

28 iCCM START UP: Challenges and feedbackResources – Commodities Quality of medicines – alignment with essential medicines list Must apply standards iCCM is not cheap; it is not about software; it is about filling a treatment gap, and this gap has to be filled with commodities!” Weak health systems for ease of roll out Supply chain management Supportive supervision and quality control Changing landscape - Uganda Budget constraints for easy integration

29 iCCM: Better practices identifiedCHW AIM functionality tool Integration with existing systems Solving the supervisor gap: Group supervision methods Lead CHWs/ buddying Mobile TTC development

30 Where are we heading? Alignment between National Strategies, procurement plans and iCCM role out Matching the pharmaceutical resources to the need – essential commodities to where its needed Promote quality standards in procurement and distribution for iCCM Long term planning – on what, where & how? Health Systems - feeding into the local supply chains? Sustainability – buffer stocks, cost recovery Harmonization with partners?

31 Financing Model for iCCM

32 How much does it cost?

33 iCCM COSTING AND FINANCING TOOLTotal <5 Population in iCCM Coverage Areas Incidence Rates for iCCM Treatments Total Expected Caseload Direct CHW Time per Case Other Direct Resource per Case (medicine etc.) Total Direct Resources Required Total Direct Salary Costs Total # of CHWs Needed Time Available on iCCM per CHW Total Medicine and Supply Costs Total Program Startup (Training Costs) Total Indirect Costs (Supervision etc.) Total Direct Salary Costs Total Program Startup (Training) Costs Total Medicine and Supply Costs TOTAL iCCM PROGRAM COSTS

34 Costing, Cost-effectiveness and Financing of i-CCM programs LessonsNot all iCCM programs are created equally; costing must accurately account for variations due to contextual factors and different iCCM models Costing exercises must occur in conjunction with planning and policymaking The importance of linking cots to progress through good M&E is also crucial Developing a clear and realistic financing plan is critical to achieving sustainability

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36 Who are the Champions? GTRN Registered iCCM Strategists: Joan Mugenzi Polly Walker Alfonso Rosales iCCM Technical Working group : Champions: Gagik Karapetyan Abena Thomas Azadeh Baghaki Ann Claxton (GF) Dan Irvine (Pharma) Register to be an iCCM practitioner / trainer / strategist on GTRN!!!

37 Thank You & Questions