Integrated community case management (iCCM) is a cost-effective strategy that engages community health workers living in hard-to-reach areas to diagnose and treat 3 deadly but curable illnesses: malaria, pneumonia and diarrhoea.
We have travelled for over 2 hours from Minna in Nigeria's rural Niger State. The final 45 minutes are on unpaved roads, and we exchange nods and waves as our jostling four-wheel drive vehicle passes people walking or tending to crops. Coming to a field ringed with trees, we exit the vehicles to walk down a precipitous trail leading to the village of Etsu Gudu.
Naumi, a community educator, offers a hand when someone stumbles on the steep path. She recounts how women have given birth on the mountainside, unable to complete the ascent while in labour. Still other women leave home for up to a month before giving birth, so they can be nearer to a health facility.
This is the reality, amidst the beauty and serenity of the pastoral landscape. There is plentiful water from the river that passes next to the village – enough for puddles that attract mosquitos. There are hills that insulate the community. There are plots of land for growing bananas, palm and kola nuts, food that supports the subsistence needs of the village's 300 inhabitants. Children find playmates outside the door of almost every single-room house. And a school stands at the edge of the clearing where we find Mohammed El Hadj, the village head.
No children have died in 3 years
The village elders already have gathered, and women lift themselves from the front steps where they are drying grains and cleaning and weaving palm leaves. We are here to talk about Miriam.
Miriam is the health worker who was chosen by the community because she is well-respected, literate and trusted. With medicines supplied through the WHO Rapid Access Expansion (RAcE) programme, Miriam diagnoses and treats children under the age of 5 for the 3 killer diseases – malaria, pneumonia and diarrhoea – that cause 54% of child deaths in Nigeria. These diseases are preventable and curable.
In the 3 years since she was selected and completed training, no children have died in Etsu Gudu, and no children have been referred to the faraway hospital. She says, "as a mother and as a woman, I feel very happy and other married women feel happy. I enjoy the work."
Extending health care to remote communities
Through WHO, the Government of Canada funded a 5-year grant to bring integrated community case management (iCCM) to remote communities in sub-Saharan Africa countries with a high disease burden. Nigeria, with neighbouring Democratic Republic of the Congo, accounts for about 40% of malaria cases and deaths worldwide.
Some key elements of effective iCCM implementation are recruitment of educated workers who live within remote communities, training and regular supervision, sustained supply of quality medicines, and community support and engagement. In Etsu Gudu, the community is saving up to buy a motorcycle that will reduce the amount of time needed to pick up the medicines each month.
Ministry leads multi-level partnership
"The programme is unique because it involves both the community and the health system," says Dr Abosede R Adeniran, the Director of Family Health within the Nigeria Ministry of Health. "In Niger and Abia States, we now have local evidence that this is the way to go as it relates to addressing the unacceptably high under 5 mortality rate in Nigeria."
Between 2013 and 2017, RAcE in Nigeria worked with local government and partners in Abia and Niger States to deliver activities, including recruiting and training community health workers and supporting the Ministry of Health to implement iCCM. When RAcE was implemented in these pilot states in 2013, there were 128 child deaths per 1000 live births.
An external evaluation conducted in 2017 provides evidence that RAcE contributed to reducing child deaths in Niger and Abia States, and the Ministry of Health plans to extend iCCM to other states as part of its strategy to provide health coverage.
In areas like Etsu Gudu, the pleasures of rural life and close-knit communal living are balanced by subsistence-level incomes and limited, difficult access to health facilities. Arranging for a single sick child visit could mean missing one or more days of work, as well as costing up to one third of the family's monthly income.
"Since iCCM came to the community, all children are safe," says Etsu Gudu village chief, Mohammed El Hadj, offering the RAcE support team kola nuts, bananas and woven palm fans. "He who brings the kola nut, brings life," he continues, referencing the Nigerian tradition of welcoming visitors and offering respect. "This iCCM has brought life."