Category Archives: Community

RSAP Themed Issue on Pharmaceutical Logistics for integrated Community Case Management (iCCM) – Call for Papers

RSAP_v11_i4_COVER.inddA themed issue for Research in Social and Administrative Pharmacy (RSAP at http://www.journals.elsevier.com/research-in-social-and-administrative-pharmacy/) will feature the challenges of guaranteeing regular and adequate pharmaceutical supplies and commodities for integrated Community Case Management (iCCM). iCCM can be described as a comprehensive approach to providing essential health services in and by the community. iCCM relies on having basic commodities like Rapid Diagnostic Tests (RDTs) and artemisinin-based combination therapy (ACT) medicines for malaria, oral rehydration solution (ORS) packets and zinc for diarrhea, in addition to appropriate antibiotics like amoxicillin and cotrimoxazole for pneumonia available in the community.

Early successes describing the documentation of need and initial procurement of these essential therapies in developing nations have been published; however, this themed issue will share original research, models, and expert commentaries on ensuing stages in procurement and supply chain management (PSM) that will sustain iCCM.

PSM/logistical success for iCCM can occur in countries that have a department or unit that focuses on community health promotion and supports standardized training and equipping of Community Health Workers (CHWs) even in small villages. Unfortunately, most programs lack adequate procurement and supply management systems, especially planning and forecasting. Front-line health center staff who train and supervise village-based iCCM volunteers express concern about the difficulty in acquiring enough medicines for their own clinical needs, let alone supplies for volunteer community health workers.

DSCN5479Other programs reserve iCCM only for selected communities in a catchment area based on distance or availability of community health extension/auxiliary workers. There are also examples of iCCM that are narrowly focused on one or two health problems, while others take a more comprehensive approach. Clearly each has different logistical concerns such as the generic issues of forecasting, procurement, shipping and storage, while others experience the difficulty obtaining funding support when many disease control programs have vertical financial streams.

There are various models for providing medicines at the community level. One is the pioneering work of the World Health Organization’s (WHO’s) Tropical Disease Research (TDR) program in promoting Community-Directed Treatment with Ivermectin (CDTI) for River Blindness Control, which evolved into the Community Directed Intervention (CDI) approach for delivering basic health commodities by the community, itself.[1]

Policymakers, health organizations, and front-line clinicians often say, “no product, no program.” This themed issue will share the experiences and lessons of iCCM, both successes and challenges, to help the global health community see the need for more systematic planning of PSM for iCCM. International agencies and donors clearly recognize that alternative forms of essential health service delivery are needed to achieve coverage targets and save lives. The community as a source of care has a solid foundation as established at the International Conference on Primary Health Care, which produced global guidance through the Alma Ata Primary Health Care Declaration of 1978,[2] but in all those years, actualization of this ideal has been difficult for logistical reasons. This RSAP themed issue should not only help us understand the present challenges, but map a way forward to better access to essential health commodities in communities throughout the developing world.

The themed issue will include various contributions such as:

  • Commentary/Overview from the World Health Organization staff who have spearheaded the iCCM movement
  • Implementation/intervention research on:
    • The link between front-line clinics and community health workers/distributors in guaranteeing iCCM commodities
    • The challenge of providing iCCM commodities for use by nomadic populations
    • Provision of iCCM commodities by different types community workers
    • Successes and challenges in maintaining supplies and commodities for large-scale and national community primary health care programs
    • Comparative lessons from other community based programs such as family planning commodity distribution and home-based care for people living with HIV
  • Documented program experiences including:
    • The challenges of maintaining iCCM supplies and logistics in emergency situations, as with disaster refugee and outbreak situations
    • The role of donors and non-governmental organizations (NGOs) in providing commodities.

We are still seeking additional contributions. If you have a paper or idea for one or more, please contact the guest editors. Papers must be submitted on the Elsevier RSAP platform at http://ees.elsevier.com/rsap/ by February 1, 2016 for publication in fall of 2016.

Guest Editors:

  • William R Brieger, MPH, DrPH, Professor, Department of International Health, Bloomberg School of Public health, The Johns Hopkins University; Senior Malaria Specialist, Jhpiego; RSAP Editorial Board Member. <bbbrieger@yahoo.com>
  • Maria KL Eng, MPH, PhD, Departmental Associate, Department of International Health, Bloomberg School of Public health, The Johns Hopkins University; Instructor for “Pharmaceuticals Management for Under-Served Populations” <meng@jhu.edu>

[1] http://www.who.int/bulletin/volumes/88/7/09-069203/en/

[2] http://www.who.int/dg/20080915/en/

Data for Decision Making Series: The Importance of CHW Data Collection

This posting appeared originally on website of 1 Million Community Health Workers.

This week marks our final installment in the Data for Decision Making series! For our final interview weDSCN1535 talked with Dr. William (Bill) Brieger, Senior Malaria Specialist at Jhpiego and a Professor in the Health Systems Program of the International Health Department at John Hopkins Bloomberg School of Public Health. For over two decades Dr. Brieger taught at the African Regional Health Education Center at the University of Ibadan, Nigeria. He also previously served as a public health and health education consultant to various international organizations including the World Bank, the African Program for Onchocerciasis Control, UNICEF, the World Health Organization, US Peace Corps, and various USAID implementing partners. Dr. Brieger is internationally known for his expertise in social and behavioral aspects of disease control and prevention.

What are the most pressing challenges in the development of scaled-up CHW programs today?

 I think part of the challenge is that it is difficult to obtain a clear commitment and approach regarding the implementation of CHW programs. A good contrast is seen in the difference between integrated community case management (iCCM) and community directed intervention (CDI). With iCCM, organizations focus on getting treatments to people, whereas with CDI, organizations are interested in building up capacity within communities to support distribution of key health services. Philosophically, iCCM and CDI programs are two different approaches, with CDI aiming to help communities make a conscious decision about participating in the process and making a comDSCN5479mitment to support any volunteers within the community.

The other challenge is that NGOs provide different programs and interventions, which is difficult for countries – mainly Ministries of Health – to manage. I think Rwanda has been the most successful with harmonization and represents a good example of overcoming NGO program fragmentation. Rwanda has systematized the implementation of NGO programs, by requiring NGOs to go through the Ministry of Health to ensure that their programs adhere to the national standards. Burkina Faso has also tried to tackle this problem, and the Ministry of Health has created a “Community Health Promotion Directorate” to assist in harmonizing service provision amongst NGOs. There are certain structural approaches to management that can help scale-up programs while maintaining community commitment; but CHW scale-up will not work unless the community is strongly involved in the selection of health volunteers and is holding those volunteers accountable to community norms and expectations.

Why is data on frontline health workers, particularly CHWs, important?

Data on CHWs and data from CHWs are equally important. Organizations need to know who is providing services in the community so they can plan for training and continuing education. Having a good record of community volunteers and keeping that record updated is important, especially at the health center level. Data collection starts with the health center keeping data on the villages where they operate – the geographical coverage, counts on the volunteers within that village, demographic information about the volunteers, and where they work. Monthly records should be submitted by CHWs to ensure proper service delivery and patient tracking. If all of this is being done, then the data needed for making programmatic decisions can be sent forward to the district, state, or regional province.

In your opinion, what are the largest gaps in data on frontline health workers, particularly CHWs, right now?

 One of the largest gaps in CHW datDSCN1485aa is data showing whether CHW deployment mirrors community needs. For example, based on experiences in Rwanda and Nigeria, we know it is very important to have older female CHWs provide maternal health services, particularly woman who have been pregnant before. It is critical for an older woman to provide these services because she will be able to gain the trust of her community, which will allow pregnant women in the community to see the volunteer to discuss their pregnancy and receive treatment without any stigma. Situations like this demonstrate how important it is to keep track of the demographics of CHWs, along with the service needs of communities, especially services involving confidentiality like home-based care for HIV. With this information in hand, it can be quickly determined if an organization has CHWs with the appropriate characteristics to serve a community.

How can we begin to close these gaps?

DSCN1595 volunteer brings his village register to clinic for checking Currently, most health centers do not keep a good record of community volunteers. This is where we can start to close the gaps in CHW data. If organizations and governments start streamlining data at the health center level, this data can then be reported to other levels of the health system. It is important to at least have an annual or semiannual assessment to determine changes, such as exits and promotions, within the CHW population. I have always envisioned it as a partnership between the health center and the community, so that the health center really knows the catchment area. For example, in most of the health centers and small clinics in Nigeria, the staff draws a hand-drawn map of their catchment area so that they know where their clients will come from. While imperfect, this allows the health center staff to have a good understanding of the community demographics. However, before this can happen it is critical that we start to actually keep track of community volunteers and health workers.

The neighborhood godmothers – “Badjenu Gox” – pledge to have Zero Malaria in Senegal

Yacine Djibo, Founder & President of Speak Up Africa is helping focus International Women’s Day (March 8th) on efforts to protect women from malaria in Senegal. She is highlighting the commitments of 8 strong and beautiful women, in Senegal, that are dedicated to eliminating malaria in their country. These commitments are part of an inclusive mass communication campaign that aims to launch a national movement in favor of malaria elimination in Senegal: the “Zero Malaria! Count Me In” campaign

ZeroPaluInternational Women’s Day, represents an opportunity to celebrate the achievements of women all around the world. This year’s theme is “Empowering Women – Empowering Humanity: Picture it” envisions a world where each woman and girl can exercise her choices, such as participating in politics, getting an education or fighting malaria. Below is the sixth feature on women fighting malaria……

Ndèye Fatou Diallo is the National President of the Badjenu Gox (neighborhood godmothers in Wolof, one of the languages spoken in Senegal). She lives in Grand Dakar and is responsible for the Badjenu Gox in 557 towns across Senegal.

5. Ndeye Fatou Diallo ENG

Ndèye Fatou Diallo, National President, Badjenou Gox, Senegal.

Ndèye Fatou Diallo and her fellow Badjenu Gox are committed to making a difference in the lives of their neighbors.

The Badjenu Gox program was launched in January 2009 in every village of Senegal to leverage the presence and the leadership of women in the communities.

The “Badjenu Gox” program aims to reduce maternal and child morbidity and mortality to achieve MDGs 4, 5 and 6. Chosen by the community, the Badjenu Gox are volunteers that live in the communities and work to ensure systematic use of health services by the communities. This community led approach program allows community ownership of the health issues that affect them.

The Badjenu Gox are trained and provided with the appropriate tools they need to raise awareness about maternal and child health, including around malaria prevention and iwd_squarecontrol. They do so through home visits and by holding sensitization meetings in their neighborhoods.

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Headquartered in Dakar, Senegal, Speak Up Africa is a creative health communications and advocacy organization dedicated to catalyzing African leadership, enabling policy change, securing resources and inspiring individual action for the most pressing issue affecting Africa’s future: child health.

 

 

Counting on Sadane Ndiaye and other community supervisors like her to eliminate malaria in Senegal

Yacine Djibo, Founder & President of Speak Up Africa is helping focus International Women’s Day (March 8th) on efforts to protect women from malaria in Senegal. She is highlighting the commitments of 8 strong and beautiful women, in Senegal, that are dedicated to eliminating malaria in their country. These commitments are part of an inclusive mass communication campaign that aims to launch a national movement in favor of malaria elimination in Senegal: the “Zero Malaria! Count Me In” campaign

ZeroPaluInternational Women’s Day, represents an opportunity to celebrate the achievements of women all around the world. This year’s theme is “Empowering Women – Empowering Humanity: Picture it” envisions a world where each woman and girl can exercise her choices, such as participating in politics, getting an education or fighting malaria. Below is the fourth feature on women fighting malaria.

Along with 369 community supervisors throughout Senegal, Sadane Ndiaye of the Keur Momar Sarr district completed a one-week comprehensive training to learn all aspects of malaria treatment, prevention and care as a part of the Football Combatting Malaria Program (FCM). FCM, implemented through a partnership with local health districts, the National Malaria Control Program, Speak Up Africa, Aspire Academy, and the Leo Messi Foundation, catalyzes grassroots advocacy and behavior change communication to further reduce the burden of malaria in the community.

Sadane Ndiaye, Supervisor, Football Combating Malaria, Senegal

Sadane Ndiaye, Supervisor, Football Combating Malaria, Senegal

At the end of the week-long course, which included key information on how to install and properly maintain insecticide treated mosquito nets, Sadane became a Community Supervisor, charged with returning to her community and training four additional change agents. Daily, Sadane leads this team in malaria awareness activities including household visits, lectures, and social mobilization activities, reaching hundreds of community members and making a sustainable impact.

Football Combating Malaria aims to emphasize communication and community leadership to beat this disease. As a community supervisor, Sadane sets the example of exactly that which is needed to reach a malaria free Senegal.

iwd_squareThank you Sadane for joining the national malaria elimination effort and educating your fellow community members around malaria prevention and treatment.

*****

Headquartered in Dakar, Senegal, Speak Up Africa is a creative health communications and advocacy organization dedicated to catalyzing African leadership, enabling policy change, securing resources and inspiring individual action for the most pressing issue affecting Africa’s future: child health.

Fighting Malaria with Community Case Management (CCM) Scale-Up in Kenya

Arianna Hutcheson has posted the following blog on our course website – Social and Behavioral Foundations of Primary Health Care

Screen Shot 2015-03-04 at 11.25.22 AM

Source: https://www.ifrc.org/Global/Publications/Health/Beyond_Prevention_HMM%20Malaria-EN.pdf

Access to health services is particularly difficult for the poor and those in more inaccessible areas of Kenya. This lack of endemic disease treatment for communities has proven to be quite deadly. With more than 11.3 million cases recorded annually, malaria is the leading killer of children under five years of age in Kenya. CCM, supported by organizations such as WHO and UNICEF, allows Kenya to effectively fight Malaria by using evidence-based life saving treatments that increase the availability and quality of proven interventions.

Using a CCM strategy has shown to decrease under-five malaria mortality by 60% overall under-five mortality by 40%. In Kenya particularly, the CCM pilot program has generated convincing results as seen in the graphic below.

Screen Shot 2015-03-04 at 11.34.45 AM

Access to Artemisinin-based Combination Therapy (ACT)  has increased and the education of communities provided by health workers has improved treatment seeking behavior. While the pilot CCM program is an important step to combating malaria, we are in the right time to take the success of this program and implement it country-wide.

Most importantly, CCM is part of the National Malaria Strategy, but it requires a more pronounced place in the plan to implement the successes of the pilot program in all 8 districts.

Action Needed: The Kenyan Ministry of Public Health and Sanitation (MoPHS) needs to commit and push ahead their own stated agenda for putting community health first by integrating malaria treatment into the already implemented diarrhea CCM program by the end of 2015.

Graphic: https://www.ifrc.org/Global/Publications/Health/Beyond_Prevention_HMM%20Malaria-EN.pdf

Expanding Health Ministry Capacity to Deliver Malaria and Other Health Commodities at the Community Level in Nigerian States

Bright Orji of Jhpiego‘s Nigeria office presents a poster at the American Society of Tropical Medicine and Hygiene 2014 Annual Meeting at noon on 5th November. The poster represents Jhpiego’s technical assistance provided to seven Nigerian States as part the World Bank Malaria Booster Program. The abstract follows:

CDI ModelThe highly participative process of community directed interventions (CDI) was first pioneered in 1996 by the African Program for Onchocerciasis Control for the delivery of ivermectin. CDI was further tested and found effective in delivering other health commodities.

In 2007 Jhpiego began a proof of concept project in Akwa Ibom State, Nigeria and learned that CDI could be a useful vehicle for increasing access to and coverage of malaria in pregnancy interventions. Building on this success, Jhpiego expanded this work to include integrated community case management of malaria, diarrhoea and pneumonia. through community led efforts.

Number trainedThe World Bank Malaria Booster Program, observing Jhpiego’s efforts in Akwa Ibom State, asked the Nigeria National Malaria Control Program to enlist Jhpiego’s help in building the capacity of seven State Ministries of Health (MOH) to organize CDI for what was termed the malaria plus package consisting of community case management and health promotion activities. The scale-up process started with workshops for state CDI implementation teams consisting of staff from malaria control and primary health care in the MOHs.

services providedThen these state teams developed their own intervention packages and organized workshops for local government teams, who in turn trained staff from their front line health facilities. These facility staff mobilized communities in their facility catchment areas (wards) to select volunteers for training on the CDI process and intervention package.

Although technical assistance was provided to each state, challenges arose including commodity supplies and coordination among different program units within the state MOHs. In conclusion, state teams can train local government teams, ultimately cascading CDI to the community in order to scale up maternal and child health interventions.

Prevention of Malaria in Pregnancy with Community Health Volunteers in Kenya: Jhpiego at ASTMH

CHV 1904-image-003Augustine M. Ngindu of Jhpiego’s USAID-MCHIP Project in Nairobi, Kenya will present a poster entitled, “Prevention of Malaria in Pregnancy: Community Health Volunteers (CHVs) promote community-based activities to increase uptake of Intermittent Preventive Treatment of malaria in pregnancy (IPTp) in Kenya,” at the ASTMH Annual Meeting at noon on Monday 3 October. Below is the abstract – stop by the session to learn more.

Malaria in pregnancy is associated with poor pregnancy outcomes including maternal anaemia, miscarriages and intrauterine growth retardation. In an effort to increase IPTp coverage, Kenya is implementing the community strategy by using community health volunteers (CHVs) to promote community-based activities to increase uptake of malaria in pregnancy interventions (MIP).

Bungoma Picture1The CHVs visit each household every month to register new pregnant women, collect data from existing pregnant women including last IPTp dose taken and gestation, sensitize them to continue ANC visits and refer late starters and defaulters of scheduled ANC visits.

In Bungoma sub-county with a catchment population of 169,000, 382 CHVs from 14 community units identified a total of 4,925 (95%) out of an expected 5,092 pregnant women and followed them up between February to April 2014.

In Kenya the recommended time for starting IPTp is from weeks of pregnancy or after quickening.

IPTp and CHV referralsResults showed that among the registered pregnant women 92% had taken at least IPTp1 and 61% IPTp2 doses respectively. IPTp doses taken by weeks of pregnancy showed that 1.3% had accessed IPTp by 16 weeks of pregnancy, 8.6% between 16-20 weeks, 4.7% between 21-25 weeks, 5.7% between 26-30 weeks, 6.5% between 31-35 weeks and 3.7 % between 36-40 weeks.

IPTp doses Picture1However, 1.5% had not started IPTp at 40 weeks of pregnancy. The data further showed that among those who started IPTp early 1% completed 7 IPTp doses at 40 weeks of pregnancy.

CHVs can be used to effectively promote community-based activities including collection of data on the number of IPTp doses taken during pregnancy, which is a good indicator of the proportion of pregnant women protected against the adverse effects of malaria during pregnancy. This practice if scaled up can serve as an alternative method of monitoring coverage rates of interventions without waiting for the 3-5 year community survey data

Ghana at ASTMH: Mapping out of antimalarial drugs on stock at the market in a rural districts of Ghana

The first Poster Session of theDodowa American Society of Tropical Medicine and Hygiene (Monday noon) will feature a study on availability of malaria medicines in rural Ghana. “Mapping out of antimalarial drugs on stock at the market in a rural districts of Ghana” was developed by Alexander A. Nartey, Evelyn K. Ansah, Patricia Akweongo, Gloria A. Nartey, Mary A. Pomaa, Doris  Sarpong, Clement Narh, and Margaret Gyapong of the Dodowa Health Research Centre.

AA Picture1Antimalarial drugs are a very important component of any policy for effective reduction of morbidity and mortality related to the malaria disease. The availability of efficacious and high quality antimalarials and their correct use can mitigate the risk of morbidity and mortality among the people of sub-Saharan Africa who have the highest risk of contracting and dying
from malaria.

Chemical (medicine) shops are major source of care for most developing countries where anti-malarial drugs can be purchase at the counter. The paper seeks to identify the different kinds of anti-malarial drugs on the market for malaria treatment in a rural district in Ghana.

Chart Picture1A structured questionnaire was used during two seasons (peak and low malaria transmission seasons) to collect information on anti-malarial drugs from all 58 chemical shops within the Dangme West district now (Shai Osudoku and Ningo Prampram districts). Pictures of the anti-malarial drugs were taken,

The active ingredients, and also the source of the drugs documented. GIS locations of the shops were also recorded to ascertain the proximity of the shops to households in the communities. Majority (72.0%) of the chemical and pharmacy shop owners are males. Only 7.0% of the shops are pharmacy while the remainder is licensed chemical shops.

GHSThe total numbers of antimalarial drugs counted were forty nine (49). Among the stock, 4.2% were quinine, 31.9% of them were monotherapies such as artemether, Amodiaquine, Artesunate etc. Altogether, 59.4% of the artemisinin combination therapies (ACTs) were artemether + Lumefantrine, 25.0% were Artesunate + Amodiaquine.

Other antimalarials observed were 9.4% Sulfadoxine + Pyrimethamine and 3.1% of of Artesunate + Sulfamethoxypyrazine + Pyrimethamine. About 47% of the anti-malarial drugs were pediatric formulations.

Map Picture1GIS mapping shows that majority of the households are within a periphery of 5km to a chemical shop.

The national antimalarial drug policy recommends the use of ACTs for malaria treatment however; all sorts of anti-malarial drugs which are not ACTs are in stock at the chemical shops in Ghana. Chemical shops are closer to households and play a very important role in the treatment of malaria hence there is the need to train chemical sellers to stock and administer the recommended antimalarials.

The reception of village malaria workers in rural Cambodia: knowledge, perceptions, and preferences in user communities

The recently concluded Global Health Systems Research Symposium in Cape Town featured a number of abstracts that touched directly or indirectly on malaria. Malaria services and movement toward malaria elimination cannot be achieved in a country without a strong health system that involves both communities, program staff and policy makers.

globalsymposium_logosBelow is an abstract by Marco Liverani, Ra Sok, Daro Kim, Panarith Nou, Sokhan Nguon, Chea Nguon, Shunmay Yeung of the London School of Hygiene and Tropical Medicine, UK, Partners for Development, Cambodia and Ministry of Health, Cambodia on malaria village health workers in Cambodia.

“Despite sustained efforts to strengthen the health system and significant progress, Cambodia still suffers from critical shortages of health professionals and inequities in the distribution of health services. This problem is particularly acute in remote areas, where the incidence of infectious diseases such as malaria and typhoid fever is higher, where access to health facilities may be limited by environmental barriers, and where poor communities bear the greatest economic burden of illness.

Village Malaria Worker courtesy of WHO: http://who.int/malaria/areas/greater_mekong/cambodia-frontline-heroes/en/

Village Malaria Worker courtesy of WHO: http://who.int/malaria/areas/greater_mekong/cambodia-frontline-heroes/en/

“Over the past decade, the deployment of lay members of the community to provide basic medical services amongst the most vulnerable populations has been one of the key interventions to address this problem.

“We conducted a qualitative study to examine the reception and impact of the Village Malaria Workers (VMW) programme in Cambodia, a community-based intervention to support the management of malaria cases and childhood illnesses.

“Methods included observations and in-depth interviews (n=80) in user communities. A thematic question guide with open-ended questions was used for the interviews. Thematic content analysis was then conducted to explore factors that may promote or discourage service utilisation.

“Many respondents thought that VMWs can deliver appropriate medical care and services, but some expressed a preference for private providers as these were seen to offer more comprehensive and qualified health care. Many respondents had inadequate awareness of VMWs and the range of services they provide.”

“Findings from our study point to the need for innovative communication strategies to increase the utilisation of VMWs. We argue that investment in symbols and visual communication tools are required to promote the visibility, status, and identity of health volunteers in user communities, also given current policy trends – in and outside Cambodia – towards an increasing use of community workers to perform roles and tasks that are conventionally associated with health professionals.

Is community case management sustainable in Mozambique? A qualitative policy analysis

The recently concluded Global Health Systems Research Symposium in Cape Town featured a number of abstracts that touched directly or indirectly on malaria. Malaria services and movement toward malaria elimination cannot be achieved in a country without a strong health system that involves both communities, program staff and policy makers.

globalsymposium_logosBelow is an abstract by Baltazar Chilundo, Julie Cliff, Alda Mariano, Daniela Rodrigues, and Asha  George of the University Eduardo Mondlane, Mozambique and the Johns Hopkins School of Public Health on the sustainability of community case management, building on longstanding community health worker programs.  They stress the importance of community commitment, an often missing factor when CHW and CCM programs are organized by national agencies.

“In Mozambique, community case management (CCM) of diarrhoea, malaria and pneumonia is embedded in the national community health worker (CHW) programme. Since 1978 this programme functioned fitfully and was relaunched in 2010, with a target to train and retrain over 6000 CHWs.

MOZ_mean“Considering the checkered history of the CHW program, sustainability lies at the heart of concerns related to the design and implementation of CCM in CHW programs at scale in Mozambique and in people centred health systems more broadly.

“Using qualitative retrospective case study methodology, we reviewed 54 national documents and interviewed 21 key national informants for a policy analysis of CCM in Mozambique. The data were analysed thematically according to a sustainability framework and validated though a national debriefing workshop.

“The sustainability of CCM was facilitated by embedding it in the national CHW programme, which was relaunched after wide consultation within government and with supportive donors and non-governmental organizations (NGOs).

“Although communities were not widely consulted, they were eager for CHWs to provide curative services. The new CHW program aimed to improve CHW retention, by paying them a salary and giving priority to females. However, salary costs come from partners and in practice most CHWs are male.

“The poor capacity of the health system to adequately supervise CHWs and guarantee drug supplies for CCM, the dependence on external partners for funding, and on NGOs for implementation and the lack of mobilization of communities and top policy makers remain critical concerns.

“Embedding CCM in the national CHW programme favoured sustainability, however this made CCM susceptible to the same factors that undermine sustainability of the CHW programme. Moving forward, these policy concerns need to be addressed to ensure a national CHW program, responsive to community needs, supportive of CHW themselves and owned by national governments.”