Understanding the implementation of community case management of childhood illness in Indonesia families' and primary health care workers' perspectives

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Indonesia is striving to achieve the Millennium Development Goal 4 target of less than 23 infant deaths per 1000 live births by 2015. In order to reach this target, a community case management (CCM) model, was introduced by the American funded Maternal and Child Health Integrated Program (MCHIP) and the Indonesian Ministry of Health (MoH) in 2011. Little is known about how CCM has been delivered and there is no research that examines the factors that contribute to the successful implementation of CCM in Indonesia. The aim of this research was to gain insight into how CCM was implemented in the Kutai Timur district, East Kalimantan, Indonesia from the perspective of primary health care workers (PHCWs): community nurses, midwives and community health workers; and from the families who received care. Interpretive description was used to gain insight into participants’ perceptions and experiences. This method allowed me to generate knowledge about the implementation of CCM and to gain an understanding of the experience of the participants involved and the impact on health and health care practice. Data were collected following PHCWs training and the initial phase of implementation. Interviews were conducted with six key informants from MCHIP, MoH, the district health office and Puskesmas (community health centres), three program supervisors, 15 PHCWs and seven mothers. PHCWs were observed while delivering interventions to families. One focus group discussion was conducted with PHCWs and documents related to the CCM implementation were analysed. Five main themes emerged: improved family wellbeing; enhanced PHCWs’ practice; barriers to CCM implementation; enablers of CCM implementation; and cultural influences. It was reported that families’ access to care improved, along with the family’s satisfaction of care, compliance with care plans and health literacy. In addition, it was found that the program had increased PHCWs’ family and child health knowledge and professional confidence to deliver evidenced-based practice, in conjunction with improved clinical reasoning and more structured clinical intervention. Despite the reported success of the CCM program, a number of barriers and concerns highlight the need for programs to be better tailored to the socio-cultural context. An integrated model of community child health delivery that emphasises the importance of health system strengthening; the improved alignment of child health programs with maternal, newborn and reproductive programs; PHCWs support; and community participation is proposed. This model can be used to guide the implementation of community case management models in the rural Indonesian context.
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