Malaria Consortium Uganda, Kampala, Uganda.
Malaria Consortium, London, UK.
Glob Health Sci Pract. 2020 Jun 30;8(2):190-204. doi: 10.9745/GHSP-D-19-00318.
Several countries have adopted integrated community case management (iCCM) as a strategy for improved health service delivery in areas with poor health facility coverage. Early implementation of iCCM is often run by nongovernmental organizations financed by donors through projects. Such projects risk failure to transition into programs run by the local health system upon project closure. Engagement of subnational health authorities such as district health teams (DHTs) is essential for a smooth transition.
We used a repeated qualitative study design to assess the readiness of and progress made by DHTs in institutionalizing iCCM into the functions of locally decentralized health systems in 9 western Uganda districts. Readiness data were derived from structured group interviews with DHTs before iCCM policy adoption in 2010 and again in 2015. Progressive institutionalization achievements were assessed through key informant interviews with targeted DHT members and local government district planners in the same areas.
In the readiness study, DHTs expressed commitment to institutionalize iCCM into the local health system through the development of district-specific iCCM activity work plans and budgets. The DHTs further suggested that they would implement district-led training, motivation, and supervision of community health workers; procurement of iCCM medicines and supplies; and advocacy activities for inclusion of iCCM indicators into the national health information systems. After iCCM policy adoption, follow-up study data findings showed that iCCM was largely not institutionalized into the local district health system functions. The poor institutionalization was attributed to lack of stewardship on how to transition from externally supported implementation to district-led programming, conflicting guidelines on community distribution of medicines, poor community-level accountability systems, and limited decision-making autonomy at the district level.
Successful institutionalization of iCCM requires local ownership with increased coordination and cooperation among governmental and nongovernmental actors at both the national and district levels.
一些国家采用综合社区病例管理（iCCM）作为改善卫生服务提供的策略，特别是在卫生设施覆盖较差的地区。早期实施 iCCM 通常由非政府组织通过项目由捐助者资助。这些项目在项目结束时，往往无法顺利过渡到由当地卫生系统管理的项目。地方卫生当局（如地区卫生工作队）的参与对于顺利过渡至关重要。
我们使用重复的定性研究设计来评估 9 个乌干达西部地区地区卫生工作队在将 iCCM 纳入地方分散卫生系统职能方面的准备情况和取得的进展。准备数据来自于 2010 年 iCCM 政策通过前与地区卫生工作队的结构化小组访谈，以及 2015 年再次进行的访谈。通过对同一地区的目标地区卫生工作队成员和地方政府地区规划人员进行关键人物访谈，评估渐进式体制化成就。
在准备研究中，地区卫生工作队表示承诺通过制定特定于地区的 iCCM 活动工作计划和预算，将 iCCM 纳入地方卫生系统。地区卫生工作队进一步建议，他们将实施由地区领导的培训、激励和监督社区卫生工作者；采购 iCCM 药品和用品；以及倡导将 iCCM 指标纳入国家卫生信息系统。在 iCCM 政策通过后，后续研究数据显示，iCCM 并没有被纳入地方地区卫生系统的职能。体制化程度低归因于缺乏关于如何从外部支持的实施过渡到由地区主导的规划的管理，关于社区分发药品的指导方针相互矛盾，社区层面问责制薄弱，以及地区一级决策自主权有限。
成功的 iCCM 体制化需要地方所有权，需要国家和地区各级政府和非政府行为者加强协调与合作。
