The Government of Malawi (GoM) initiated activities to deliver treatment of common childhood illnesses (suspected pneumonia, fever/suspected malaria, and diarrhea) in the community in 2008. The service providers are Health Surveillance Assistants (HSAs), and they are posted nationwide to serve communities at a ratio of 1 to 1,000 population. The GoM targeted the establishment of 3,452 village health clinics (VHCs) in hard-to-reach areas by 2011. By September of 2011, 3,296 HSAs had received training in integrated case management of childhood illness, and 2,709 VHCs were functional. An assessment has shown that HSAs are able to treat sick children with quality similar to the quality provided in fixed facilities. Monitoring data also suggest that communities are using the sick child services. We summarize factors that have facilitated the scale up of integrated community case management of children in Malawi and address challenges, such as ensuring a steady supply of medicines and supportive supervision.

A systematic review was conducted to categorize and describe Intervention Models involving community health workers (CHWs) that aim to improve case management of sick children at the household and community levels. The review focused on management of children with signs of malaria or pneumonia. Seven Intervention Models were identified, and classified according to: (1) the role of CHWs and families in assessment and treatment of children, (2) system of referral to the nearest health facility (verbal or facilitated), and (3) the location in the community of the drug stock. Standardization of terminology for Intervention Models using this or a similar classification could facilitate comparison and selection of models, including deciding how to modify programmes when policies change concerning first-line drugs, and setting priorities for further research. Of the seven models, that of CHW pneumonia case management (Model 6) has the strongest evidence for an impact on mortality. Pneumonia case management by CHWs is a child health intervention that warrants considerably more attention, particularly in Africa and South Asia.

Objective To assess the quality of care provided by Health Surveillance Assistants (HSAs)—a cadre of community-based health workers—as part of a national scale-up of community case management of childhood illness (CCM) in Malawi.Methods Trained research teams visited a random sample of HSAs (n = 131) trained in CCM and provided with initial essential drug stocks in six districts, and observed the provision of sick child care. Trained clinicians conducted ‘gold-standard’ reassessments of the child. Members of the survey team also interviewed caregivers and HSAs and inspected drug stocks and patient registers.Findings HSAs provided correct treatment with antimalarials to 79% of the 241 children presenting with uncomplicated fever, with oral rehydration salts to 69% of the 93 children presenting with uncomplicated diarrhoea and with antibiotics to 52% of 58 children presenting with suspected pneumonia (cough with fast breathing). About one in five children (18%) presented with danger signs. HSAs correctly assessed 37% of children for four danger signs by conducting a physical exam, and correctly referred 55% of children with danger signs.Conclusion Malawi’s CCM programme is a promising strategy for increasing coverage of sick child treatment, although there is much room for improvement, especially in the correct assessment and treatment of suspected pneumonia and the identification and referral of sick children with danger signs. However, HSAs provided sick child care at levels of quality similar to those provided in first-level health facilities in Malawi, and quality should improve if the Ministry of Health and partners act on the results of this assessment.

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Pneumonia is the leading cause of child mortality globally. Community case management (CCM) of pneumonia by community health workers is a feasible, effective strategy to complement facility-based management for areas that lack access to facilities. We surveyed experts in the 57 African and Asian countries with the highest levels and rates of childhood mortality to assess current policies, implementation and plans regarding CCM of pneumonia. About one-third (20/54) of countries reported policies supporting CCM for pneumonia, and another third (18/54) reported no policy against the strategy. Half (27/54) the countries reported some implementation of CCM for pneumonia, but often on a small scale. A few countries sustain a large-scale programme. Programmes, community health workers and policy parameters varied greatly among implementing countries. About half (12/26) of non-implementing countries are planning to move ahead with the strategy. Momentum is gathering for CCM for pneumonia as a strategy to address the pneumonia treatment gap and help achieve Millennium Development Goal 4. Challenges remain to: (1) introduce this strategy into policy and implement it in high pneumonia burden countries; (2) increase coverage of this strategy in countries currently implementing it; and (3) better define and monitor implementation at the country level.