CASE STUDY
Background
Integrated community case management (ICCM) of childhood illness works to provide access to community-based care for children under 5 for pneumonia, malaria and diarrhoea through the training of community health workers (CHWs). In Zambia in 2010, 36% of deaths of children under the age of 5 were due to these 3 childhood illnesses, accounting for 21,600 deaths.
ICCM is being implemented in all 7 districts of Luapula province in Northern Zambia by Malaria Consortium, funded by the Canadian International Development Agency (CIDA). This includes Samfya district where the local environment – large swamps and vast lakes where people live on small islands – makes it a particularly challenging area in which to successfully implement health interventions.
The CHWs in Samfya district currently see 6 people per day: 4 with malaria and 2 or 3 with diarrhoea. To date, in the whole of Luapula province, 1,332 CHWs have been trained and are working there.
Access to health care has significantly improved
One of the most significant improvements since the implementation of ICCM is the decongestion of health facilities, noted by 2 CHWs in Samfya district as well as a member of staff from the local health facility. The health facility ‘is now able to cope’.
The numbers of children aged 2 months to 5 years visiting the health facility have been dramatically reduced as they are now cared for primarily in the community and are only referred to the facility when necessary.
For the communities, access to health services has greatly increased as a result of the ICCM programme. As one CHW described, they are now able to access health care ‘right at their doorway’ and including during the night because the CHWs are part of the community and are always accessible. Even when there was a recent shortage of drugs, the CHWs explain that they have still been received well by the community and attitudes towards them have not changed.

Community members really appreciate this programme. They can easily access the medicine’
Community health worker

For the communities, access to health services has greatly increased as a result of the ICCM programme. As one CHW described, they are now able to access health care ‘right at their doorway’ and including during the night because the CHWs are part of the community and are always accessible. Even when there was a recent shortage of drugs, the CHWs explain that they have still been received well by the community and attitudes towards them have not changed.
Overcoming local challenges to ICCM
When ICCM was first implemented in the area, some community members were wary as the rapid diagnostic tests for malaria involve a blood test – a pin prick of blood taken from the patient’s finger – which contributed to an impression amongst some in the area that the CHWs were ‘bewitched’.
However, the clear support of the ICCM programme by the district health facilities has helped to reassure the community members. Health facility staff often ask children who visit the health facility why they did not first seek care from the CHWs and encourage them to do so. This has helped communicate to community members the government’s support for ICCM.
On the whole, there are still some community members who are slow to seek care, but CHWs and Malaria Consortium are working hard to address this by educating and encouraging the community.
For maximum impact, outstanding challenges need to be addressed
Whilst implementation of ICCM has been a success in Luapula province, the 2 CHWs in Samfya district highlighted some of the obstacles they face in providing health care for their communities.
Firstly, that they need bicycles. In Zambia, CHWs work voluntarily and in many cases earn their primary income, or sustain their families, through farming. They are required to collect the drugs from the district health facilities on a regular basis and also to deliver a monthly report. They also make routine follow-up visits to their patients to check their recovery.
All of these duties can involve travelling considerable distances on foot. They sacrifice a lot of time, at the expense of their own livelihood, and the community often does not have the capacity to support them.
The CHWs also need better torches. In rural areas, often far from the electricity grid, CHWs struggle to provide care for patients at night with the small and often faulty torches they currently have.
Finally, whilst the government is supportive of ICCM, endorsing guidelines and training manuals, there is as yet no national ICCM policy in place. For the maximum impact of ICCM to be realised and to ensure the sustained motivation and capacity of the CHWs, these challenges must be addressed.
Malaria Consortium, as part of COMDIS-HSD, is conducting research on ICCM in Luapula to provide further evidence on the rational use of antibiotics at community level and inform future implementation of ICCM.
Find out more about the ICCM project and the findings from our study of community case management of pneumonia in Zambia. Read our full research articles:

• Sinyangwe C, Graham K, Nicholas S, King R, Mukupa S, Kallander K, Counihan H, Montague M, Tibenderana J, Hamade P. (2016) Assessing the quality of care for pneumonia in integrated community case management. PLOS ONE doi.org/10.1371/journal.pone.0152204
• Graham K, Sinyangwe C, Nicholas S, King R, Mukupa S, Kallander K, Counihan H, Montague M, Tibenderana J, Hamade P. (2016) Rational use of antibiotics by community health workers and caregivers for children with suspected pneumonia in Zambia: a cross-sectional mixed methods study. BMC Public Health doi.org/10.1186/s12889-016-3541-8

This project has been funded by UK aid from the UK government.