A paper published this week in the American Journal of Tropical Medicine and Hygiene highlights efforts in Uganda to incorporate newborn care into the national integrated Community Case Management (iCCM) program that is being scaled up by government together with partners like Malaria Consortium, UNICEF, Healthy Child Uganda and International Rescue Committee. Uganda has made substantial progress in reducing child mortality with under-five mortality dropping from 178 per 1000 live births in 1990 to 90 in 2011. The leading causes of child deaths are neonatal causes (26%); pneumonia (17%); malaria (13%); and diarrhea (10%).
Uganda’s village health strategy renewed
In order to address these causes of death and to reflect the need for improved primary health care, in 2006 Uganda revitalized its Village Health Team (VHT) program. The VHT consists of 5-6 community volunteers who provide maternal, newborn, and child services. In 2010, the Ministry of Health committed to scaling upiCCMfor children under-five. VHT members are trained to assess and treat malaria (ACTs), pneumonia (amoxicillin), diarrhea (ORS and zinc) for children 2-59 months. Preventive newborn careis also included in the iCCM package including postnatal home visits, danger signs recognition, and assisting referral. Learning from the Uganda Newborn Study (UNEST) was incorporated into the basic VHT training as well as the add-on iCCM training (see box for details). However, iCCM clinical practice sessions do not include a newborn example and newborn content is not covered in the post-training assessment.
Aspects of newborn care covered in Uganda’s basic training for Village Health Team members
Newborn care review provided during iCCM training
(2 hours on the final day of the 6-day iCCM training)
Integration of newborn care within iCCM
In order to assess the effectiveness of the integration of newborn care within iCCM, interviews and focus group discussions were conducted with Village Health Team members, facility-based health workers, and caregivers in 3 mid-western districts of Uganda with full scale implementation.
The linkage between the health facilities and VHT members is strong. Health facility staff are responsible for training, supervising, and providing medications to VHT members:
“When we receive their medicine we call them to come pick it and they refer patients to us. Basically we work hand in hand with the VHT members.’’ - Health worker interview.
VHT members trained in iCCM unanimously reported referring sick newborns to facilities:
“During the training, we were told not to treat the newborns at all; we just refer them to the health workers in the health units.” - VHT, focus group discussion
Whilenearly all of the VHT members could list some danger signs they did not identify the most important signs of severe newborn illness. Two-thirds of VHT members mentioned promoting exclusive breastfeeding but less than half mentioned counseling on importance of keeping baby warm, hygienic care practices or inquiring about birth weight.
Overall iCCM is perceived as beneficial, but caregivers, VHT members, and health workers want to do more for sick babies at facilities and in communities. When VHTs do identify and refer sick newborns, it is imperative that the health facilities are equipped and staffed to provide appropriate care:
“It is like we do not have a program for the newborns here. Even if we go to the health facility there are no drugs.” – Caregiver, focus group discussion
“The program is not good concerning newborns because we cannot treat them.” – VHT, focus group discussion
More to be done
Uganda has been one of the first countries to incorporate newborn care into their national iCCM package and their experience is important for other settings considering service integration across the continuum of care. The benefits of iCCM for older children are well known and iCCM also has potential to improve newborn survival in communities where it is being implemented. In order to build on this important program, additional research is needed to assess the ability of VHT members trained in the basic package as well as iCCM to correctly identify newborn danger signs. Barriers to compliance with referrals and the quality of newborn treatment at facilities should be examined to determine the bottlenecks in linking care between communities and health facilities.
iCCM supplement launch
The supplement of over 20 papers reviewing evidence from implementation research has been launched this week at the 61st Annual Meeting of American Society of Tropical Medicine and Hygiene. On November 14, 2012 there was a special session on scaling up iCCM for children in low-resource settings. This symposium presented some of the most recent results of research on iCCM including findings from large-scale programs in challenging, low-resource settings, new data on the potential effectiveness of teaming different cadres of community-based health workers, engaging the private sector in iCCM activities and an evaluation of the potential integration of newborn care into iCCM.