CCH_Nate Miller_5.7.14

Community case management in emergencies | May 7, 20141 |
CCM in Emergencies & Fragile
Contexts
Nate Miller, PhD
UNICEF
CORE Group Annual Meeting
May 7, 2014

iCCM background
Source: Liu, et al.
Global causes of under 5 death, 2010
Pneumonia, diarrhea,
and malaria account for
36% of child deaths
globally.
In Africa, they account
for 44% of deaths.
Coverage of effective
treatments remains low.

iCCM background
Definition of iCCM: Community-based management of
childhood pneumonia, diarrhea, and malaria
– May also include malnutrition, neonatal sepsis, other interventions

iCCM background
Quality of care:
– Ethiopia: 64% of children with pneumonia, diarrhea, malaria, or
malnutrition received correct treatment
– Malawi: 63% of children with pneumonia, diarrhea, or malaria
received correct treatment
– Zambia: 68% of children with pneumonia received correct
treatment
– Others studies showed lower quality of care
CCM impact has been shown in controlled studies
Lack of evidence of impact of large-scale implementation of
iCCM

Child health in emergencies
 Increased morbidity and mortality,
especially among children
– Basic services may be destroyed,
disrupted, or overwhelmed
– Access to services may be
reduced due to disrupted
transport, insecurity, or population
displacement
– Emergency response can miss
most vulnerable in the community
 Mostly the same causes of child
death in emergencies

Resilience
 Natural disasters expected to increase in frequency and severity
 Chronic conflict and insecurity in many areas
 Pre-existing programs shut down during acute crisis
 Typical emergency response is too slow and fails to reach many
vulnerable communities
 Communities and health systems need to be better prepared
against shocks
 Community-level interventions may allow most timely response
and highest coverage of interventions

iCCM in emergencies & fragile contexts
Reduce demand/reliance on overwhelmed health services
Increase access to and coverage of services, including to the
most affected and vulnerable
Outside help may may be delayed
Increase community resilience and reduce underlying
vulnerability
More cost effective

iCCM in emergencies & fragile contexts
1) iCCM for vulnerability reduction: reduce the burden of top causes of illness and
death
2) Adjust/adapt existing iCCM to target at risk communities or during an
emergency
3) Implement iCCM during an acute emergency

Way forward
CCM Taskforce: Emergencies working group
Literature review
Case studies
Pilot implementation with M&E and operational research
Dissemination of results

Literature review
Review of published material
– PubMed, Google, grey literature
– 6 journal articles, 5 reports
– Afghanistan, Cote d’Ivoire, DRC, Ethiopia, Malawi, Mali, Myanmar,
Pakistan, South Sudan, Sri Lanka
3 interviews from Central African Republic

Key lessons
1. Community-based interventions can achieve greater
coverage than facility-based care in crises
2. CHWs can provide a platform for delivery of emergency
interventions
3. Need to integrate emergency response and preparedness
into regular development programming

Key lessons
Examples:
– Ethiopia
• Policy change to make CMAM a routine service in response to periodic
famine
• Allowed faster recognition of and response to crisis
• Integrating the emergency response into regular development
programming ensured available funding

Key lessons
Examples:
– Mali
• Health system was not prepared for emergency response when conflict
started
• Scaling up relief programs during crisis took too long
• Training and deploying CHWs during the crisis strengthened the platform
for nutrition and health interventions post-crisis
• Flexible funding from donors allowed for shifts in programs to emergency
and then transition back to development

Key lessons
Examples:
– Malawi
• During food crisis, most vulnerable children were not reached by services
in health facilities
• Previously trained cadre of CHWs allowed for rapid rollout of CMAM
program (underway in 10 days)
• Achieved much higher coverage of care than facility-based programs
• Able to scale up program with no health professionals other than trainers
– Sri Lanka
• Previously trained cadre of CHWs allowed for rapid training on malaria
case management during crisis

Key lessons
Examples:
– Pakistan
• CHWs were first to provide care after floods.
• Outside emergency response took much longer
• CHWs provided a large network through which to deliver relief
– Myanmar
• CHWs trained in primary care and emergency response prior to cyclone
• They were the first to provide care before outside relief arrived
• Relief programs delivered through CHW network

Key lessons
4. Funding needs to be longer-term and flexible
 Examples
– CAR
• Short-term funding led to closing of iCCM program after one year
– Ethiopia, Mali, Afghanistan
• Flexible, longer-term funding allowed programs to transition back and forth
between development and emergency response

Key lessons
5. It is possible for CHWs to continue providing care through
periods of moderate conflict and insecurity
 Example:
– CAR
• Malaria CCM program has operated with no breaks in services for the
last 6 years, including through the current crisis

Key lessons
6. Initiating a new CCM program during acute crisis will be
very difficult
 Examples:
– CAR
• NGO trying to expand geographic coverage during current crisis
• Several instances of armed robbery, base was looted, can’t transport
equipment to field site
• Need frequent access to CHWs for training, supervision, etc.
– Cote d’Ivoire
• Insecurity after elections halted geographic expansion of program

Key lessons
7. Recruiting and training health workers for emergency
response is difficult and time-consuming
 Examples:
– Myanmar
• Shortage of qualified medical staff
• More effective to use previously trained CHWs
– CAR
• Health facility staff fled their posts and recruited staff refused to go to
insecure areas
• CCM was only way to deliver care to many communities

Key lessons
8. Need to adapt standard guidelines to fit local context
 Example:
– South Sudan
• Low literacy of CHWs caused poor understanding of clinical guidelines and
inability to correctly complete registers
• CHWs weren’t able to correctly count respiratory rate due to poor
numeracy
• Simplified, more visual, training materials, job aids, and registers improved
understanding
• Use of beads for counting respiratory rate improved pneumonia diagnosis

Key lessons
9. May need to find alternative ways of contacting CHWs
– Drug supplies, supervision, data collection
 Examples:
– CAR
• NGO staff could not leave town due to insecure roads
• CHWs were able to travel to town for drug supplies and to bring reports
– Cote d’Ivoire
• CHWs had difficulty getting drug stocks and submitting reports because
of insecurity
• NGO provided larger drug stocks to CHWs and extra incentive to
supervisors to continue providing services during conflict after elections

Key lessons
10.CHWs need larger stocks of drugs to cover longer period of
time to allow for continued care during crisis
 Examples:
– Cote d’Ivoire
• NGO provided larger drug stocks to CHWs continue providing services
during conflict after elections
– Myanmar
• Regular stocks with CHWs were insufficient for needs following cyclone
– South Sudan
• CHWs given stocks of several months to continue care during rainy
season when many areas become inaccessible
• Needed larger storage facilities for drugs and supplies

Key lessons
11.CMAM can be integrated into iCCM
 Example:
– South Sudan
• Simplified nutrition screening of MUAC and oedema were feasible CHWs
with poor literacy and numeracy
• Higher level of training, literacy, numeracy needed for treatment of SAM

Key lessons
12.Continuity of care/referral care is a challenge
 Example
– CAR
• Shortages of drugs and supplies in health facilities before the crisis
• Health facilities were looted, health workers abandoned posts
• Children with severe illness referred to health facilities by CHWs, but no
care available

Key lessons
13.Donor and NGO policies force programs to shut down in
an emergency. Need to find more resilient strategies.
 Examples
– CAR
– South Sudan

Key lessons
14.Work with local communities to negotiate access
 Example:
– Afghanistan
• Difficult to access areas due to insecurity and hostile local leaders
• Conducted local security analyses
• Used local access negotiators and dialogue with local leaders
• Discuss priorities for community and try to address their priorities as part
of program

Key lessons
15.Experience with nomadic populations may be relevant for
mobile IDPs
– Fixed facilities and mobile clinics not effective
– CHWs were most effective
• Should be selected from communities and move with population
• Delivery of drugs and supplies is key challenge
– Supply through strategic locations known to CHWs along travel route
– Allow CHWs to attain drugs through any public facilities
• Supervision and monitoring
– CHWs can send reports through health facilities, government
officials, local leaders, etc.
– Supervision at strategic locations along travel route

Emergency CCM programs needing
documentation
Myanmar
Nicaragua
Bangladesh
Uganda Mozambique
Kenya
Haiti
Pakistan
Afghanistan Sri Lanka
Somalia
Yemen
South Sudan
Mali
Niger
DRC
Nigeria
Nepal

Case scenario: iCCM in CAR
 High insecurity, road bandits, towns and villages attacked, NGO
bases looted
 Peacekeepers in Bangui and some towns
 Some people displaced in camps, some displaced in rural
areas, many at home, but without access to care, food
shortages
 Complete breakdown of health system
 NGOs providing services in camps and some towns
 High child mortality from infectious diseases, especially malaria
 Dangerous environment for aid workers
 Little experience with CCM
 Only few small CHW networks linked to NGOs

Is iCCM appropriate in this context?
– Does the potential impact outweigh the risk and challenges?
At what scale should iCCM be implemented?
What is the minimum security level necessary in an area to
implement an iCCM program?

How to address main challenges?
– Supply chain
– Supervision
– M&E
– Quality of care
– Security of staff and CHWs

What components should be included in the iCCM
program?
– CMAM
– Neonatal sepsis
– Essential newborn care
– Immunization
– HIV
– GBV/sexual violence
What is the most appropriate policy for management of
severely ill children?

What are priority research questions regarding CCM in
emergencies?
What is an appropriate evaluation design?
– Are household surveys feasible?

CCH_Nate Miller_5.7.14

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