Abstract

BackgroundNational 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.MethodsThis 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.ResultsAlthough 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.ConclusionsMalawi’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.

Highlights

  • National community-based health worker (CBHW) programs often face challenges in ensuring that these remote workers are adequately trained, equipped and supervised

  • Methods the concept of health systems supports for community case management (CCM) can be broadly conceptualized to include many factors, this study focuses on the primary concerns of the Ministry of Health (MOH) in Malawi during early implementation of the CCM program: 1) implementation of training; 2) supervision; 3) drug supply; and 4) job aids

  • Some Health Surveillance Assistant (HSA) serve urban areas, the majority are posted to rural communities and are supervised by Assistant Environmental Health officers (AEHOs)–nonclinicians under the MOH’s Preventive Health Section and based at health facilities–and Senior HSAs–HSAs posted in communities who have been promoted to a supervisory role

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Summary

Introduction

National community-based health worker (CBHW) programs often face challenges in ensuring that these remote workers are adequately trained, equipped and supervised. Despite the growing interest in scaling-up CCM programs in many countries, implementing and sustaining support for these programs remains a major challenge in low-income settings and there has been little published research investigating implementation of routine CCM programs [10,11,12]. This has prompted calls for urgent research that explores how CCM programs can be implemented effectively [13,14,15]

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