Health systems supports for community case management of childhood illness: lessons from an assessment of early implementation in Malawi

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.

Motivation of health surveillance assistants in Malawi: A qualitative study

“…10 In Malawi, CHWs are known as health surveillance assistants (HSAs); their history can be traced back to the 1950s when they were initially known as "public vaccinators" and later "smallpox vaccinators". 11 The Ministry of Health (MOH) defines an HSA as a primary healthcare worker serving as a link between a health facility and the community. 12,13 There are currently around 9173 HSAs in Malawi (MOH Chief Environmental Health Officer.…”

“…Earlier studies within Malawi identified several constraints to HSA work. 8,11,12,[17][18][19][20] Besides a heavy workload resulting from multiple tasks and large catchment areas, HSAs also face challenges related to poor remuneration, inadequate supplies and materials, and lack of a clear career path. 8,17 Hermann et al found that in Malawi, Uganda, and Ethiopia, CHWs cannot be retained in the long term if they do not receive adequate remuneration, and that insufficient attention to supervision and continuous training leads to decreasing quality of programmes over time.…”

Stakeholders perspectives on paper-based and electronic clinical decision support systems in Malawi Africa

“…Malawi is a land-locked country in southeast Africa with a population of 16.5 million, 1 and is ranked as one of the ten poorest countries in the world (Callaghan-Koru et al, 2013).…”

“…CCM decision support clinical guidelines were customised based on these indicators to ensure that the highest child health risks in rural Malawi would be addressed. Since 2008, CCM has now been implemented throughout Malawi, and the MoH continues to deploy national community-based health worker programmes to improve access to primary health care (Callaghan-Koru et al, 2013). Community Health Workers serve Malawian communities at a ratio of 1 to 1000 population (Nsona et al, 2012).…”

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“…Bearing this in mind we consider the case of Malawi, Africa. Malawi is ranked as one of the ten poorest countries in the world with a high rate of child mortality and morbidity (Callaghan-Koru, Gilroy et al 2013). Therefore, Malawians may perceive that the advantages (e.g.…”