Health Workers' and Managers' Perceptions of the Integrated Community Case Management Program for Childhood Illness in Malawi: The Importance of Expanding Access to Child Health Services

Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Preventive Health, Malawi Ministry of Health, Lilongwe, Malawi
The American journal of tropical medicine and hygiene (Impact Factor: 2.7). 11/2012; 87(5 Suppl):61-68. DOI: 10.4269/ajtmh.2012.11-0665


Community case management (CCM) is a promising task-shifting strategy for expanding treatment of childhood illness that is increasingly adopted by low-income countries. Its success depends in part on how the strategy is perceived by those responsible for its implementation. This study uses qualitative methods to explore health workers' and managers' perceptions about CCM provided by health surveillance assistants (HSAs) during the program's first year in Malawi. Managers and HSAs agreed that CCM contributed beneficially by expanding access to the underserved and reducing caseloads at health facilities. Managers differed among themselves in their endorsements of CCM, most offered constrained endorsement, and a few had stronger justifications for CCM. In addition, HSAs uniformly wanted continued expansion of their clinical role, while managers preferred to view CCM as a limited mandate. The HSAs also reported motivating factors and frustrations related to system constraints and community pressures related to CCM. The impact of CCM on motivation and workload of HSAs is noted and deserves further attention.

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    • "Health Surveillance Assistants are a cadre of CBHW in Malawi that was originally established in the 1960s to support smallpox vaccinations [28]. HSAs are formal non-clinician health workers who are salaried by the government, are required to have 10 to 12 years of education, and undergo a 10-week basic training [29]. "
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    ABSTRACT: Background National community-based health worker (CBHW) programs often face challenges in ensuring that these remote workers are adequately trained, equipped and supervised. As governments increasingly deploy CBHWs to improve access to primary health care, there is an urgent need to assess how well health systems are supporting CBHWs to provide high quality care. Methods This paper presents the results of a mixed-methods assessment of selected health systems supports (supervision, drug supply, and job aids) for a national community case management (CCM) program for childhood illness in Malawi during the first year of implementation. We collected data on the types and levels of drug supply and supervision through a cross-sectional survey of a random sample of Health Surveillance Assistants (HSAs) providing CCM services in six districts. We then conducted in-depth interviews and focus group discussions with program managers and HSAs, respectively, to gain an understanding of the barriers and facilitating factors for delivering health systems supports for CCM. Results Although the CCM training and job aid were well received by stakeholders, HSAs who participated in the first CCM training sessions often waited up to 4 months before receiving their initial supply of drugs and first supervision visits. One year after training began, 69% of HSAs had all essential CCM drugs in stock and only 38% of HSAs reported a CCM supervision visit in the 3 months prior to the survey. Results of the qualitative assessment indicated that drug supply was constrained by travel distance and stock outs at health facilities, and that the initial supervision system relied on clinicians who were able to spend only limited time away from clinical duties. Proactive district managers trained and enrolled HSAs’ routine supervisors to provide CCM supervision. Conclusions Malawi’s CCM program is promising, but health systems supports must be improved to ensure consistent coverage and quality. Mixed-methods implementation research provided the Ministry of Health with actionable feedback that it is using to adapt program policies and improve performance.
    BMC Health Services Research 02/2013; 13(1):55. DOI:10.1186/1472-6963-13-55 · 1.71 Impact Factor
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    • "More research is required to understand the balance between the preventive and curative roles that CHWs undertake. Although CHWs report that CCM increases their status,35,36 making their health prevention and promotion roles more credible, this finding has not been corroborated by households. Research is also required to see whether preventative commodities can as effectively boost CHW credibility and demand for CCM services as curative commodities. "
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    ABSTRACT: We describe community health workers (CHWs) in government community case management (CCM) programs for child survival across sub-Saharan Africa. In sub-Saharan Africa, 91% of 44 United Nations Children's Fund (UNICEF) offices responded to a cross-sectional survey in 2010. Frequencies describe CHW profiles and activities in government CCM programs (N = 29). Although a few programs paid CHWs a salary or conversely, rewarded CHWs purely on a non-financial basis, most programs combined financial and non-financial incentives and had training for 1 week. Not all programs allowed CHWs to provide zinc, use timers, dispense antibiotics, or use rapid diagnostic tests. Many CHWs undertake health promotion, but fewer CHWs provide soap, water treatment products, indoor residual spraying, or ready-to-use therapeutic foods. For newborn care, very few promote kangaroo care, and they do not provide antibiotics or resuscitation. Even if CHWs are as varied as the health systems in which they work, more work must be done in terms of the design and implementation of the CHW programs for them to realize their potential.
    The American journal of tropical medicine and hygiene 11/2012; 87(5 Suppl):85-91. DOI:10.4269/ajtmh.2012.11-0757 · 2.70 Impact Factor
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    ABSTRACT: Provision of integrated community case management (iCCM) for common childhood illnesses by community health workers (CHWs) represents an increasingly common strategy for reducing childhood morbidity and mortality. We sought to assess how iCCM availability influenced care-seeking behavior. In areas where two different iCCM approaches were implemented, we conducted baseline and post-study household surveys on healthcare-seeking practices among women who were caring for children ≤ 5 years in their homes. For children presenting with fever, there was an increase in care sought from CHWs and a decrease in care sought at formal health centers between baseline and post-study periods. For children with fast/difficulty breathing, an increase in care sought from CHWs was only noted in areas where CHWs were trained and supplied with amoxicillin to treat non-severe pneumonia. These findings suggest that iCCM access influences local care-seeking practices and reduces workload at primary health centers.
    The American journal of tropical medicine and hygiene 11/2012; 87(5 (Suppl)):105. DOI:10.4269/ajtmh.2012.11-0799 · 2.70 Impact Factor
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