Background
Methods
Study setting
Study design
Dimension of access (defined by Obrist et al.) | Key questions adapted in relation to iCCM services |
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Availability The existing health services and goods meet clients’ needs. | • What services do iCCM VHT members provide? Are the types of services provided by VHT members perceived to be appropriate? (What should VHT members be allowed to do or not do? Do iCCM services and goods meet caregivers’ needs?) • Are there sufficient numbers of iCCM VHT members available to perform services? Are they able to meet demand? • Are iCCM treatment and commodities available? Is supply sufficient to meet demand? Are the types of commodities available sufficient and appropriate to the services provided? |
Accessibility The location of supply is in line with the location of clients. | • Is the location of iCCM VHT members in line with the location of the community? • Are iCCM services easily accessible via VHT members? (Are they proximally located? Is transport required? Time required to reach?) • Are services at the referral health facility easily accessible (distance, time and transport required to reach)? |
Affordability The prices of services fit the clients’ income and ability to pay. | • What are the direct and indirect costs associated with accessing iCCM services? • What are the direct and indirect costs (transportation, lost time and income, fees) associated with accessing referral services? |
Adequacy The organization of health care meets the clients’ expectations. | • Does the organisation of iCCM services meet community expectations? (i.e. how services are provided) • Is there adequate space for service provision? • Are the VHT members’ homes and treatment areas clean and well-kept? • Are supplies and other materials well organised? Is the organisational set-up adequate? • Do the opening hours (availability of VHT members for service provision) match caregiver needs? Can the VHT members be easily located when needed? |
Acceptability The characteristics of providers match with those of the clients. | • Do the characteristics of iCCM service providers match with the expectations of the community? Do caregivers feel welcome and cared for? • How do the characteristics (attitudinal and performance) or personality of VHT members influence iCCM acceptability? • How do perceptions of VHT member competency or skills influence iCCM acceptability? (Are VHT members perceived to be qualified to provide services? Do caregivers trust the competency of VHT members?) • What is the acceptability of the available iCCM treatments and information provided? • What was the acceptability of the process through which VHT members were selected? Was the community sufficiently engaged? How did VHT selection influence VHT member acceptability? |
Target groups per village | Data collection activities |
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Rapid appraisal activities (visualisation tools to generate group discussions)
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One group of caregivers and one group of iCCM-trained VHT members (Activities conducted separately with each group) | Transect walk: conducted by participants, with guidance from the moderator. Observed village boundaries, locations and basic characteristics of all health service providers, and other important landmarks so as to acquaint the study team with the village and inform subsequent activities. |
Health service venn diagram: identified all available health service providers and organisations within and beyond the village, including external sources of power or influence; explored the relative importance of various actors; mapped relationships that influence health service delivery and uptake | |
Historical matrices: explored changes pre and post-iCCM introduction in demographic factors, livelihood assets (human, financial, natural and physical capital) and available health services, gathering a detailed description of the dynamic, transitional nature of peri-urban environments | |
Health service delivery matrices: explored relationships influencing service delivery and uptake (covering iCCM implementation, process, results), gathering perceptions of various trends over time related to health service delivery and uptake | |
Problem and solution ranking: participants first identified and prioritised problems related to iCCM, and then discussed and ranked potential interventions to address the identified problems | |
Key informant interviews
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Community leaders | Historical profile: in depth interviews conducted with community leader or long-term resident exploring present village characteristics, historical information on the village (demographic, household, economic, livelihood assets, transport), available health care services and care seeking practices |
Non-iCCM VHT members | Semi-structured interview: topics covered VHT member role, selection, training, working relationship with iCCM VHT members, and areas for improvement |
Participants and sampling
Village | Rapid appraisal activities/group discussions | Key informant interviews | ||
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Caregivers | iCCM VHT members | Community leaders | Non-iCCM VHT members | |
Village 1 | 12 | 2 | 1 | 2 |
Village 2a
| 12 | 2 | n/a | n/a |
Village 3 | 12 | 2 | 1 | 2 |
Village 4 | 12 | 2 | 1 | 2 |
Village 5 | 12 | 2 | 1 | 2 |
Village 6a
| 12 | 2 | n/a | n/a |
Village 7 | 13 | 2 | 1 | 2 |
Total | 85 | 14 | 5 | 10 |
Data collection
Analysis
Results
Study participant and village characteristics
At least one school was located in each village and a majority (ranging from 60 to 90%) of the population was estimated to have ever attended school. Although there were some differences in access to transport facilities, boda bodas and bicycles were widely reported to be available when required, with an increasing number of cars reported in the most peri-urban villages.The village has developed so there is no land for agriculture. Most land is being taken on for settlement and other business. In the future, this land is going to become smaller. (Caregiver, Village 5)Mainly people have small businesses – especially the women – like kiosks, retail shops, boda boda (motorcycle taxi) riders, brickmaking, bars, some people can sell water if one has got a big tank. (Community leader key informant, Village 6)
Effective treatment access
High utilisation of iCCM services was reported across villages, with many caregivers reportedly shifting from primarily attending private clinics and traditional healers to VHT members as a first point of care. There was also some limited mention of switching from health centres, hospitals and pharmacies as first point of care, as well as reduced self-medication or home use of herbal remedies.The LCs no longer make burial letters because the children no longer die like it was in the past. (Caregiver, Village 5)
Relative to other health service providers, participants valued VHT members’ free, proximal, 24-h availability; caring attitudes; treatment quality; perceived competency and protocol use; unique follow-up services; and effective referral services.Most women have stopped taking their children to traditional healers and clinics, they take them to VHT [members]. If they fail, the children are referred to hospital. (Caregiver, Village 1)
Cost, proximity and 24-h availability
When the child gets ill, she gets prompt treatment and gets better because treatment is free and near. Whereas for other service providers a child may spend three days with no treatment as one looks for money and it is far. (Caregiver, Village 3)There are no lines to make so you just reach and then get treatment, thus no time is wasted. This has saved us from the long lines we used to make in [name] health centre. (Caregiver, Village 6)
Caring attitudes and performance
The iCCM VHT [members] welcome and care for us so we can easily go back to them for health care. Unlike in other health facilities where health providers are so rude. (Caregiver, Village 7)
Treatment quality and acceptability
In the past the children used to fall sick and go to the private health providers who sometimes do not have the skill and this comes with its own complications. Like here in our village we have two people who were affected because of the injections. (Caregiver, Village 5)The medicine they give is so effective and in three days the child is better. Previously we could buy syrups which were not effective at all. (Caregiver, Village 3)
Competency and protocol use
In [private] clinics, even when they find that they will not treat the patient, because they are business-oriented, they continue to give you medicine which will not heal the person. Whereas the VHT [members] refer you immediately, before the child gets seriously ill. (Caregiver, Village 7)The iCCM VHT [members] do have cards they use to administer medication. They also first thoroughly check the patient before administering medication because they have the testers to use. (Caregiver, Village 6)We treat as the caregivers read the job aid too, because it’s written in Luganda. So they know that we don’t just think about the treatment, but we do what we are supposed to do. … We follow the job aid and beyond that, we don’t do anything other than referring the patient. (VHT member, Village 5)
Unique follow-up services
They always come to do follow up to ensure that the children are fine after the treatment they give to us. Some parents are lazy when it comes to giving their children medicine so they ensure to come to us and make sure we have given our children medicine in full dosage. (Caregiver, Village 2)[In private clinics] it’s the caretaker to take back the child and seek advice. The VHT [members] do follow-ups and in case the child does not get better, he gives you a referral. (Caregiver, Village 1)
Referral system
Caretakers too have believed in us in that when we refer them, they now accept, because they get different treatment from there, unlike before when they would insist by saying, ‘Do what you can for me.’…The patients used to plead with us to do anything in line of treatment, but today they do not plead, they just go. (VHT member, Village 2)When they treat and see that the child is not getting well, they immediately refer. They also escort us during referral, and at the health centre, they deal with us immediately. We don’t have to make long lines. (Caregiver, Village 4)
Factors limiting VHT members’ perceived effectiveness
Types of services (diagnostics, newborn care)
The need for additional training, medicine and equipment to manage newborns was underlined by caregivers and most VHT members across villages, with some suggesting that this would reduce mortality and referrals. However, in one village, VHT members underscored the challenges and risk of mortality associated with managing newborns, noting that they would prefer to restrict their involvement.We know that anyone with malaria has to be measured with thermometer, so we don’t feel comfortable if it’s not used. (Caregiver, Village 4)Some people just prefer going there [to the health centre I] because for them, they can even do blood testing for the children which we don’t do as VHT [members] since we don’t have the machines. (VHT member, Village 7)
There were also a few VHT member reports that poor acceptability of the absence of services for older children drove low utilisation by some caregivers.Most times after birth the mothers are weak and cannot easily move and yet if the iCCM VHT [members] had the skills this would be solved. (Caregiver, Village 5)
Drug stockouts
Most times the medicine is not there for pneumonia. (Caregiver, Village 5)The medicine given takes two months and we spend the third month with no medicine because they restock after three months. (VHT member, Village 6)
VHT availability
Caregivers also generally perceived that two iCCM VHT members were insufficient to meet the high demand, given the large population size. However, these perceptions also reflected some cases of poor distribution of services, due to large geographic areas or inappropriate VHT member selection as described below.When it comes to the time they offer the services to us, we cannot be strict on this because it is voluntary work. They open the services to us at their convenience, but they endeavour that they give to us the biggest portion of time. (Caregiver, Village 2)We can walk like four times climbing that hill to look for the VHT [member]. I get tired yet I have my small business and the child is getting worse, I get so tired that I can’t do other work and I have not got the medicine… In most cases she is not at home. [She] goes at 7:00 am up to 6:30 pm and the child is worsening. You cannot stay home waiting for referral letter. Shall we move at night? (Caregiver, Village 3)
The population is high; it cannot be served by two VHT [members] and we expect the population to increase. (Caregiver, Village 6)
Low community engagement
They just planned this program for us and we were not involved at all. The VHT [members] stay in their homes and operate their work from their homes. We can’t decide therefore where they operate their work from. (Caregiver, Village 5)They are not located properly. Because they are few they are not distributed well in the village. Some beneficiaries travel long distances to get to their homes to receive treatment. (Caregiver, Village 7)
Non-use of VHT services
The rich people are not comfortable with the iCCM VHTs’ service. The very educated first want to see someone’s documents papers before accessing services. They even don’t see them with uniforms. They believe in someone with documents. They say, ‘What kind of service someone can provide from home?’ (Caregiver, Village 5)In our village, you may know someone as a farmer or businessman, but when you are told that is currently giving children drugs you cannot accept it easily, so you decide to go to the hospital. It is not easy to trust the VHTs; we are not sure of their training. (Caregiver, Village 7)
Referral gaps
If the child is referred, the caregivers may not have money for transport, which would take some time to get means of transport and the fees while the sick child is worsening. (Caregiver, Village 7)There are times they refer us but when we go to [name of health centre], we find that they do not have the services we need, like for instance putting a drip on a child. In the long run, you end up just buying these things. However, there are times when you do not even have the money to buy these things. (Caregiver, Village 2)There are times when we refer the caregivers to [name of public hospital] but they always complain that they never find there medicine. The caregivers reach there and they are referred again to other service providers to go and get medicine. Some caregivers think that we intentionally refer them there and this has really affected our service. (VHT member, Village 1)
Impacts on livelihood assets
Participants in all villages also underscored that the regular availability, proximity and rapid provision of VHT services – along with the decreased frequency and duration of childhood illnesses as a result of effective treatment and prevention – enabled caregivers to save time and avoid other indirect costs (including transport and other travel costs) associated with treatment seeking and caring for sick children. This ‘saved time’ was perceived to translate into important economic benefits, allowing caregivers to return home quickly and attend to productive activities.We are able to do savings since the services are free of charge. We no longer depend on our husbands so much when it comes to money for treatment. (Caregiver, Village 6)It has improved the feeding of our children. The money we used to spend on buying medicine is now saved and we use it to buy milk, clothes and other basics we could want for home. (Caregiver, Village 6)Men don’t like giving their wives money, so these women can't tell them about iCCM, so she saves the money for her hair management, to buy books and clothes for the children. So they don’t tell their husbands, women take full responsibility of children. (VHT member, Village 5)
iCCM was also perceived to have increased human capital in the study communities, with wide reports of higher school attendance and improved access to education as a result of VHT services. Participants related this both to healthier children, leading to reduced absenteeism, and to decreased health-related expenditures enabling households to pay school fees and purchase scholastic materials. Increased caregiver knowledge and skills – such as newborn and sick child care, correct medicine use (administration, treatment completion, storage), hygiene and sanitation, net use, nutrition, and disease symptoms and causality – were also widely reported as a result of iCCM services, frequently in relation to VHT follow-up visits. VHT members also reported changes in caregiver beliefs regarding herbal treatments and witchcraft.Services are within the community so less time is used and we can do other work. We don’t have to go to [name of health centre] where one can spend the whole day. (Caregiver, Village 3)We can be able to do our work though the child is sick because she’s on medication. This has helped us to work and have food in the homes. (Caregiver, Village 1)
Finally, caregivers also widely perceived that iCCM was promoting a demographic shift, frequently noting that, in their view, the availability of free care, caregiver satisfaction with iCCM and having healthy children encouraged higher birth rates.Currently our nursery children can study for a whole term without falling sick. Initially they used to be infected from school, as one child infected others who were not sick. Now we quickly take them to VHT [members] to be treated. Children study and perform better. (Caregiver, Village 3)We have learnt so many things from them, like giving full dosage for children, because they clearly explain to us how to do it. (Caregiver, Village 5)
Our children also grow up when they are healthy and energetic and this makes us happy as parents and what comes out of happiness is giving birth to other children. The happiness of a father is children in the homes. (Caregiver, Village 4)
Discussion
Implementation issues in peri-urban settings
Overall iCCM improvement design
Theme | Conclusions and recommendations |
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Targeting of iCCM implementation | When determining targeting of iCCM implementation, health planners should consider factors beyond geographic proximity and assess the broader health service landscape and user preferences (such as reliability of services, perceptions of quality and unmet demand), particularly where rapid population growth has put pressure on existing services. |
Research should explore the cost-effectiveness of iCCM as a transitional strategy, and identify potential benchmarks for facility access and quality improvement that signify when the programme is no longer needed. | |
Peri-urban implementation | Develop tailored sensitization and community engagement approaches to facilitate community participation in the VHT selection process. |
Establish or review norms for VHT density and geographic coverage in larger communities to ensure equitable distribution, considering population changes and expectations for service hours. | |
Potentially consider other delivery strategies for iCCM as an alternative to the VHT model, in high density peri-urban settings. | |
Develop peri-urban typologies in relation to the health care context in order to support appropriate health policy and planning. | |
Overall iCCM improvement design | Continued attention is needed to improve diagnostics availability, strengthen supply chains and improve access along the referral care pathway in order to maximise the benefits of iCCM service provision. |
Explore options for increasing postnatal support in the community. | |
Even where transport facilities exist, organising and affording referral transport remains challenging and needs to be addressed in implementation strategies. | |
Sensitise communities on the health system and complementary roles of community and facility-based care, clarifying that VHT members are intended to serve as a first point of care rather than provide a comprehensive range of services. |