community health workers

Malawi has a mature integrated community case management (iCCM) programme that is led by the Ministry of Health (MOH) but that still relies on donor support. From 2013 until 2017, under the Rapid Access Expansion (RAcE) programme, the World Health Organization supported the MOH to expand and strengthen iCCM services in four districts. This paper examines Malawi’s iCCM programme performance and implementation strength in RAcE districts to further strengthen the broader programme. Baseline and endline household surveys were conducted in iCCM-eligible areas of RAcE districts. Care-seeking from HSAs and treatment of fever improved over the project period. At endline, however, less than half of sick children were brought to an HSA, many caregivers reported a preference for providers other than HSAs, and perceptions of HSAs as trusted providers of high-quality, convenient care had decreased. HSA supervision and mentorship were below MOH targets. Stockouts of malaria medicines were associated with decreased care-seeking from HSAs. Additional qualitative research is needed to examine challenges and to inform potential solutions. Malawi’s mature iCCM programme has a strong foundation but can be improved to strengthen the continuity of care from communities to facilities and to ultimately improve child health outcomes.

The WHO’s Rapid Access Expansion (RAcE) program supported the Malawi Ministry of Health to align their Community-Based Maternal and Newborn Care (CBMNC) package with the latest WHO guidelines and to implement and evaluate the feasibility and coverage of home visits in Ntcheu district. A population-based survey of 150 households in Ntcheu district was conducted in July-August 2016 after approximately 10 months of CBMNC implementation. Thirty clusters were selected proportional-to-size using the most recent census. In selected clusters, five households with mothers of children under six months of age were randomly selected for interview. The Health Surveillance Assistants (HSAs) providing community-based services to the same clusters were purposively selected for a structured interview and register review. Less than one third of pregnant women (30.7%) received a home visit during pregnancy and only 20.7% received the recommended two visits. Coverage of postnatal visits was even lower: 11.4% of mothers and newborns received a visit within three days of delivery and 20.7% received a visit within the first eight days. These findings were similar to previous studies, calling into question the feasibility of the current visitation schedule. It is time to re-align the CBMNC package with what the existing platform can deliver and identify strategies to better support HSAs to implement home visits to those who would benefit most.

Community health worker (CHW) interventions to manage childhood illness is a strategy promoted by the global health community, which involves training and supporting CHW to assess, classify, and treat sick children at home. To inform CHW policy, the Government of Tanzania launched a program in 2011 to determine if community case management (CCM) of malaria, pneumonia, and diarrhea could be implemented by CHW in that country. This paper reports the results of an observational study on the CCM service delivery quality of a trial cohort of CHW in Tanzania, called WAJA. In the majority of cases, WAJA correctly assess sick children for CCM-treatable illnesses (malaria, pneumonia, and diarrhea) and general danger signs (90% and 89%, respectively), but too few correctly assess for physical danger signs (39%). In majority of cases (78%) WAJA treated children correctly (84% of malaria, 74% pneumonia, and 71% diarrhea cases). Errors were often associated with lapses in health systems support, mainly supervision and logistics. For CCM to be effective, in Tanzania, a strategy to implement it must be coordinated with efforts to strengthen local health systems.

An intervention brought together community health workers, health facility staff, and accredited drug dispensing outlet (ADDO) dispensers to improve maternal and newborn health through a mechanism of collaboration and referral. Relationships among the three levels of care improved after the linkage intervention, especially for ADDO dispensers and health facility staff who previously had no formal communication pathway. The study participants' perceptions of success included improved knowledge of case management and relationships among the three levels of care, more timely access to care, increased numbers of patients/customers, more meetings between community health workers and health facility staff, and a decrease in child and maternal mortality.

The study aimed to conduct capacity assessments of the community health worker (CHW) system and determine stakeholder perspectives of CHW performance. Formative assessments evidenced that CHWs were highly valued as they provided equitable, accessible and affordable 24-hour care. Their loyalty, dedication and the ability for women to access care without male family escorts was appreciated by communities. With rising concerns of workforce deficits, insecurity and budget constraints, the health system must enhance the capacity of these frontline workers to improve the continuum of care.

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