Description of the condition
In 2015 an estimated 5.9 million children died before reaching the age of five, mostly in low- and middle-income countries (LMICs) and particularly the regions of sub-Saharan Africa (SSA) (50% of deaths) and South Asia (31% of deaths) (You 2015). Cause of death estimates suggest that most under-five deaths are due to preventable or treatable conditions (Liu 2015). As of 2013 (the latest year for which data were available), 52% of under-five mortality globally was caused by infectious diseases including pneumonia (16%), diarrhoea (10%), and malaria (14%) (Liu 2015). In SSA 40% of under-five deaths were due to pneumonia, malaria, and diarrhoea and 34% were due to neonatal causes — a subset of which were also related to severe infections (Liu 2015). In South Asia, 54% of under-five deaths were due to neonatal causes, a subset of which were related to severe infections. Pneumonia and diarrhoea were also major causes, contributing 14% and 10% of the total respectively (Liu 2015).
Efficacious interventions for addressing the major causes of preventable under-five mortality exist (Darmstadt 2005; Jones 2003). In the mid-1990s the World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and technical partners developed a strategy called the Integrated Management of Childhood Illness (IMCI) to reduce child mortality, illness and disability, and to promote improved growth and development among children younger than five years of age (Tulloch 1999; WHO 1997). IMCI includes three main components (Gera 2016; Tulloch 1999): 1) improvements in case-management skills of health staff through the provision of locally adapted guidelines on integrated management of childhood illness and activities to promote their use; 2) improvements in the health system required for effective management of childhood illnesses; and 3) improvements in family and community practices.
IMCI was designed to deliver treatment interventions of known efficacy for the main causes of under-five mortality through an integrated case management approach, recognizing that children presenting at health facilities often have multiple, overlapping signs and symptoms of these conditions (Fenn 2005; O'Dempsey 1993; Tulloch 1999; WHO 1997). A Cochrane Review of IMCI concluded with low certainty that IMCI may reduce child mortality, may reduce infant mortality (where interventions for the neonatal period are included), and may have mixed effects on care-seeking behaviour, morbidity and quality of care (Gera 2016).
In an earlier multi-country evaluation of IMCI, Bryce and colleagues found that "improving the quality of care in first-line government health facilities was not sufficient" to improve low utilization and population coverage; the components on health systems and family and community practices were slow to be implemented (if at all); and they concluded that "Delivery systems that rely solely on government health facilities must be expanded to include the full range of potential channels in a setting and strong community-based approaches...we must move beyond health facilities, and develop new and more effective ways of reaching children with proven interventions to prevent mortality. In most high-mortality settings, this means providing case management at community level, as well as focusing on prevention and reducing rates of undernutrition" (Bryce 2005).
Other researchers have also found accessibility of treatment services at government health facilities to be inadequate, particularly in SSA (Blanford 2012; Huerta Munoz 2012; Noor 2003; Noor 2006; Tsoka 2004).
Description of the intervention
In the 2000s the WHO and UNICEF, in collaboration with other development partners, developed an approach — now known as integrated community case management (iCCM) — to bring treatment services 'closer to home' and advocated for LMICs to adopt it (Bennett 2015; Diaz 2014; WHO/UNICEF 2012). The adoption of iCCM has been rapid, particularly in sub-Saharan Africa where most countries have some form of written policy to enable implementation of iCCM (Rasanathan 2014).
iCCM is an extension of IMCI — providing treatment services outside of the healthcare facility at community level (Bennett 2015; Gera 2016); and c-IMCI — the original community-based component of IMCI which focused on promoting key family and community practices for improving child health (WHO 1997). iCCM is an approach to providing integrated case management services for two or more illnesses — including diarrhoea, pneumonia, or malaria (the latter in malaria-affected countries) — among children younger than five years of age at community level (i.e. outside of healthcare facilities) by lay health workers where there is limited access to health facility-based case management services (WHO/UNICEF 2012). Case management services as defined here include assessment, treatment, and referral services (WHO/UNICEF 2012), following locally adapted WHO/UNICEF guidelines (WHO 2011). In some contexts iCCM may also include case management services for acute malnutrition and newborn illness (Rasanathan 2014; WHO 2007). iCCM is considered an equity-focused approach in that it is primarily implemented in rural and hard-to-reach areas with limited access to facility-based case management services (WHO/UNICEF 2012).
Components of the intervention
There are three main components of iCCM (Diaz 2014; McGorman 2012; WHO/UNICEF 2012; Young 2012). Table 1 classifies the three main components of iCCM according to the Effective Practice and Organization of Care (EPOC) taxonomy of health systems interventions (EPOC 2015), providing a framework and common language for understanding and describing iCCM and its component interventions. The three main components of iCCM are summarized below:
|EPOC Category||EPOC Sub-category||Target||Intervention||iCCM Component and Purpose|
|Who provides care and how the healthcare workforce is managed|
Role expansion or task shifting
Recruitment and retention strategies for underserved areas
|Health workers||Interventions to recruit, train and retain lay health workers to provide iCCM||Training and deployment component: interventions with the main purpose of increasing access to integrated case management services for children younger than five years of age by increasing the number of lay health workers trained on the generic or adapted WHO/UNICEF guidelines for integrated case management services and deployed where facility-based case management services are limited|
|Interventions targeted at health workers||Clinical practice guidelines||Health workers||Implementation of simplified IMCI-adapted clinical guidelines for iCCM providers|
|Mechanisms for the payment of health services||Payment methods for health workers||Health workers||Interventions for the payment of iCCM providers such as salary, fees for service, capitation|
|Coordination of care and management of care processes||Referral systems||Health system||Interventions to improve systems for referral of patients between community and facility levels||Systems component: interventions with the main purpose of improving implementation of iCCM by strengthening health systems organization and management, including supplies, speficially related to iCCM|
|Procurement and distribution of supplies: systems for procuring and distributing drugs or other supplies||Interventions to improve the supply of iCCM drugs and equipment|
|Information and communication technology (ICT)||Health information systems||Health system||Interventions to improve health information systems and use of information communication technology for iCCM|
|The use of information and communication technology|
|Interventions targeted at health workers||Monitoring the performance of the delivery of healthcare||Health workers, supervisors, managers, policy makers||Interventions to improve monitoring, evaluation, and research for iCCM|
|Managerial supervision||Supervisors, managers||Interventions to improve managerial supervision of iCCM providers|
|Authority and accountability for health policies||Community mobilization||Communities and caregivers||Interventions to promote good practices for health and nutrition and generate demand for use of iCCM providers when children are ill||Communication and community mobilization component: interventions with the main purpose of promoting good practices for health and nutrition and generating demand for case management services for ill children through communication and mobilization of communities and caregivers|
|Based on EPOC 2015|
1. Training and deployment component: interventions with the main purpose of increasing access to integrated case management services for children younger than five years of age by increasing the number of lay health workers trained on the generic or adapted WHO/UNICEF guidelines for integrated case management services and deployed where facility-based case management services are limited.
2. Systems component: interventions with the main purpose of improving implementation of iCCM by strengthening health systems' organization and management, including supplies, specifically related to iCCM.
3. Communication and community mobilization component: interventions with the main purpose of promoting good practices for health and nutrition and generating demand for case management services for ill children through communication and mobilization of communities and caregivers.
iCCM providers may include any lay health workers (paid or voluntary) who:
provide iCCM (integrated case management services for two or more illnesses among children younger than five years of age);
are trained on iCCM, but have received no formal professional or paraprofessional certificate or tertiary education degree (adapted from Lewin 2010).
This definition includes iCCM providers who receive a certificate on completion of their iCCM training but excludes healthcare providers who receive pre-licensure or post-licensure training certified by a professional body, such as a nursing or midwifery council.
Package of services
assessment and classification of the child's condition(s) using a simplified IMCI-adapted algorithm;
referral of cases with general danger signs and other complicated cases;
provision of treatment for the following conditions:
non-severe pneumonia with oral antibiotics;
non-severe diarrhoea with oral rehydration salts and zinc;
non-severe malaria with artemisinin-based combination therapy (in malaria-affected countries).
iCCM may also include assessment, classification and treatment of neonatal sepsis with oral antibiotics and referral as necessary; and assessment, classification and treatment of uncomplicated severe acute malnutrition (SAM) with ready-to-use therapeutic food and oral antibiotics, with referral as necessary (Rasanathan 2014; WHO 2007).
How the intervention might work
Interventions in the training and deployment component target lay health workers to improve access to integrated case management services for children younger than five years of age at community level where facility-based case management services are limited. The logic of these interventions assumes that increasing the number of lay health workers trained to deliver integrated case management services based on locally adapted WHO/UNICEF guidelines (WHO 2011) for children younger than five years of age (who may present with multiple, overlapping symptoms), and deploying them to areas where facility-based case management services are limited, will improve the availability and geographic accessibility of integrated case management services by bringing these services closer to caregivers (Diaz 2014; WHO/UNICEF 2012; Young 2012).
Interventions in the systems component aim to strengthen health systems components such as supply chain management, supervision, referral pathways, and health management information systems. The logic of these interventions assumes that effective iCCM implementation is dependent on a continuous supply of drugs and diagnostic tools, regular supervision, effective referral mechanisms, and a strong health management information system.
Interventions in the communication and community mobilization component target communities and caregivers with the main purpose of promoting good practices for health and nutrition and generating demand for case management services for ill children through communication and mobilization of communities and caregivers. The logic of these interventions assumes that effective iCCM implementation is dependent on effective communication and mobilization strategies, plans, materials, and messages around good health and nutrition practices as well as for increasing demand for case management services.
Why it is important to do this review
WHO and UNICEF have endorsed iCCM (WHO/UNICEF 2012); and the uptake of iCCM by national governments has been rapid (Rasanathan 2014; UNICEF 2005). Evidence-based policy making is critical to health outcomes (Bosch-Capblanch 2012; Langlois 2015; Lavis 2009; Oliver 2014). To date no systematic review of iCCM — that is, as an integrated approach for the management of diarrhoea, pneumonia, malaria (in malaria-affected areas), acute malnutrition, or newborn sepsis (or combinations of these conditions) at the community level by lay health workers — has been undertaken. This presents an important information gap relevant to evidence-based decision making of the general public, practitioners, policy makers, and researchers in low- and middle-income countries.
Systematic reviews have been undertaken and published on single-disease community case management (CCM) — that is CCM for diarrhoea (Das 2013), CCM for malaria (Okwundu 2013; Ruizendaal 2014; Sazawal 2003) and CCM for pneumonia (Das 2013; Druetz 2013; Ruizendaal 2014; Sazawal 2003) — among children younger than five years of age in LMICs. The reviews that used the GRADE approach for assessing certainty of the evidence reported moderate-certainty evidence for the effectiveness of CCM on care-seeking behaviour (Das 2013), mostly moderate-certainty evidence for the effectiveness of CCM on appropriate treatment (Das 2013; Okwundu 2013) and timeliness of treatment (Okwundu 2013), and mostly moderate-certainty evidence for effectiveness of CCM on mortality among children younger than five years of age (Das 2013, Okwundu 2013). Two reviews (Das 2013 and Druetz 2013) included studies on iCCM; however only Das 2013 used GRADE and both were primarily focused on the effects of CCM — not iCCM — and therefore did not address the objectives of this review.
A review of community-based management of pneumonia by Theodoratou 2010 included studies on CCM by lay health workers but did not report these results separately from the results of studies that included other types of healthcare workers such as nurses.
A systematic review assessed the evidence for the effect of integrating CCM for malaria with other interventions, including CCM for pneumonia, on outcomes for CCM for malaria — in particular quality of care and facilitators and barriers to high-quality CCM for malaria (Smith Paintain 2014). They found that integrating additional interventions with case management services at community level for malaria did not reduce the quality of the malaria services in contexts where training and supervision were maintained but quality of pneumonia case management was lower and variable (Smith Paintain 2014). This review did not use GRADE and was focused on the effects of iCCM on malaria outcomes, not outcomes across diseases as in this review.
A "scoping review" of the training, supervision and quality of care of iCCM that did not use GRADE reported evidence of positive effects on quality of care in large iCCM programmes where multifaceted interventions including training, supervision, and supply chain management were implemented (Bosch-Capblanch 2014).
Amouzou and colleagues undertook a non-systematic review of the effect of iCCM on child mortality in sub-Saharan Africa and found that large heterogeneity of programme implementation and evaluation design precluded meta-analysis but revealed in six of eight studies a greater decline in mortality among children aged 2 to 59 months in intervention areas compared to comparison areas (Amouzou 2014).
Other systematic and non-systematic reviews have covered the effectiveness of lay health workers in terms of providing a range of maternal, newborn, and child health interventions (Christopher 2011; Hopkins 2007; Lewin 2010; Sanders 2007; Zaidi 2009).
The current review will build on previous reviews — which primarily focused on CCM or effects of iCCM on outcomes for a single disease — by focusing on the effects of iCCM as an integrated approach on outcomes across diseases using the rigorous Cochrane methodology, including the GRADE approach for assessing the certainty of the evidence.