Special Supplement on integrated Community Case Management
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Health planners commonly use geographic proximity to define access to health services. However, effective access to case management requires reliable access to a trained, supplied provider. We defined effective access as the proportion of the study population with geographic access, corrected for other barriers, staffing patterns, and medicine availability. We measured effective access through a cross-sectional survey of 32 health facilities in Malawi, Mali, and Zambia and modeled the potential contribution of community case management (CCM). The population living within Ministry of Health (MOH)–defined geographic access was 43% overall (range = 18–52%), but effective access was only 14% overall (range = 9–17%). Implementing CCM as per MOH plans increased geographic access to 63–90% and effective access to 30–57%. Access to case management is much worse than typically estimated by distance. The CCM increases access dramatically, again if providers are available and supplied, and should be considered even for those within MOH-defined access areas.

[open-access] This is an Open Access article distributed under the terms of the American Society of Tropical Medicine and Hygiene's Re-use License which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.


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  1. You D, Jones G, Wardlaw T, on behalf of the United Nations Interagency Group for Child Mortality Estimation; , 2011. Levels and trends in child mortality: 2011 Report. Available at: http://www.unicef.org/media/files/Child_Mortality_Report_2011_Final.pdf. Accessed September 14, 2011. [Google Scholar]
  2. Walker F, Black RE, , 2010. Zinc for the treatment of diarrhea: effect on diarrhea morbidity, mortality, and incidence of future episodes. Int J Epidemiol 39: i63i69.[Crossref] [Google Scholar]
  3. Munos MK, Fischer Walker CL, Black RE, , 2010. The effect of oral rehydration solution and recommended home fluids on diarrhoea mortality. Int J Epidemiol 39: i75i87.[Crossref] [Google Scholar]
  4. Evropi T, Al-Jilaihawi S, Woodward F, Ferguson J, Jhass A, Balliet M, Kolcic I, Sadruddin S, Duke T, Rudan I, Campbell H, , 2010. The effect of case management on childhood pneumonia mortality in developing countries. Int J Epidemiol 39: i155i171.[Crossref] [Google Scholar]
  5. Thwing J, Eisele TP, Steketee RW, , 2011. Protective efficacy of malaria case management for preventing malaria mortality in children: a systematic review for the Lives Saved Tool. BMC Public Health 11 (Suppl 3): S14.[Crossref] [Google Scholar]
  6. Islam M, , ed., 2007. Health Systems Assessment Approach: A How-To Manual. Submitted to the U.S. Agency for International Development in Collaboration with Health Systems 20/20, Partners for Health Reformplus, Quality Assurance Project, and Rational Pharmaceutical Management Plus. Arlington, VA: Management Sciences for Health, 1820. [Google Scholar]
  7. Ministry of Health, Republic of Uganda, 2010. Health Sector Strategic Plan III 2010/11-2014/15. Available at: http://www.health.go.ug/docs/HSSP_III_2010.pdf. Accessed September 29, 2011. [Google Scholar]
  8. Rutherford ME, Mulholland K, Hill PC, , 2010. How access to health care relates to under-five mortality in sub-Saharan Africa: systematic review. Trop Med Int Health 15: 508519.[Crossref] [Google Scholar]
  9. Jacobs B, Ir P, Bigdeli M, Annear PL, Van Damme W, , 20112. Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries. Health Policy Plan [Epub ahead of print]. [Google Scholar]
  10. Ricketts TC, Goldsmith LJ, , 2005. Access in health services research: the battle of the frameworks. Nurs Outlook 53: 274280.[Crossref] [Google Scholar]
  11. McIntyre DI, Thiede M, Birch S, , 2009. Access as a policy-relevant concept in low- and middle-income countries. Health Econ Policy Law 4: 179193.[Crossref] [Google Scholar]
  12. Chen L, Evans T, Anand S, Boufford JI, Brown H, Chowdhury M, Cueto M, Dare L, Dussault G, Elzinga G, Fee E, Habte D, Hanvoravongchai P, Jacobs M, Kurowski C, Michael S, Pablos-Mendez A, Sewankambo N, Solimano G, Stilwell B, de Waal A, Wibulpolprasert S, , 2004. Human resources for health: overcoming the crisis. Lancet 364: 19841990.[Crossref] [Google Scholar]
  13. World Health Organization, 2011. World Health Statistics 2011. Available at: http://www.who.int/whosis/whostat/2011/en/index.html. Accessed September 29, 2011. [Google Scholar]
  14. Mueller DH, Lungu D, Acharya A, Palmer N, , 2011. Constraints to implementing the essential health package in Malawi. PLoS ONE 6: e20741.[Crossref] [Google Scholar]
  15. Hamer DH, Ndhlovu M, Zurovac D, Fox M, Yeboah-Antwi K, Chanda P, Sipilinyambe N, Simon JL, Snow RW, , 2007. Improved diagnostic testing and malaria treatment practices in Zambia. JAMA 297: 2222722231.[Crossref] [Google Scholar]
  16. Moïsi JC, Gatakaa H, Noor AH, Williams TN, Bauni E, Tsofa B, Levine OS, Scott AG, , 2010. Geographic access to care is not a determinant of child mortality in a rural Kenyan setting with high health facility density. BMC Public Health 10: 19.[Crossref] [Google Scholar]
  17. Schoeps A, Gabrysch S, Niamba L, Sie' L, Becher H, , 2011. The effect of distance to health-care facilities on childhood mortality in rural Burkina Faso. Am J Epidemiol 173: 492498.[Crossref] [Google Scholar]
  18. Rutherford ME, Dockerty JD, Jasseh M, Howie SR, Herbison P, Jeffries DJ, Leach M, Stevens W, Mulholland K, Adegbola RA, Hill PC, , 2009. Access to health care and mortality of children under 5 years of age in the Gambia: a case-control study. Bull World Health Organ 87: 216224.[Crossref] [Google Scholar]
  19. Noor AM, Zurovac D, Hay SI, Ochola SA, Snow RW, , 2003. Defining equity in physical access to clinical services using geographical information systems as part of malaria planning and monitoring in Kenya. Trop Med Int Health 8: 917926.[Crossref] [Google Scholar]
  20. Gabrysch S, Cousens S, Cox J, Campbell OM, , 2011. The influence of distance and level of care on delivery place in rural Zambia: a study of linked national data in a geographic information system. PLoS Med 8: e1000394.[Crossref] [Google Scholar]

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  • Received : 01 Dec 2011
  • Accepted : 24 Feb 2012
  • Published online : 07 Nov 2012

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