These results highlight the achievements and challenges faced by the Malawi MOH and partners as they worked to rapidly scale up a CCM program to expand access to curative services for under-fives in a large rural population. In addition to the six districts addressed in this case study, training and implementation was taking place simultaneously in the majority of Malawi’s districts. The MOH reported that by 2009, over 1,000 HSAs had received the six-day CCM training. The SCRF, which serves as the basis of the training and the job aid for CCM, was well received by all stakeholders and can be considered a critical element in the program’s success. The high levels of support for the program provided by partner organizations, in terms of technical assistance and funds for training and supervision, facilitated the rapid scale up.
These findings also highlight several areas for program improvement. Early assessments of CBHW programs from the 1980s indicated the need to plan for and deliver necessary health system supports for CBHW programs [17, 19]. However, this evaluation illustrates how large-scale CCM programs, while expanding access, can be stymied by the lack of effective health system support. Inadequacies in the initial implementation plans and policies presented important barriers to the scale-up of CCM. Although drug supply strategies integrated well with existing systems, drug availability remained a challenge. Additionally, the initial supervision strategy was not clearly defined or sustainable and district-level program managers faced significant barriers in following the supervision expectations.
This study was nested in an early study of the quality of care provided by HSAs, so districts included in this study were chosen based on adequate implementation strength . Other districts are likely to have weaker implementation of health system supports during the same calendar period. That said, the levels of health systems supports documented in this case study raise concerns about whether Malawi’s CCM program will achieve the expected increases in coverage levels for treatment of pneumonia, malaria, and diarrhea.
The health systems support with the most direct impact on effectiveness and coverage of the program is drug supply. We found that one-third of HSAs did not have all of the essential CCM drugs in stock on the day of the visit, and analysis of clinical errors revealed that over half of mismanaged fever and diarrhea cases were due to the HSA not having stock of the required treatments . The most important barrier identified by informants--general drug availability at the restocking points for CHWs--is statistically correlated with drug availability among HSAs in Malawi . Health center drug supply is a large health systems problem in Malawi, although accurate data measuring the frequency and severity of drug stock outs is limited. The government cites “lengthy procurement processes, poor specifications, weak logistical information systems, inadequate and unpredictable funding for medicines and inadequate infrastructure,” districts overspending on private sector drug purchases, and shortage of pharmaceutical staff as causes of drug stock outs . Solving larger drug supply problems will take coordinated efforts at institutional reform and systems strengthening by many stakeholders . At the same time, CCM program managers can make targeted improvements to factors under their control, such as providing supply chain training to CHWs and managers and addressing transportation barriers .
Just as districts struggled to provide consistent drug supplies, they were similarly unable to provide regular supervision with coaching on clinical skills. The focus in Malawi on the administrative side of supervision (e.g., checking records) is consistent with practices reported in other low-income countries . However, these results raise concerns about whether the inability of supervisors to address problems and complaints might reduce HSAs’ motivation, as supportive supervision is important for morale [42–44]. In fact, HSAs expressed a desire for more assistance and problem solving from supervisors and for an expansion of their clinical role, while program managers in Malawi viewed CCM as a limited mandate for HSAs . Sustaining supervision is a common challenge for both facility and community-based programs in weak health systems [41, 45]. The initial supervision strategy in the Malawi CCM program of adding CCM supervision to the workload of busy facility-based clinicians, which is common in other programs [43, 46, 47], may be an unrealistic approach for regular and sustained supervision in many settings. Although CCM programs are often implemented in environments with constrained resources, planning for resources to implement effective supervision strategies is essential for scale-up . Supervision initiatives that include training for supervisors in quality assurance, problem solving and coaching may improve performance and motivation [48–51].
Finally, an important finding of this study is the initiative and capacity demonstrated by some district health managers to adapt implementation strategies in order to overcome challenges. Health systems in LICs face considerable challenges in supporting CCM and other community-based programs. It is therefore encouraging to see that dedicated program managers can develop and gain support for strategies to address some of the barriers that they face, such as overcoming CCM supervision barriers through the involvement of HSAs’ routine supervisors. Although none of the reported strategies were statistically associated with better drug supply or supervision, this lack of association is possibly due to the relatively recent implementation of these strategies at the time of data collection. In the future, program implementers may consider fostering this type of decentralized problem solving through adaptive and flexible scale-up strategies . Such efforts could potentially lead to solutions to local problems, as well as generalizable strategies that can be learned from and adopted across a program [52, 53].