Community-Oriented Primary Health Care for Improving Maternal, Newborn, and Child Health
- Amira M. Khan, Amira M. KhanDepartment of Pediatrics and Child Health (Centre for Global Child Health), The Aga Khan University
- Zohra S. LassiZohra S. LassiDepartment of Health and Medical Sciences (Robinson Research Institute), The University of Adelaide
- and Zulfiqar A. BhuttaZulfiqar A. BhuttaDepartment of Pediatrics and Child Health (Centre for Global Child Health), The Aga Khan University
Nearly 80% of the world’s population lives in low- and middle-income countries (LMICs) and these regions bear the greatest burden of maternal, neonatal, and child mortality, with most of the deaths occurring at home. Much of global maternal and child mortality is attributable to easily preventable and treatable conditions. However, the challenge lies in reaching the most vulnerable communities, especially the rural populations, making it imperative that maternal, newborn, and child health (MNCH) interventions focus on communities in tandem with facility-based strategies. There is widespread consensus that delivering effective primary health care (PHC) interventions through the continuum of care, starting from pregnancy to delivery and then to the newborn, infant, and the young child, is an integral component of health strategies in high-, middle- and low-income settings.
Despite gaps in research, several effective community-based PHC approaches have been proven to impact MNCH positively. Implementation of these strategies is needed at scale in LMICs and in partnership with all stakeholders including the public and private sector. Community-based PHC, operating on the principles of community engagement and community mobilization, is now more critical than ever. Further robust studies are needed to evaluate certain strategies of community-based PHC and their impact on maternal and child health outcomes, such as the use of mobile technology and social franchises. Recognition of community health workers (CHWs) as a formal cadre and the integration of community-based health services within PHC are vital in strengthening efforts to impact maternal, neonatal, and child health outcomes positively. However, despite the importance of community-based PHC for MNCH in LMICs, the existence of a strong health system and skilled workforce is central to achieving positive health outcomes in these regions.
The past few decades have seen remarkable reductions in maternal and child mortality. For the first time in history, under-five deaths in a year are now less than 6 million; current estimates show that 5.8 million under-five children died in 2015, a significant decrease from 12.7 million in 1990 (GBD 2015 Child Mortality Collaborators, 2016). Concurrently, maternal deaths have declined from 532,000 in 1990 to 303,000 in 2015 (World Health Organization [WHO], 2015).
The rate of annual under-five mortality reduction has risen from 1.8% in 1990–2000 to 3.9% in 2000–2015 (UNICEF, 2015). However, the annual rate of decrease of neonatal mortality has been less impressive, standing at 2.9% as compared to 4.9% for children aged 1 to 59 months (Liu et al., 2015). Of the 5.8 million younger-than-five children who died in 2015, 2.6 million were neonates. In addition, there were 2.1 million stillbirths, which reflects poorly on maternal care during pregnancy and childbirth (GBD 2015 Child Mortality Collaborators, 2016).
Nearly 80% of the world’s population lives in LMICs and these regions bear the greatest burden of maternal, neonatal, and child mortality with most of the deaths occurring at home (Lassi & Bhutta, 2015). The risk of dying from maternal causes is 33 times higher for a woman in an LMIC than one in a high-income setting (Maternal and Reproductive Health, n.d.). Moreover, the under-five mortality rate in LMICs is nearly 11 times that of the average rate in high-income countries, with 99% of all neonatal mortality concentrated in these regions (Lassi, Kumar, & Bhutta, 2016; WHO, 2018). Sub-Saharan Africa continues to bear the highest burden of maternal and under-five deaths with 66% of the maternal and nearly 50% of under-five mortality concentrated in the region (UNICEF, 2015; WHO, 2015). Inequities exist globally in all countries regardless of a country’s economic status. Populations, even in high-income settings, are faced with disparities in access to care and health outcomes between the rich and the poor, and between urban and rural areas. Underprivileged and slum populations in urban areas and people in conflict settings are at greater risk. This global phenomenon of health inequity, however, is more pronounced in LMICs.
Much of global maternal and child mortality is attributable to easily preventable and treatable conditions. However, the challenge lies in reaching the most vulnerable communities, especially the rural populations, whose needs are the greatest. Globally, rural women consistently have more children than urban women (Population Reference Bureau, 2015). That, combined with the lack of awareness of optimal health practices and limited access to health facilities, puts this group at greater risk. In 2015, 40 million births in LMICs were unattended; 90% of these were in South Asia and sub-Saharan Africa (Delivery Care—UNICEF Data, 2017). Lack of antenatal care and unattended births increases the risk of perinatal and neonatal mortality (Lassi, Das, Salam, & Bhutta, 2014).
The Millennium Development agenda mobilized governments, gained political commitment, and obtained results. Though targets were not met, the commitment to Millennium Development Goals (MDG) 4 and 5, which focused on reduction of child and maternal mortality respectively, helped make unprecedented progress in maternal and child health. However, mortality in both mothers and children continues to be unacceptably high. Scaling up interventions in maternal and child health will be critical in achieving the targets 3.1 and 3.2 of the Sustainable Development Goals (SDGs), which aim to reduce the global maternal mortality ration to less than 70 per 100,000 live births and end preventable deaths of newborn and children under 5 by 2030, respectively (Sustainable Development Goal 3, Sustainable Development Knowledge Platform, 2017).
Community-Oriented Primary Health Care
In 1978, at the Alma-Ata historical International Conference on Primary Health Care (PHC), the WHO introduced the concept of PHC (WHO, 1978). It was declared that “the health status of hundreds of millions of people in the world today is unacceptable” and called for a “new approach to health and health care.” Governments were called upon to embrace and promote PHC as part of their national health systems in partnership with other sectors. The conference described PHC as “Essential (health) care . . . made universally accessible to individuals and families in the community by means acceptable to them through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination” (WHO, 1978, p. 16).
It was in the late 1960s and early 1970s when frustration of public health experts with unsatisfactory top-down strategies led to calls for reconceptualization of health and development activities. The importance of interventions at the community level and “horizontal system” of services was recognized (Elzinga, 2005, para 1). The horizontal system favors linking vertical services and programs with general preventive and curative services at the grassroots level.
Although hard to define, community-oriented PHC has been simply described as delivering primary care to a community based on its health needs through integration of public health practice with primary care service delivery (Mullan & Epstein, 2002). Decades before the Alma- Ata conference, there were two physicians, the Karks, who conceptualized community-oriented PHC. Residing in rural South Africa, their work not only involved treating illnesses but also assessing the community’s health, implementing preventive measures as well as training community members in basic preventive and health services (Mullan & Epstein, 2002). As such, the essence of community-oriented PHC lies in reaching the community where people live with the health services they need.
For most women in LMICs, the antenatal, natal, and postnatal phases take place in the community, making it imperative that maternal and newborn interventions focus on communities in tandem with facility-based strategies. Research has recognized that delivering quality maternal and child health interventions through PHC can be largely beneficial even without delivering care through a secondary-care hospital (Bhutta et al., 2008). Moreover, evidence suggests that presence of skilled care at birth could reduce intrapartum-related neonatal mortality by 25% (Bhutta et al., 2014).
Additionally, WHO and UNICEF have long recognized that deaths of young children from pneumonia, diarrhea, malaria, and malnutrition can be prevented by simple, affordable measures, many of which could be implemented at the community level (WHO, 1997). The Integrated Management of Childhood Illnesses (IMCI) strategy launched in the 1990s, with a key component of “improving relevant family and community practices,” was an effort to promote child health by provision of preventive and curative services for young children (WHO, 1997, p. 1). More recently, the Integrated Community Case Management (iCCM) approach also aims to address childhood illnesses with the help of trained CHWs.
Community Engagement and Participation
Community participation remains an integral component of the PHC approach. The Alma-Ata conference declared community participation as a core principle of primary health where the people should have the right and the duty to participate in the planning and implementation of their health care (Social Determinants of Health | “WHO Called to Return to the Declaration of Alma-Ata,” 2008). Over the years, efforts have been made to promote community involvement in the planning, organization and implementation of PHC projects so as to ensure self-reliance and sustainability. Community health workers (CHWs) have played a vital role in supporting community participation in PHC delivery (McGuire & Costa-Font, 2012). Fundamentally, a CHW is a person who is from or related to the community and is usually known and trusted by them (LeBan, Perry, Crigler, & Colvin, 2014). CHW programs with ownership of the community as well strong linkages at the national, district, and local levels are imperative for their success. As mentioned, globally 99% of maternal and child deaths occur in low- and middle- income countries (LMIC) and most at the community level where there is a dearth of trained health professionals. Thus, the need and importance of community-oriented PHC and CHW programs is even more critical in these regions (Gilmore & McAuliffe, 2013). Additionally, non-health-worker-based community engagement strategies such as women’s groups are important community-based interventions within PHC.
Evidence suggests that in the years leading to the MDG deadline, CHW programs have been effective in implementing maternal and child health interventions, especially mother-performed strategies such as breastfeeding and kangaroo mother care (Gilmore & McAuliffe, 2013). Moreover, CHW programs have played a role in the decrease of maternal and child mortality rates especially in LMICs (Global Health Workforce Alliance, WHO, 2010). However, there have been growing concerns that the essence of community participation is being lost and CHW programs are falling victim to a lack of supervision, weak linkages to existing health systems, and a lack of incentives (Lawn et al., 2008).
Community-Based PHC Approach and the Continuum of Care (MNCH)
There is widespread consensus that effective maternal, newborn, and child care is driven by the basic principle of continuum of care, which includes provision of care starting from pregnancy until delivery and then to the newborn, infant, and young child (Figure 1) (Aboubaker, Qazi, Wolfheim, Oyegoke, & Bahl, 2014). Delivering services across this continuum of care, both at the facility and the community level, is an integral component of the Global Strategy for Women’s and Children’s Health (United Nations/The Partnership for Maternal, Newborn & Child Health, 2010).
Equity, intersectoral coordination, and community participation are some of the principles of PHC (Lassi, Kumar, & Bhutta, 2016). The most traditional PHC strategy at the community level remains establishing a health center, primarily to provide basic maternal and child health services including antenatal and postnatal care, neonatal care, and immunization. However, the essence of PHC is that it targets all members of the community and not only those who attend a clinic (Hart, Belsey, & Tarimo, 1990). Therefore, multiple strategies and innovations have been adopted to implement community-oriented PHC, especially in the realm of maternal, neonatal, and child care. Integration of the facility-based PHC system with the communities is essential for a strong health care system. Community mobilization, home visits, social marketing and other community-based programs are vital in developing these linkages (Figure 2).
Some of the key strategies employed in community-based PHC to impact maternal and child health are detailed including community mobilization, outreach services, and community case management. The evidence supporting these strategies has been outlined in Table 1.
Table 1. Evidence on Impact of Community-Based PHC Strategies on Maternal and Child Health
Evidence on Maternal Health
Evidence on Perinatal/Newborn/Child Health
49% reduction in maternal mortality if at least 30% of pregnant women attended women’s groups (Prost et al., 2013)
Community mobilization-based packages had significant impact on maternal morbidity (RR: 0.75, 95% CI: 0.61–0.92) (Lassi, Das, Salam, & Bhutta, 2014)
20% reduction in neonatal mortality (Prost et al., 2013)
Birth and newborn PHC care packages using community mobilization and home visits reduced neonatal deaths by 40% (Lassi & Bhutta, 2015)
21% reduction in neonatal mortality including early (30%) and late neonatal mortality (23%) when interventions were given through community mobilization in combination with home visits (Lassi, Middleton, Bhutta, & Crowther, 2016).
Community mobilization-based packages had significant impact on neonatal mortality (RR: 0.76 95% CI: 0.68–0.84) and perinatal mortality (RR: 0.80, 95% CI: 0.71–0.91) (Lassi, Das, Salam, & Bhutta, 2014)
Outreach Services and Home Visitation
45% increase in healthcare seeking for neonates when interventions were provided by CHWs through home visits (Lassi, Middleton, Bhutta, & Crowther, 2016)
Home visitation–based community packages significantly improved neonatal mortality (RR: 0.76 95% CI: 0.68–0.84) and perinatal mortality (RR: 0.80, 95% CI: 0.71-0.91) (Lassi, Das, Salam, & Bhutta, 2014)
Community Case Management
Community-based case management of pneumonia reduced pneumonia mortality in an intervention group by 42%, 36%, and 36% among neonates, infants, and children respectively (Sazawal, & Black, 2003)
70% reduction in pneumonia mortality in children under-five years (Theodoratou et al., 2010).
32% reduction in pneumonia mortality in children under-five, with an increase of 13% in care seeking (Das, Lassi, Salam, & Bhutta, 2013)
An increase of 9% in care seeking for diarrhea with a 75% decline in the irrational use of antibiotics for diarrhea, a 160% increase in the use of ORS, and an 80% increase in the use of zinc (Das, Lassi, Salam, & Bhutta, 2013)
Community-based strategies led to significant decrease in malaria prevalence (RR: 0.46, 95% CI: 0.29, 0.73) and malaria incidence (RR: 0.70, 95% CI: 0.54, 0.90) (Salam, Das, Lassi, & Bhutta, 2014)
50% reduction in risk of progression to severe malaria after training community mothers in treating uncomplicated malaria with pre-packaged drugs (Sirima et al., 2003)
40% reduction in all-cause mortality in under-five when local mothers were trained to recognize and treat malaria (Kidane & Morrow, 2000)
Community-based interventions (CBIs) for TB prevention, case detection, and treatment showed significant rise in TB detection rates (RR: 3.1, 95% CI: 2.92, 3.28) and improvement in treatment success rates (RR: 1.09, 95% CI: 1.07, 1.11) (Arshad et al., 2014)
Neglected Tropical Diseases (Helmintic)
CBIs for the prevention and control of helminthiasis reduced the prevalence of soil-transmitted helminthiasis (RR: 0.45, 95% CI: 0.38, 0.54) and schistosomiasis (RR: 0.40, 95% CI: 0.33, 0.50) and reduced anemia prevalence (RR: 0.90, 95% CI: 0.85, 0.96) (Salam, Maredia, Das, Lassi, & Bhutta, 2014)
Neglected Tropical Diseases (Non-Helmintic)
CBIs for dengue preventive measures including use of ITN and curtains significantly reduced dengue-positive serology by 70% (RR: 0.30, 95% CI: 0.23, 0.38)
For Chagas disease, preventive insecticide spraying with housing improvement led to a 68% reduction in infestation rate (RR: 0.32, 95% CI: 0.19, 0.55) and a 22% reduction in serology (RR: 0.78, 95% CI: 0.61, 0.98)
For leishmaniasis, CBI with education significantly reduced the incidence of cutaneous leishmaniasis by 58% (RR: 0.42, 95% CI: 0.36, 0.49)
For leprosy, treatment with community education led to a 68% reduction in the incidence (RR: 0.32, 95% CI: 0.30, 0.34) (Das, Salam, Arshad, Maredia, & Bhutta, 2014)
There has been a long-standing consensus that participation and engagement of the community is essential for improving their health and for effective implementation of PHC interventions (WHO, 2008). From the Alma-Ata Declaration to the more recent Rio Political Declaration on Social Determinants of Health, empowering and enabling the communities has been central to the agenda for promoting participation in PHC especially for health promotion and policy making (Rio Political Declaration on Social Determinants of Health, 2011; WHO, 1978).
WHO defines community empowerment as “the process of enabling communities to increase control over their lives,” where enabling indicates that people can only empower themselves and cannot “be empowered” (WHO, Track 1: “Community empowerment”; 7th Global Conference on Health Promotion, 2009, para 1).
In terms of the maternal and child health component of PHC, community empowerment is best achieved by community mobilization, education, and health promotion activities. Involvement of individuals, families, and communities is vital for the sustainability of community platforms across the continuum of care.
Community mobilization in PHC for improvement of maternal, newborn, and child health can be approached in several ways. Over the years, the community action cycle model has been used extensively to implement mobilization activities where stakeholders are identified and facilitated to explore and address their health problems, and evaluate the results (Figure 3) (ACCESS/USAID, 2009).
Community PHC packages have increasingly used the services of CHWs and community volunteers to facilitate support groups and women’s groups which aim to educate the audience about maternal, neonatal and child health problems, solutions, available health services, and barriers to care (Lassi, Das, Salam, & Bhutta, 2014). Groups can focus on a wide range of issues, from pre-conception health to care seeking during pregnancy and childbirth to identification of danger signs in newborns.
There is growing evidence to show that the community mobilization component of PHC has had a significant impact on maternal and child health. A 2016 systematic review assessed an impact of various interventions on maternal and neonatal health in LMICs and concluded that impact of interventions was enhanced when implemented in combination with community mobilization (Lassi, Middleton, Bhutta, & Crowther, 2016). The impact on care-seeking behaviors and perinatal mortality was more when community mobilization was combined with home visits. Furthermore, a 2013 systematic review studied the effects of women’s groups in four LMICs and showed that exposure to women’s participatory learning groups was associated with a 20% reduction in neonatal mortality (Prost et al., 2013). However, their subanalysis showed that there was a similar effect on maternal mortality if a minimum proportion of pregnant women attended the groups. They declared that with adequate coverage and participation from at least a third of pregnant women, women’s groups were a valuable intervention for maternal and neonatal survival in LMICs. According to their estimates nearly 283,000 neonates’ and 37,000 mothers’ lives could be saved if the strategy was applied in 74 Countdown countries (MDG priority countries which accounted for more than 95% of all maternal, newborn, and child deaths).
More recently, a Cochrane review evaluated the effectiveness of community-based intervention packages in diminishing maternal and neonatal morbidity and mortality and found the most effective packages were those which included community mobilization, education, and home visitation components (Lassi & Bhutta, 2015). The analysis showed that birth and newborn PHC care packages using community mobilization and women’s groups had an impact on reducing total and early neonatal deaths, while those that had an added component of home visitation and focused on antenatal care had an additional impact on perinatal deaths and stillbirths.
Based on a systematic review of seven studies the WHO issued recommendations for implementation of community mobilization through facilitated participatory learning and community action cycles with women’s groups to improve maternal and neonatal health, with emphasis on implementation in rural, low-resource settings (WHO, 2014a). The women’s groups’ interventions involved identification and prioritization of problems in pregnancy, childbirth, and the neonatal period, followed by planning, implementation, and assessment of activities. The evidence generated from the review was the strongest for improvements in newborn health. The review cautioned that these interventions should be accompanied by strategies for the improvement of PHC services and facilities.
Outreach Services and Home Visitation
Outreach services and home-based strategies have been recognized as effective means of meeting PHC needs of populations especially in terms of maternal and child care. A WHO report defines outreach services as “any type of health service that mobilizes health workers to provide services to the population or to other health workers, away from the location where they usually work and live” (De Roodenbeke, Lucas, Rouzaut, & Bana, 2011, p. 1). Such services complement facility-based care especially in remote and rural areas by increasing access to health workers. Mobile clinics are one of the outreach strategies that enable temporary but timely access to care for areas where health workers are scarce. Mobile clinics can provide basic PHC services or even specialized care, and have been particularly successful in emergency settings or settings with minimal health-service coverage (Moon et al., 2014). However, owing to a lack of rigorous research, the evidence for impact of mobile clinics on maternal and child health is inconclusive (Abdel-Aleem, El-Gibaly, EL-Gazzar, & Al-Attar, 2016).
In many LMIC settings, especially in the maternal and neonatal context, outreach services can be provided by local community members who are employed as CHWs or who are volunteers and are responsible for these services as part of their work schedule especially in the form of home visits. Importantly, PHC services offered during home visits can include antenatal care, skilled birth attendance, and postnatal care (for mother and baby). Hence, as noted in reviews, home visits seldom include a single intervention and are usually a vehicle for a variety of other interventions such as collection of demographic data, counseling, parent education, psychosocial support for mothers, and facilitation of health facility visits—all of which support optimal delivery of PHC (Bull, McCormick, Swann, & Mulvihill, 2004). Moreover, in some settings CHWs also provide basic curative services during home visits such as the treatment of fever, oral rehydration salts for diarrhea, and even antibiotics for respiratory infections in children (Global Health Workforce Alliance, WHO, 2010).
The evidence supporting home visits during pregnancy and after birth, to support maternal and newborn health, is substantial. The home visitation strategy in PHC is primarily a vehicle for delivering care and education during pregnancy, improving neonatal care, and recognizing early signs of maternal and neonatal illness (Aboubaker, Qazi, Wolfheim, Oyegoke, & Bahl, 2014). CHWs are the key players in this strategy, which takes care right to the doorstep of the mother and child.
Nearly 50% of all pregnant women in LMICs do not receive adequate PHC in the antenatal period, which underpins the need for delivering care via home visits (Finlayson & Downe, 2013). Interventions that include community mobilization and antenatal home visits are recommended in the WHO’s updated antenatal care guidelines (WHO, 2016). The recommendations are particularly for rural settings with poor access to health services. WHO/UNICEF advise that trained CHWs make at least two home visits to each pregnant mother to educate them and help them prepare for their delivery. Identification of complications and prompt referral can be lifesaving for a pregnant woman. Evidence suggests that home visits in combination with community mobilization are successful in improving maternal and neonatal care seeking in addition to neonatal outcomes (Lassi, Middleton, Bhutta, & Crowther, 2016). Some reviews have shown an association of home-visitation-based community care packages with significantly reduced maternal morbidity as well as perinatal and neonatal mortality (Lassi, Das, Salam, & Bhutta, 2014).
The postnatal period—especially the first few days—remain a vulnerable time for both the mother and her neonate. Nearly 25% to 45% neonatal deaths occur in the first 24 hours and more than 50% in the first 48 hours (WHO/UNICEF, 2009). Evidence generated by studies conducted in South Asia prompted the WHO to issue recommendations for home visits as part of PHC for the newborn child. (Bang, Bang, Baitule, Reddy, & Deshmukh, 1999; Baqui et al., 2008; Bhutta, 2008; Kumar et al., 2008). The studies had demonstrated that home visits could bring down neonatal mortality in LMIC settings by 30% to 61% by improving newborn care behaviors such as early and exclusive breastfeeding, skin-to-skin contact, delayed bathing, handwashing, and clean cord care.
Similarly, in its more recent postnatal care guidelines, the WHO issued strong evidence-based recommendations for home visits in the first week after birth for PHC of the mother and her baby in the postnatal period (Table 2) (WHO, 2014b). However, the WHO cautioned that home visits during pregnancy and after childbirth should not replace care from a health facility; rather, home visits should promote and encourage antenatal and postnatal care seeking. The systematic review forming the basis of this recommendation included five trials from South Asia and concluded that home visits for antenatal and neonatal care combined with community mobilization activities led to reduced neonatal and perinatal mortality in high-mortality settings (Gogia & Sachdev, 2010). It also suggested that the impact was greater when home visits covered more than 50% of the households.
Although skilled health care workers are best qualified to conduct PHC outreach and home visits, the skilled human resource deficit in LMICs and high-mortality settings rarely makes it feasible. The WHO and the Global Health Workforce Alliance, report a global deficit of 7.2 million skilled health professionals with the bulk of its existing in the most vulnerable regions (2014). Around 90% of all maternal deaths and 80% of still births occur in countries that have low skilled-health-worker coverage. Challenges with availability of skilled health providers have led to expansion in the role of CHWs, where well-trained CHWs offer basic and essential primary health services. An example is the Health Extension Program in Ethiopia where the salaried Health Extension Workers conduct outreach activities for 75% of their time, which have proven to improve maternal and newborn health practices at scale (Karim et al., 2013).
Table 2. WHO-Recommended Interventions for Postnatal Home Visits
Newborn Care During Home Visits in the First Week of Life:
Promote and support early (within the first hour after birth) and exclusive breastfeeding
Help to keep the newborn warm—promote skin-to-skin care
Promote hygienic umbilical cord and skin care
Assess for danger signs and counsel on their prompt recognition and care seeking by the family (not feeding well, reduced activity, difficult breathing, fever or feels cold, fits or convulsions)
Promote birth registration and timely vaccination according to national schedules
Identify and support newborns who need additional care (e.g., those with low birthweight [LBW], who are sick, or whose mother is HIV infected). If feasible, provide home treatment for local infections and some feeding problems
Maternal Care During Home Visits in the First Week After Birth:
Ask about mother’s well being
Ask about excessive bleeding, headache, fits, fever, feeling very weak, breathing difficulties, foul-smelling discharge, painful urination, severe abdominal or perineal pain. If she has any of these symptoms, refer her to a health facility for care
Ask for swollen, red or tender breast or nipples, manage breastfeeding problems if possible; if not, refer her to a health facility for care
Counsel about danger signs for mother and newborn and advise on where to seek early care when needed
Provide birth spacing and nutrition counselling
Note: These interventions should be delivered by appropriately trained and supervised health workers.
Source: World Health Organization/Global Health Workforce Alliance (2014).
Community Case Management
Integrated Community Case Management (iCCM) is an approach where case management is carried out by CHWs who are trained to identify, treat, and, if needed, refer cases of key childhood illnesses. Although the iCCM package is tailored as per context, the most commonly included illnesses are diarrhea, pneumonia, and malaria. Neonatal problems and malnutrition are also included in iCCM in some care packages.
In a joint statement issued by WHO and UNICEF, iCCM was termed as an “equity-focused strategy” aimed at “sustained reduction in child mortality” (WHO/UNICEF, 2012, p. 6). The strategy aligns well with the core philosophies of PHC—especially the principles of “universal access to care and coverage on the basis of need” and “commitment to health equity” and thus should exist as part of a comprehensive PHC system. Recognizing the challenges associated with delivering health services to the most vulnerable populations where existing treatment coverage is low, the iCCM approach has been advocated to provide timely and effective management for diseases that are the leading causes of death in young children. The treatment strategy, based on IMCI (now IMNCI), is delivered by suitably trained and equipped CHWs. Over the years, evidence generated has already proven that IMCI training of CHWs has led to better recognition of illnesses, improved PHC practices, and increased care seeking (Arifeen et al., 2009; Nguyen, Leung, McIntyre, Ghali, & Sauve, 2013). However, supervision remains vital for this program to be successful and in low-resource setting it has been suggested that integrating supervision of ICCM with other community PHC services is time- and cost-effective (Figure 4).
The evidence supporting iCCM as part of PHC is considerable. An initial UNICEF/WHO joint statement on treatment of pneumonia in community settings (2004) was based on a meta-analysis of trials of community-based case management of pneumonia that showed pneumonia mortality in an intervention group was reduced by 42%, 36%, and 36% among neonates, infants, and children (0–4 yrs), respectively (Sazawal & Black, 2003). Another systematic review suggested that iCCM of pneumonia could bring down pneumonia mortality by 70% in children under five years (Theodoratou et al., 2010). In their systematic review, Das and others reviewed (2103) 24 studies and demonstrated that community-based interventions led to 32% reduction in pneumonia mortality in children under five, with an increase of 13% and 9% in care seeking for pneumonia and diarrhea respectively. Moreover, there was a 40% decline in treatment failure rates for pneumonia and a 75% decline in the irrational use of antibiotics for diarrhea. The uptake of appropriate treatment of diarrhea improved significantly with a 160% increase in the use of ORS and an 80% increase in the use of zinc.
Evidence also supports that iCCM of malaria as part of PHC can lead to associated morbidity and mortality. A randomized trial in Ethiopia used “mother coordinators” to train other local mothers to recognize malarial symptoms and provide prompt treatment (Kidane & Morrow, 2000, p. 550). A reduction of 40% was seen in all-cause mortality in children younger than five years in the community. Another observational study in malaria-endemic Burkina Faso assessed the impact of training a core group of community mothers in treating uncomplicated malaria with prepackaged antimalarial drugs (Sirima et al., 2003). They observed that the risk of progression of disease to severe malaria was reduced by nearly 50%.
The use of high-quality rapid diagnostic tests (RDTs) for malaria has made diagnosis at the community level feasible. In the iCCM strategy, WHO recommends that all suspected malaria cases are tested using the RDTs and then treated if positive (Integrated community case management of malaria, 2016). Owing to the overlap in symptoms for pneumonia and malaria, the CHWs are trained in an integrated approach for apt diagnosis and treatment at the primary level.
An RCT from Zambia evaluated the feasibility of using CHWs to treat non-severe pneumonia with amoxicillin and use rapid diagnostic tests (RDTs) for malaria to diagnose and treat test-positive children (6 months to 5 years) with artemether-lumefantrine (Hamer et al., 2012). They were successful in showing that, with the help of the RDTs, trained CHWs could provide appropriate and timely treatment for malaria. Moreover, a higher number of children with non-severe pneumonia received effective treatment in the intervention arm.
ICCM was envisioned as a strategy to complement existing PHC facilities and not replace them. The iCCM program implementation can be largely unsustainable if PHC centers are not fully functional. The facilities provide the program the essential supervision, supplies, and a referral point if needed. Thus, though not a substitute for facility-based or other community services, iCCM remains an effective way to provide treatment, especially to vulnerable and hard-to-reach populations. As a multicountry analysis of iCCM programs noted, to gain maximum impact from iCCM it is critical that services be available promptly with linkages to facilities in case referral is needed (Collins, Jarrah, Gilmartin, & Saya, 2014). However, in circumstances where PHC facilities are weak, sustaining the iCCM program may prove more costly.
Innovations to Support Community-Based Strategies for MNCH
Use of Mobile Technologies
The Global Observatory for eHealth has defined mobile health or mHealth as “medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants, and other wireless devices” (WHO, 2011, p. 6).
With nearly 90% of the adult population in LMICs owning a mobile phone, mHealth technology has emerged as a widespread complementary strategy in these regions for supporting delivery of health services and facilitating community-based PHC. Governments, nongovernmental organizations, and multilateral agencies and corporations, have increasingly adopted mHealth to strengthen PHC delivery in low-resource settings. The technology has been utilized for establishing health call centers, mobile telemedicine, health education, and emergency response (Balakrishnan et al., 2016; Sondaal et al., 2016). In community and primary care settings mHealth tools assist CHWs in collecting population health data, sending reminder text messages, linking with health facilities, training, and learning (Lassi, Kumar, & Bhutta, 2016).
Importantly, mHealth has been progressively applied in maternal, neonatal, and child health interventions at the PHC level for several years now. There is growing evidence on the effectiveness and impact of mobile technology on the continuum of care—however more robust studies are needed to inform policy decisions.
A four-year project in rural Afghanistan provided local CHWs with mobile-based modules to counsel pregnant women about antenatal and postnatal care, birth preparedness, danger signs during pregnancy, labor and delivery, and caring for the newborn (USAID/World Vision, 2014). The module included audiovisual messages which help facilitate the CHWs’ discussion on care and health seeking with expectant and new mothers. The project aimed to improve care-seeking behavior and uptake of essential PHC services by pregnant women and mothers. It was found that mothers in the intervention area were more likely to seek antenatal care, have a birth plan, and recognize danger signs.
The Tanzania CommCare project utilized app-generated automated text messages to remotely monitor midwives and provide CHWs with reminders for patient visits (Svoronos et al., 2010). The group using the platform showed an improved number of timely visits to pregnant mothers. More recently, an adapted form of the CommCare platform, the Continuum of Care Services mHealth platform for frontline workers, was tested in a resource-constrained district of Bihar, India. The application provides a home visit planner as well as units for the continuum of care starting from pregnancy registration to breastfeeding and complementary feeding. The researchers found that usage of the platform led to a higher coverage of eight maternal and child care indicators from across the continuum of care.
Reminder text messages with treatment protocols can help health workers provide accurate management at the PHC level. In one study, health workers received text messages on pediatric malaria case management for six months as part of a cluster RCT in rural Kenya (Zurovac et al., 2011). The trial results showed that the intervention led to improved case-management practices among the workers. Similar reminder text messages have also been shown to improve adherence to antiretroviral treatment for HIV as well as improve vaccination uptake in children (Gibson et al., 2017; Haji et al., 2016; Kelly & Giordano, 2011; Lester et al., 2010).
As mobile phone coverage and access continues to grow worldwide, so do the opportunities to leverage the mHealth platform to improve maternal and child PHC practices at the community level.
Private Sector and Social Franchises
The private sector’s role in PHC, especially in the maternal and child context, has grown in LMICs, surpassing the public sector in many countries (Forsberg, Montagu, & Sundewall, 2011). Acknowledging a lack of resources and adequate publicly funded health care, governments in these countries are largely promoting private sector engagement in PHC. These health care providers are often the first point of contact for mothers and children, even in resource-poor environments. Although local private clinics run by doctors or nurses can exist, most private PHC “delivery points” at the community level in LMICs include traditional birth attendants (TBAs), CHWs, midwives, pharmacists, and traditional healers. In some settings, pharmacists might be the only “health care providers” that the community access. Moreover, these pharmacies can also be pick up points for medication for CHWs and serve a supervisory role.
The private sector, though largely unregulated, provides a fair share of PHC and thus impacts health outcomes of the community. On the surface, it would be assumed the cost of private PHC services would make them unattainable for the underprivileged communities in LMICs. However, alternative business models such as social franchising, vouchers systems, and microfinancing have provided a different and more affordable conduit for service delivery.
Social franchising has emerged as an effective model for enhancing the quality of community-oriented PHC services and improving care seeking in LMICs and even in high-income settings. The term social franchise refers to “any activity directed towards a social goal that maintains an independent coordinating network to support the individual activities of network members, working towards improving social welfare” (Bishai, Shah, Walker, Brieger, & Peters, 2008, p. 190).
In franchised healthcare systems, private-sector-based PHC services are provided through a widely distributed network that operates under a certain brand and central franchisor. This system enables multiple service delivery points to thrive and offer low-cost health care, while following specific franchisor-determined standards. Apart from the standards, the coordinating body also identifies the desired outcomes, provides training, and conducts periodic monitoring and evaluation. Figure 4 depicts the key elements of a social franchise especially in terms of flow of money and coordination to ensure quality and access to care for the population.
Globally, most of the social franchise programs are maternal and child health driven, focusing on family planning, reproductive health, neonatal care, immunization, and HIV/AIDS. Nearly 93% of social franchise programs in LMICs offer family planning services, while 63% and 40% programs offer safe motherhood and pediatric services respectively (Viswanathan, Behl, & Seefeld, 2016). Pediatrics services can include treatment of pneumonia, diarrhea, malaria, and nutrition actions.
Although documented by some studies, there is a dearth of robust evidence on the impact of social franchises on maternal and child health outcomes. By and large, research indicates that social franchises in maternal and child PHC lead to a greater uptake of services and improved client experience. Family planning services remain one of the most widely used social franchise services worldwide. According to a detailed survey of health services provided by clinical social franchises in LMIC, more than half (52%) of the DALYs (Disability Adjusted Life Years) averted by these programs were attributable to family planning services, followed by HIV-focused services and MNCH programs (Viswanathan & Seefeld, 2015).
A review of social franchises in Ethiopia, India, and Pakistan documented that franchising establishments for family planning were associated with higher client numbers than nonfranchising ones (Stephenson et al., 2004). They further noted that franchises provide an opportunity to improve access to reproductive PHC services. Moreover, in Pakistan they found that franchises reported higher numbers of patients even for services (antenatal care, tetanus toxoid immunization, delivery) other than family planning. Other reviews of reproductive health franchises in Nepal also reported improved client perception of quality of care and increase in uptake of services (Agha & Balal, 2003; Agha, Karim, Balal, & Sosler, 2007). A systematic review on impact of social franchising on health services in LMICs discovered that although franchises are associated with an improved quality of care and service utilization, there was a lack of studies that evaluated the health outcomes associated with these programs (Beyeler, York De La Cruz, & Montagu, 2013).
A program impact pathway analysis of a community-based social franchise focusing on infant and young child feeding (IYCF) practices in Vietnam recorded an association with enhanced health worker knowledge of IYCF, improved counselling skills and service utilization (Nguyen et al., 2014).
Microcredit and Cash Transfers
One-dimensional interventions cannot be sufficient to address the manifold issues of maternal and child health, especially in LMICs. Multisectoral interventions are essential to strengthen health systems and address inequities that exist in these vulnerable regions. Financial services such as microcredit schemes, cash transfers, and other social safety nets are now recognized as effective strategies to accompany PHC for achieving income security and better health outcomes (Were et al., 2015). Such schemes have been adopted in many LMICs in sub-Saharan Africa, Latin America, and Southeast Asia. Microcredit or cash transfers are provided to households or individuals without conditions or granted in return for the recipient adopting and maintaining certain health-related behaviors (Bassani et al., 2013).
Although there have been studies reporting positive effects of microcredit schemes on care seeking behaviors and maternal and child health (Hamad & Fernald, 2015; Moseson, Hamad, & Fernald, 2014; Quayyum et al., 2013), there is still gap in high-quality evidence supporting the same (Bassani et al., 2013; Lorenzetti, Leatherman, & Flax, 2017). However, robust evidence exists of improvement in maternal and child health outcomes for certain long-standing microfinance schemes such as those developed by BRAC and Grameen Bank in Bangladesh (Bhuiya & Chowdhury, 2002; Orton et al., 2016).
Literature shows that cash transfers improve health-seeking behaviors as well as the coverage of preventive health practices (Bassani et al., 2013) with the maximum benefits seen in the disadvantaged (Yuan et al., 2014). A systematic review of studies on conditional cash transfers (CCT) conducted by Glassman et al. (2013) showed that the CCT programs improved PHC practices such as increased antenatal visits, skilled attendance at birth, delivery at a health facility, and reduced low birthweight (LBW) incidence. Similar to microcredit schemes, long-established CCT schemes have demonstrated impact. The Bolsa Familia programme in Brazil, for instance, has decreased overall child mortality particularly from poverty-related causes such as diarrhea and undernutrition (Rasella, Aquino, Santos, Paes-Sousa, & Barreto, 2013).
Research and Implementation Gaps
A considerable amount of research has been conducted on community-based PHC interventions for maternal and child health, especially in the run up to the MDGs. However, gaps remain in the evidence generated. Although most CHW programs are based in South Asia and sub-Saharan Africa, maximum studies have come out of Asia with limited research being generated from LMIC countries in Africa (Lassi, Middleton, Bhutta, & Crowther, 2016). Also, most available research in this realm lacks high-quality study designs, and more randomized controlled trials are needed to evaluate PHC interventions. Routine implementation research is imperative to identify gaps and limitations of interventions and to inform future PHC programs. Moreover, as noted in reviews there is a lack of evidence on cost-effectiveness of community-based interventions and reporting on this data (costs per lives saved or DALYs averted) in a standardized format is needed. Further robust studies are needed to evaluate newer, innovative strategies of community-based PHC such as mHealth and their impact on service utilization and on maternal and child health outcomes. Integration of PHC services is expected to improve efficiency, quality, and access to services. Integration of services can be within the health sector to encourage a continuum of care approach and to maximize benefits and outcomes. PHC services can also improve outcomes by integration with programs for poverty alleviation, education, and rural development that indirectly work towards improving health. However, more studies are required to evaluate the impact of integrated PHC programs with pure community-based implementation. Also, gaps exist in evaluating the characteristics of CHWs, their training and supervision, and their association with PHC program outcomes (Global Health Workforce Alliance, World Health Organization, 2010).
Despite gaps in research, several effective community-based PHC preventive and health-promoting strategies have been proven to impact maternal, neonatal, and child health positively. However, implementation of these strategies is needed at scale in LMICs and in partnership with all stakeholders including the public and private sector, the communities, and the donors. Moreover, as discussed, most PHC strategies in LMICs are dependent on community-based health care workers and thus efforts are needed to ensure improvement in recruitment, training, incentives, and retention of these workers. CHWs dissatisfaction with their work environment, lack of resources, inadequate linkages with the health system, and ignorance of government policies all impact PHC programs negatively (Banchani & Tenkorang, 2014).
Conclusion and Way Forward
On the road to 2030, it is believed that attaining the SDGs is unlikely without a concerted effort to improve maternal and child health outcomes through the continuum of care. Although substantial progress has been made in reducing maternal and child mortality in the MDG era, a growing global population, rising political instability, and economic uncertainty pose challenges for existing health programs especially in remote and rural areas of LMICs, putting the most vulnerable populations at risk. Community-based PHC, operating on the principles of community engagement and community mobilization, is now more critical than ever. Recognition of CHWs as a formal cadre and the integration of community-based health services in PHC would aid in strengthening efforts to impact maternal, neonatal, and child health outcomes positively. However, although community-based PHC is critical for maternal and child health in LMICs, the existence of a strong health system and skilled workforce is central to achieving positive health outcomes in these regions (Bhutta et al., 2008).
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