Facilitators to intergration of ICCM into the health system consisted of community involvement and support for the program, active community case detection and timeliness of health services, the program was not considered a significant shift from other community-based health interventions, district leadership and ownership of the program, availability of national and district-level policies supporting ICCM and engagement of international co-operating partners. Program incompatibility with some socio-cultural and religious cotexts, stock-out of prerequisite drugs and supplies, staff reshuffle and redeployment, inadequate supervision of health facilities, and nonpayment of community health worker incentives inhibited intergration of ICCM into the health system.
Our study findings reveal that community involvement and support for the ICCM program, which is consistent with a multi-country study in South Sudan, Uganda, and Zambia [24], Uganda [30], [34], and Nicaragua [35]. The community involvement and support ensured ICCM activity, of training CHWs, was included on the district action plan as a costed element of the district annual budget. It further facilitated the recognition and acceptance of the ICCM program by communities, motivated and boosted the performance of CHWs, and encouraged a sense of ownership among communities as their participation and inputs are valued and considered. These findings implied the acceptance and motivation of CHWs and uptake of the ICCM program by communities, in which it’s implemented, should not be overlooked to enhance the integration process, as CHWs are the key actors and drivers of the program.
The active community case detection and timeliness of health services were revealed to have fostered ICCM integration into the health system through shortening the infectious period of patients by ensuring early diagnosis, treatment, and/or referrals, to improve treatment outcomes of patients. which is consistent with a previous study in Sri Lanka [36]. This finding suggested that countries like Zambia aim at eliminating malaria could deploy active community case detection, therefore, scaling up RDTs to ensure detection of asymptomatic cases and treating them is vital.
The strong ownership of the ICCM program by district leadership helps facilitate ICCM implementation and integration. The findings are supported by a case study in the Democratic Republic of Congo (DRC) which showed that low ownership of the program in the regions and districts negatively affected implementation and integration into the health system [37]. While ICCM stakeholders’ technical working group (TWG) is in place at the national level to facilitate the overall coordination and implementation of ICCM, only a ICCM focal point person existed at the district level. This reportedly affects implementation and integration. The findings are consistent with a case study in Senegal [38], that the lack of a TWG for ICCM 1) limited interdepartmental coordination, 2) lack of support to central MoH by NGO Consortium, 3) Central MOH’s ownership and engagement at the regional and district levels weakened and led to insufficient institutionalization of ICCM coordination and leadership. Moreover, the study by Bennett et al [7] in six sub-Saharan African countries of Burkina Faso, Kenya, Malawi, Mali, Mozambique, and Niger also reported issues around coordination within the MOH and between ministries, which affected the integration of ICCM into national health systems. Similarly, the findings also support the view that integration can happen differently at the various levels of the health systems depending on the prevailing governance arrangements and supportive systems [9], [31].
The case studies in Senegal [38] and the DRC [37] documented that the presence of national policy, strategic, and implementation documents at the intermediate and operational levels, is a single important factor for successful ICCM implementation and integration. These findings agree with the current study that national and district level documents with ICCM are available at the district health leadership and health facility levels, to provide strategic program direction. The presence of policies, regulations, and strategies at these levels, promoted good leadership and governance in the health sector [39].
The current study findings indicated that district health co-operating partner CHAZ financed ICCM training, provided technical guidance and direction during the initial processes, which agrees with a case study in Senegal [38], that the engagement of development partners UNICEF and USAID made financial resources and/or technical assistance available for pilot studies, dissemination workshops, and seminars for key decision-makers and expansion of ICCM strategy that facilitated integration into the Senegalese health system.
The program incompatibility with the socio-cultural and religious beliefs limited the acceptance and adoption of the ICCM. The socio-cultural myths and misconceptions about blood withdrawal are consistent with a multi-country study in South Sudan, Uganda, and Zambia [24]. Religious beliefs, of forbidding church members, have also been reported in Malawi [25], [26]. The lack of user acceptance has been reported as a barrier to implementation [27]. These findings highlight the need to understanding the compatibility of ICCM with the community in which it’s implemented, which is critical to successful integration, hence the socio-cultural and religious settings with associated barriers to adoption are critical to consider in designing context-specific implementation strategies.
Stock-out of prerequisite ICCM drugs and supplies affects demand and threatens communities’ trust and confidence in the ICCM strategy. Gaps in ICCM commodities and supplies have been reported in a previous multi-country study in South Sudan, Uganda, and Zambia [28], and Uganda [29], [30]. Inadequate logistics have the potential to make a good intervention, such as ICCM be misconstrued as a bad one or none performing, as it interrupts service delivery in the communities and affects the continuity of care, which distorts the integration process [31]. As CHWs are the first level of contact between the community and the healthcare system, stock-outs of essential medicines for treating these common childhood illnesses may lead to delayed access to care thereby increasing child mortality.
Experiences with the non-payment of incentives have been reported to affect motivation and retention of CHWs, slowed the ICCM implementation process, which is consistent with previous studies in Uganda [29], [30], [32] and across the six sub-Saharan Africa countries- Ethiopia, Ghana, Malawi, Mali, Mozambique, and Niger [33]. Therefore, to ensure sustained and effective community service provision, health system components, including finances, must be strengthened [31].
Study strengths and limitations
The collection of data from a considerable number of four data sources- district health managers, ICCM supervisors, health facility managers, and district health co-operating partners, ensured broad perspectives are gathered and allowed for data triangulation. The qualitative team had a student and three experienced supervisors conducting various forms of qualitative research work and program evaluations enhanced investigator and analytic triangulation. The study had limitations: First, the study was conducted in one district with unique context-specific attributes, the small sample of participants, and using one qualitative method, limits the transferability of study findings. However, providing a rich description of background data and the phenomena (barriers and facilitators to ICCM integration), led to an in-depth account of barriers and facilitators to ICCM integration into the health system in Kapiri Mposhi district, Zambia. We also included varied selected quotes from all four data sources. Second, by the time of this study, half of the initially trained district managers in ICCM had left Kapiri Mposhi district, which probably did not capture all the relevant perspectives. Despite these shortcomings, the study provided a valuable contribution to the body of knowledge on barriers and facilitators to ICCM integration into the health system in similar contexts.