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© Christopher Stevens
The deaths of children under five from preventable causes, could be avoided if life-saving interventions could be delivered to families that need them most.


by Theresa Diaz, Chief of Chief, Knowledge Management and Implementation Research Unit, Health

In rural Africa, distances between homes and health centres can be the difference between life and death for a small child suffering from malaria, pneumonia or diarrhoea. All three of these mostly preventable diseases, although fairly easy and cheap to treat, still pose the greatest threat to children under five and claim far too many lives.

However, a quiet revolution is taking place in many of the remotest and poorest parts of the continent.  It is being led by courageous and generous women like Hawawu Mahma and Zenabu Abubakar, community based agents, who are transforming the way health care is being delivered.  Based in Kpilio, a small rural village in the Northern Region of Ghana, a highly malaria endemic area, they go house by house, armed with some basic medicines, to treat sick children and prevent their illnesses from becoming deadly.  If they cannot diagnose the condition or a child’s illness has already become severe they help families make their way to clinics.

Carrying a wooden box containing essential diagnostic kits and medicines on their heads, Hawawu and Zenabu are equipped to provide sick children with antibiotics for pneumonia, antimalarials to treat malaria, and oral rehydration packets and zinc supplements for diarrhoea.

According to the latest data available, 6.6 million children under the age of five die each year from largely preventable causes. These deaths could be avoided if life-saving interventions could be delivered to families that need them most[1]. Unfortunately, barriers such as distance to health facilities, high users fees for services, along with other out of pocket expenses, religious beliefs and/or cultural practices often prevent these interventions from being delivered effectively.

Globally, pneumonia, diarrhea and malaria account for approximately a third of all child deaths.  Since there is a large overlap in symptoms for these child killers, the support and roll-out of “integrated case management” especially at community (iCCM) level is growing.  Today, 30 countries in sub-Saharan Africa are delivering health services through ICCM programmes, while 25 countries have written policies on case management of malaria at community level specifically.


© Christopher Stevens
Since community agents are chosen from the communities they serve, they know best how to overcome many of the barriers.

Evidence presented at a recent international Review Symposium clearly indicates that the investment in community response is working and saving lives.  Recent studies have estimated that community case management of malaria can reduce overall and malaria-specific under-five mortality by 40 and 60 per cent, respectively, and severe malaria morbidity by 53 per cent[1].

This is where the role of Awawu and Zenabu becomes life-saving as they bring curative interventions to the doorsteps of those who cannot access them due to geographical, social or financial barriers. Since community agents are chosen from the communities they serve, they know best how to overcome many of the barriers.

When appropriately trained, supervised and equipped with an uninterrupted supply of medicines and equipment, community health workers can identify and appropriately treat children with symptoms of malaria, diarrhoea and/or pneumonia. Bringing services to children, especially the most poor and most marginalized, is far more effective and beneficial than waiting for parents to bring them to a health facility.

The success of empowering community health workers with the right training has been further enhanced by giving them access to simple technologies that can help test a sick child.  For example, testing for malaria at the community level is now possible thanks to the increasing availability of high-quality rapid diagnostic tests.

As part of iCCM’s integrated approach, patients are screened for all three diseases using malaria rapid diagnostic tests, taking detailed patient health histories and using simple stopwatches to time a child’s respiratory rate to determine which treatments should be administered.  Some countries are also adding treatment for severe acute malnutrition and care for newborn children into the iCCM package.  If a child shows danger symptoms, they are immediately referred to the closest health facility for more in-depth care.  

International development partners including UNICEF, the World Health Organisation (WHO), the U.S. Agency for International Development (USAID), Canada Department of Foreign Affairs, Trade and Development and the Bill and Melinda Gates Foundation are all now investing in this approach by helping governments undertake country-level situation analysis to identify locations where disease burdens are higher, plan for effective investments and better implement and monitor progress. 

It is clear from the evidence that an integrated approach to iCCM can only be truly successful if the following combination of factors is present: supportive government policies, especially at the local level; a motivated and well trained community health workers; reliable supply chains, especially for the supply of essential drugs at community level; as well as the removal of geographical, social and financial barriers that often hinder parents from seeking care, along with better ways to track impact.

Most governments, especially in Africa, are interested in rolling out Universal Health Coverage for their citizens.  As the evidence indicates, iCCM may be one way to achieve this as it offers an effective way to reach underserved and vulnerable populations with the most essential health care they need. In the meantime, the countries that have started rolling-out iCCM are already making the best investments possible to ensure their children are less likely to die of preventable and curable diseases.

[1] WHO/UNICEF Joint Statement: Integrated Community Case Management (iCCM), June 2012



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