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.
Below 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.
“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.”