Community Based Approaches, Policy & Evidence Unit, Health Section, Programme Division, UNICEF, NY 10017, USA.
Health Policy Plan. 2011 Jul;26(4):327-37. doi: 10.1093/heapol/czq048. Epub 2010 Oct 5.
Community case management (CCM) as applied to child survival is a strategy that enables trained community health workers or volunteers to assess, classify, treat and refer sick children who reside beyond the reach of fixed health facilities. The Nicaraguan Ministry of Health (MOH) and Save the Children trained and supported brigadistas (community health volunteers) in CCM to improve equitable access to treatment for pneumonia, diarrhoea and dysentery for children in remote areas. In this article, we examine the policy landscape and processes that influenced the adoption and implementation of CCM in Nicaragua. Contextual factors in the policy landscape that facilitated CCM included an international technical consensus supporting the strategy; the role of government in health care provision and commitment to reaching the poor; a history of community participation; the existence of community-based child survival strategies; the decentralization of implementation authority; internal MOH champions; and a credible catalyst organization. Challenges included scepticism about community-level cadres; resistance from health personnel; operational gaps in treatment norms and materials to support the strategy; resource constraints affecting service delivery; tensions around decentralization; and changes in administration. In order to capitalize on the opportunities and overcome the challenges that characterized the policy landscape, stakeholders pursued various efforts to support CCM including sparking interest, framing issues, monitoring and communicating results, ensuring support and cohesion among health personnel, supporting local adaptation, assuring credibility and ownership, joint problem solving, addressing sustainability and fostering learning. While delineated as separate efforts, these policy and implementation processes were dynamic and interactive in nature, balancing various tensions. Our qualitative analysis highlights the importance of supporting routine monitoring and documentation of these strategic operational policy and management issues vital for CCM success. We also demonstrate that while challenges to CCM adoption and implementation exist, they are not insurmountable.
社区病例管理（CCM）在儿童生存方面的应用是一种策略，使经过培训的社区卫生工作者或志愿者能够评估、分类、治疗和转介居住在固定卫生设施之外的患病儿童。尼加拉瓜卫生部（MOH）和救助儿童会培训并支持 brigadistas（社区卫生志愿者）进行 CCM，以改善偏远地区儿童获得肺炎、腹泻和痢疾治疗的公平性。在本文中，我们研究了影响尼加拉瓜采用和实施 CCM 的政策背景和过程。政策背景中的背景因素促进了 CCM 的采用，包括支持该战略的国际技术共识；政府在医疗保健提供中的作用以及为贫困人口服务的承诺；社区参与的历史；基于社区的儿童生存战略的存在；实施权力的分散；卫生部内部的拥护者；以及一个可信的催化组织。挑战包括对社区一级干部的怀疑；卫生人员的抵制；治疗规范和支持该战略的材料存在操作差距；影响服务提供的资源限制；围绕权力下放的紧张局势；以及行政部门的变化。为了利用政策背景的机遇并克服其面临的挑战，利益相关者采取了各种支持 CCM 的努力，包括激发兴趣、构建问题、监测和交流结果、确保卫生人员的支持和凝聚力、支持当地调整、确保信誉和所有权、共同解决问题、解决可持续性问题以及促进学习。虽然这些政策和实施过程被划分为单独的努力，但它们具有动态和互动的性质，平衡了各种紧张局势。我们的定性分析强调了支持 CCM 成功的这些战略业务政策和管理问题的常规监测和文件记录的重要性。我们还表明，虽然 CCM 的采用和实施面临挑战，但并非不可克服。
