成熟 iCCM 项目实施的成就与挑战：马拉维案例研究。
Achievements and challenges of implementation in a mature iCCM programme: Malawi case study.
机构信息
ICF, Rockville, Maryland, USA.
Abt Associates Inc, Dili, Timor-Leste.
出版信息
J Glob Health. 2019 Jun;9(1):010807. doi: 10.7189/jogh.09.010807.
BACKGROUND
Malawi has a mature integrated community case management (iCCM) programme that is led by the Ministry of Health (MOH) but that still relies on donor support. From 2013 until 2017, under the Rapid Access Expansion (RAcE) programme, the World Health Organization supported the MOH to expand and strengthen iCCM services in four districts. This paper examines Malawi's iCCM programme performance and implementation strength in RAcE districts to further strengthen the broader programme.
METHODS
Baseline and endline household surveys were conducted in iCCM-eligible areas of RAcE districts. Primary caregivers of recently-sick children under five were interviewed to assess changes in care-seeking and treatment over the project period. Health surveillance assistants (HSAs) were surveyed at endline to assess iCCM implementation strength.
RESULTS
Care-seeking from HSAs and treatment of fever improved over the project period. At endline, however, less than half of sick children were brought to an HSA, many caregivers reported a preference for providers other than HSAs, and perceptions of HSAs as trusted providers of high-quality, convenient care had decreased. HSA supervision and mentorship were below MOH targets. Stockouts of malaria medicines were associated with decreased care-seeking from HSAs. Thirty percent of clusters had limited or no access to iCCM (no HSA or an HSA providing iCCM services less than 2 days per week); 50% had moderate access (an HSA providing iCCM services 2 to 4 days per week; and 20% had high access (a resident HSA providing iCCM services 5 or more days per week). Moderate access to iCCM was associated with increased care-seeking from HSAs, increased treatment by HSAs, and more positive perceptions of HSAs compared to areas with limited or no access. Areas with high access to iCCM did not show further improvements above areas with moderate access.
CONCLUSIONS
Availability of well-equipped and supported HSAs is critical to the provision of iCCM services. Additional qualitative research is needed to examine challenges and to inform potential solutions. Malawi's mature iCCM programme has a strong foundation but can be improved to strengthen the continuity of care from communities to facilities and to ultimately improve child health outcomes.
背景
马拉维拥有成熟的综合社区病例管理（iCCM）计划，该计划由卫生部（MOH）主导，但仍依赖于捐助者的支持。从 2013 年到 2017 年，在快速准入扩展（RAcE）计划下，世界卫生组织支持 MOH 在四个地区扩大和加强 iCCM 服务。本文研究了 RAcE 地区马拉维 iCCM 计划的绩效和实施力度，以进一步加强更广泛的计划。
方法
在 RAcE 地区的 iCCM 合格地区进行基线和期末家庭调查。最近生病的五岁以下儿童的主要照顾者接受了访谈，以评估项目期间的护理寻求和治疗变化。在期末对卫生监测助理（HSA）进行调查，以评估 iCCM 的实施力度。
结果
在项目期间，从 HSA 寻求护理和治疗发热的情况有所改善。然而，在期末，不到一半的患病儿童被带到 HSA，许多照顾者报告说更喜欢其他提供者而不是 HSA，并且对 HSA 作为高质量、方便护理的可信赖提供者的看法有所下降。HSA 监督和指导低于 MOH 目标。疟疾药物缺货与从 HSA 寻求护理的减少有关。30%的集群有限或无法获得 iCCM（没有 HSA 或 HSA 每周提供 iCCM 服务少于 2 天）；50%有中等访问权限（HSA 每周提供 iCCM 服务 2 至 4 天）；20%有高访问权限（常驻 HSA 每周提供 iCCM 服务 5 天或以上）。与有限或无法获得 iCCM 的地区相比，中等程度的 iCCM 可及性与 HSA 寻求护理的增加、HSA 治疗的增加以及对 HSA 的更积极看法有关。获得高度 iCCM 可及性的地区并没有比获得中度可及性的地区显示出进一步的改善。
结论
配备齐全且得到支持的 HSA 的可用性对于提供 iCCM 服务至关重要。需要进行更多的定性研究来检查挑战并为潜在的解决方案提供信息。马拉维成熟的 iCCM 计划有坚实的基础，但可以加以改进，以加强从社区到医疗机构的护理连续性，并最终改善儿童健康结果。
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