Relaunch of the official community health worker programme in Mozambique: is there a sustainable basis for iCCM policy?

Abstract

Background: In Mozambique, integrated community case management (iCCM) of diarrhoea, malaria and pneumonia is embedded in the national community health worker (CHW) programme, mainstreaming it into government policy and service delivery. Since its inception in 1978, the CHW programme has functioned unevenly, was suspended in 1989, but relaunched in 2010. To assess the long-term success of iCCM in Mozambique, this article addresses whether the current CHW programme exhibits characteristics that facilitate or impede its sustainability.Methodology: We undertook a qualitative case study based on document review (n = 54) and key informant interviews (n = 21) with respondents from the Ministry of Health (MOH), multilateral and bilateral agencies and non-governmental organizations (NGOs) in Maputo in 2012. Interviews were mostly undertaken in Portuguese and all were coded using NVivo. A sustainability framework guided thematic analysis according to nine domains: strategic planning, organizational capacity, programme adaptation, programme monitoring and evaluation, communications, funding stability, political support, partnerships and public health impact.Results: Government commitment was high, with the MOH leading a consultative process in Maputo and facilitating successful technical coordination. The MOH made strategic decisions to pay CHWs, authorize their prescribing abilities, foster guidance development, support operational planning and incorporate previously excluded ‘old’ CHWs. Nonetheless, policy negotiations excluded certain key actors and uncertainty remains about CHW integration into the civil service and their long-term retention. In addition, reliance on NGOs and donor funding has led to geographic distortions in scaling up, alongside challenges in harmonization. Finally, dependence on external funding, when both external and government funding are declining, may hamper sustainability.Conclusions: Our analysis represents a nuanced assessment of the various domains that influence CHW programme sustainability, highlighting strategic areas such as CHW payment and programme financing. These organizational and contextual determinants of sustainability are central to CHW programme strengthening and iCCM policy support.

Towards eliminating malaria in high endemic countries: the roles of community health workers and related cadres and their challenges in integrated community case management for malaria: a systematic review

“…CHWs and related cadres faced health care financing challenges while implementing their roles in malaria interventions. This primarily included lack of sustainable sources of funds [20, 21]. As a result, CHWs and related cadres often suffered from poor or no remuneration [12, 22] and lack of incentives.…”

“…There has been a widespread lack of in-service training and other forms of continuous professional development [20]. Other related challenges include high turnover due to high attrition rates, especially for those working in hard-to-reach or remote areas [24], lack of incentives [23] and lack of motivation to continue with their work [12, 21]. …”

“…For example, in Malawi, abbreviated CHW training did not meet medical regulation standards for prescription resulting in CHWs not being allowed to prescribe anti-malarials [20]. Lack of supervision from qualified health workers and poor coordination from the existing health infrastructure affected implementation of CHWs’ role in iCCM [20, 21, 25, 26]. …”

“…Most studies mentioned stock-outs of ACT and other anti-malarials [21, 26, 27], test kits for malaria [13, 14, 25, 28] and gloves, among others [29]. …”

“…First, CHWs and related cadres were not trusted to have adequate knowledge to care and treat malaria cases in some communities [21, 22, 27]. As a result, people who had symptoms of malaria still had to travel long distances to seek similar care in health facilities [27].…”