Quality of Sick Child-Care Delivered by Community Health Workers in Tanzania

Document Type: Original Article

Authors

1 Mailman School of Public Health, Columbia University, New York City, NY, USA

2 Ifakara Health Institute, Dar es Salaam, Tanzania

3 Tanzania Training Center for International Health, Ifakara, Tanzania

4 Ministry of Health and Social Welfare, Dar es Salaam, Tanzania

Abstract

Background
Community health worker (CHW) interventions to manage childhood illness is a strategy promoted by the global health community which involves training and supporting CHW to assess, classify and treat sick children at home, using an algorithm adapted from the Integrated Management of Childhood Illness (IMCI). To inform CHW policy, the Government of Tanzania launched a program in 2011 to determine if community case management (CCM) of malaria, pneumonia and diarrhea could be implemented by CHW in that country.
 
Methods
This paper reports the results of an observational study on the CCM service delivery quality of a trial cohort of CHW in Tanzania, called WAJA. In 2014, teams of data collectors, employees of the Ministry of Health and Social Welfare trained in IMCI, assessed the IMCI skills rendered by a sample of WAJA on sick children who presented to WAJA with illness signs and symptoms in their communities. The assessment included direct observations of WAJA IMCI episodes and expert re-assessment of the same children seen by WAJA to assess the congruence between the assessment, classification and treatment outcomes of WAJA cases and those from cases conducted by expert re-assessors.
 
Results
In the majority of cases, WAJA correctly assess sick children for CCM-treatable illnesses (malaria, pneumonia, and diarrhea) and general danger signs (90% and 89%, respectively), but too few correctly assess for physical danger signs (39%); on classification in the majority of cases (73%) WAJA correctly classified illness, though more for CCM-treatable illnesses (83%). In majority of cases (78%) WAJA treated children correctly (84% of malaria, 74% pneumonia, and 71% diarrhea cases). Errors were often associated with lapses in health systems support, mainly supervision and logistics.
 
Conclusion
CCM is a feasible strategy for CHW in Tanzania, who, in the majority of cases, implemented the approach as well as IMCI expert re-assessors. Nevertheless, for CCM to be effective, in Tanzania, a strategy to implement it must be coordinated with efforts to strengthen local health systems.

Highlights

Supplementary File 1 (Download)

Supplementary File 2 (Download)

Supplementary File 3 (Download)

Supplementary File 4 (Download)

Keywords

Main Subjects


  1. Bhutta ZA, Chopra M, Axelson H, et al. Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child survival. Lancet. 2010;375(9730):2032-2044. doi:10.1016/s0140-6736(10)60678-2
  2. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. How many child deaths can we prevent this year? Lancet. 2003;362(9377):65-71. doi:10.1016/s0140-6736(03)13811-1
  3. Travis P, Bennett S, Haines A, et al. Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet. 2004;364(9437):900-906. doi:10.1016/s0140-6736(04)16987-0
  4. Bhutta ZA, Lassi ZS, Pariyo G, Huicho L. Global experience of community health workers for delivery of health related Millennium Development Goals: a systematic review, country case studies, and recommendations for integration into national health systems. Global Health Workforce Alliance. 2010;1(249):61.
  5. Pence BW, Phillips JF, Debpuur C. The Effect of Community Nurses and Health Volunteers on Child Mortality: The Navrongo Community and Family Planning Project. Population Council Working Paper. 2005 (No. 20):1-20.
  6. Afari EA, Nkrumah FK, Nakana T, Sakatoku H, Hori H, Binka F. Impact of primary health care on child morbidity and mortality in rural Ghana: the Gomoa experience [corrected]. Cent Afr J Med. 1995;41(5):148-153.
  7. Gilroy KE, Callaghan-Koru JA, Cardemil CV, et al. Quality of sick child care delivered by Health Surveillance Assistants in Malawi. Health Policy Plan. 2013;28(6):573-585. doi:10.1093/heapol/czs095
  8. Alonso PL, Lindsay SW, Armstrong JR, et al. The effect of insecticide-treated bed nets on mortality of Gambian children. Lancet. 1991;337(8756):1499-1502.
  9. Velema JP, Alihonou EM, Gandaho T, Hounye FH. Childhood mortality among users and non-users of primary health care in a rural west African community. Int J Epidemiol. 1991;20(2):474-479.
  10. Rowe SY, Olewe MA, Kleinbaum DG, et al. Longitudinal analysis of community health workers’ adherence to treatment guidelines, Siaya, Kenya, 1997-2002. Trop Med Int Health. 2007;12(5):651-663. doi:10.1111/j.1365-3156.2007.01824.x
  11. Ashwell HE, Freeman P. The clinical competency of community health workers in the eastern highlands province of Papua New Guinea. P N G Med J. 1995;38(3):198-207.
  12. Kallander K, Tomson G, Nsabagasani X, Sabiiti JN, Pariyo G, Peterson S. Can community health workers and caretakers recognise pneumonia in children? Experiences from western Uganda. Trans R Soc Trop Med Hyg. 2006;100(10):956-963. doi:10.1016/j.trstmh.2005.11.004
  13. Miller NP, Amouzou A, Tafesse M, et al. Integrated community case management of childhood illness in Ethiopia: implementation strength and quality of care. Am J Trop Med Hyg. 2014;91(2):424-434. doi:10.4269/ajtmh.13-0751
  14. Hadi A. Management of acute respiratory infections by community health volunteers: experience of Bangladesh Rural Advancement Committee (BRAC). Bull World Health Organ. 2003;81(3):183-189.
  15. Rowe SY, Kelly JM, Olewe MA, et al. Effect of multiple interventions on community health workers’ adherence to clinical guidelines in Siaya district, Kenya. Trans R Soc Trop Med Hyg. 2007;101(2):188-202. doi:10.1016/j.trstmh.2006.02.023
  16. Smith Paintain L, Willey B, Kedenge S, et al. Community health workers and stand-alone or integrated case management of malaria: a systematic literature review. Am J Trop Med Hyg. 2014;91(3):461-470. doi:10.4269/ajtmh.14-0094
  17. Baynes C, Semu H, Baraka J, et al. An exploration of the feasibility, acceptability, and effectiveness of professional, multitasked community health workers in Tanzania. Glob Public Health. 2017;12(8):1018-1032. doi:10.1080/17441692.2015.1080750
  18. The United Republic of Tanzania, Ministry of Health and Social Welfare. Primary Health Services Development Programme- MMAM 2007-2017. Tanzania: Ministry of Health and Social Welfare; 2007.
  19. Shoo R, Mzige A. Training of Community Health Workers in Tanzania. Tanzania: Ministry of Health and Social Welfare and UNICEF; 2011.
  20. Ramsey K, Hingora A, Kante M, et al. The Tanzania Connect Project: a cluster-randomized trial of the child survival impact of adding paid community health workers to an existing facility-focused health system. BMC Health Serv Res. 2013;13 Suppl 2:S6. doi:10.1186/1472-6963-13-s2-s6
  21. World Health Organization and United National Children’s Fund. Caring for the sick child in the community. World Health Organization; 2011.
  22. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-174.
  23. De Sousa A, Tiedje K, Recht J, et al. Community case management of childhood illnesses: policy and implementation in Countdown to 2015 countries.  Bull World Health Organ. 2012;90:183-190.
  24. Bryce J, Gouws E, Adam T, et al. Improving quality and efficiency of facility-based child health care through Integrated Management of Childhood Illness in Tanzania. Health Policy Plan. 2005;20 Suppl 1:i69-i76. doi:10.1093/heapol/czi053
  25. Armstrong Schellenberg J, Bryce J, de Savigny D, et al. The effect of Integrated Management of Childhood Illness on observed quality of care of under-fives in rural Tanzania. Health Policy Plan. 2004;19(1):1-10.
  26. Noordam AC, Carvajal-Velez L, Sharkey AB, Young M, Cals JW. Care seeking behaviour for children with suspected pneumonia in countries in sub-Saharan Africa with high pneumonia mortality. PLoS One. 2015;10(2):e0117919. doi:10.1371/journal.pone.0117919
  27. United Republic of Tanzania. The National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania, 2008-2015. Dar es Salaam: Ministry of Health and Social Welfare; 2008.
  28. Ministry of Health, Community Development, Gender, Elderly and Children - MoHCDGEC/Tanzania Mainland, Ministry of Health - MoH/Zanzibar, National Bureau of Statistics - NBS/Tanzania, Office of Chief Government Statistician - OCGS/Zanzibar, and ICF.  Tanzania Demographic and Health Survey and Malaria Indicator Survey 2015-2016. 2016; Dar es Salaam, Tanzania: MoHCDGEC, MoH, NBS, OCGS, and ICF. http://dhsprogram.com/pubs/pdf/FR321/FR321.pdf.
  29. Ginsburg AS, Sadruddin S, Klugman KP. Innovations in pneumonia diagnosis and treatment: a call to action on World Pneumonia Day, 2013. Lancet Glob Health. 2013;1(6):e326-327. doi:10.1016/s2214-109x(13)70117-7
  30. Bruxvoort K, Kalolella A, Nchimbi H, et al. Getting antimalarials on target: impact of national roll-out of malaria rapid diagnostic tests on health facility treatment in three regions of Tanzania. Trop Med Int Health. 2013;18(10):1269-1282. doi:10.1111/tmi.12168
  31. Winch PJ, Doumbia S, Kante M, et al. Differential community response to introduction of zinc for childhood diarrhea and combination therapy for malaria in southern Mali. J Nutr. 2008;138(3):642-645. doi:10.1093/jn/138.3.642
  32. Leonard K, Masatu MC. Outpatient process quality evaluation and the Hawthorne Effect. Soc Sci Med. 2006;63(9):2330-2340. doi:10.1016/j.socscimed.2006.06.003
  33. Kiplagat A, Musto R, Mwizamholya D, Morona D. Factors influencing the implementation of integrated management of childhood illness (IMCI) by healthcare workers at public health centers & dispensaries in Mwanza, Tanzania. BMC Public Health. 2014;14:277. doi:10.1186/1471-2458-14-277
  34. Walter ND, Lyimo T, Skarbinski J, et al. Why first-level health workers fail to follow guidelines for managing severe disease in children in the Coast Region, the United Republic of Tanzania. Bull World Health Organ. 2009;87(2):99-107.
  35. Armstrong Schellenberg J, Bryce J, de Savigny D, et al. The effect of Integrated Management of Childhood Illness on observed quality of care of under-fives in rural Tanzania. Health Policy Plan. 2004;19(1):1-10.
  36. Pariyo GW, Gouws E, Bryce J, Burnham G. Improving facility-based care for sick children in Uganda: training is not enough. Health Policy Plan. 2005;20 Suppl 1:i58-i68. doi:10.1093/heapol/czi051
  37. McCord G, Liu A, Singh P. Deployment of Community Health Workers across Rural Sub-Saharan Africa: Financial Considerations and Operational Assumptions. Bull World Health Organ. 2013;91(4):B244-253. doi:10.2471/BLT.12.109660