Overview of iCCM programmes’ objectives and strategies

A total of 29 iCCM programmes were included in this review. All programmes were implemented in African countries, but one, in Myanmar. Table 1 lists the included programmes alongside the main implementing organisation, partners and programmes’ start and end years. The documentation scrutinised referred to programmes or phases ending between 2010 and 2013 (66% of programmes), two others were older (2005 and 2008), another one was ongoing (ending in 2015) and for the remaining seven dates were missing

All programmes shared a common objective, which had to do with increasing access to good quality health services by poor populations, with a special focus on infants’ and children’s diseases, through the deployment of CHW, implementing Integrated Management of Childhood Illnesses (IMCI). 11 (40% of the 28 programmes with this information) included in their objectives morbidity and mortality targets (eg, ‘Backpack plus’, ‘Concern Niger’).

Basic clinical care was often complemented with other strategies (eg, ‘Backpack plus’, ‘MC Sudan South’), such as policy influence or advocacy (eg, ‘CORE–group’), health systems strengthening (eg, ‘Concern Niger’), provision of supplies and supply management (eg, ‘MC Uganda’), good clinical practices (eg, ‘MC Uganda’) or improve data transmission (eg, ‘Sizika’). The most common conditions addressed were, by far: malaria (or fever), diarrhoea and pneumonia (or respiratory symptoms), in children.

Programmes were often rooted in the communities themselves, but there were also examples where at least some services were integrated into the formal health sector at primary health care level (eg, ‘MOH Ethiopia’, ‘MOH Mozambique’, ‘PSI Uganda’).

The size of the programmes in terms of the number of population reached varied across programmes, phases within the same programme, population counted (ie, whole population or children of different age groups) and ways of measuring it (ie, as population in the catchment area or as population effectively treated). Median population (sometimes whole population, sometimes under–fives) was 304 245 (interquartile range: 108 484 to 536 616), ranging from a few thousands (eg, ‘Concern Burundi’ 37 379 children; ‘CORE–Cameroon’ 38 009 children) to the hundreds of thousands (‘Save South Sudan’ 125 035 children; ‘PSI–Cameroon’ 372 460 children; ‘Concern Burundi’ 310 129 vulnerable women; ‘PSI Malawi’ 304 245 children; ‘IRC Sierra Leone’ 605 981 population; ‘PSI DRC’ 636 000 population; ‘PSI South Sudan’ 722 708 population, ‘Save Mozambique’ 953 959 population); and beyond the million in ‘Save Malawi’ (1 435 219 population) and ‘PSI Malawi’ (2 336 255 population). In 14 programmes this piece of data was not retrievable. It is worth noting that studies evaluating iCCM strategies often used sub–samples of the covered population.

Community health workers

CHW are at the core of iCCM. They are designated in different ways depending on the iCCM programme ( Table 2 ). Names are in part descriptive of the functions CHW carry out but also respond to the names that may have been used in the past in certain countries (eg, Health Extension Workers in Ethiopian programmes). For the sake of clarity and simplification, we use the generic term CHW in this article.

Activities carried out in the programmes (mainly by CHW) could fall into two main groups as identified in the programmes documents:

1) provision of clinical care (with or without other components, such as health promotion and prevention);

2) provision of supplies, mainly medical supplies (eg, drugs), through social franchising schemes (eg, ‘PSI Myanmar’, ‘PSI Uganda – Five & Alive’, ‘Living goods Uganda’) or using regular procurement schemes

(Social franchising is the provision of affordable services by the non–profit health sector, complying with franchise standards targeting underserved communities [8]; micro–franchising refers to small scale entrepreneurship by CHW [9]).

Treatment conditions included: malaria, diarrhoea and respiratory diseases assessment and early treatment, conjunctivitis, malnutrition, new–born at risk, ear infections, sexually transmitted infections and HIV testing.

Health promotion and disease prevention focused on malaria, diarrhoea and respiratory diseases recognition and health seeking behaviours, immunisation, nutrition, water and sanitation, maternal and new–born care, reproductive health and family planning, breastfeeding, complementary feeding, insecticide treated nets, malaria preventive treatment, TB prevention and treatment.

CHW were selected using a wide range of different criteria. For example, the main cadres selected in ‘CHW Backpack plus’ were supervisors of primary care facilities. Some CHW had basic education (O–level graduates in ‘CORE – Malawi’), or a minimum of five years of formal education (‘MOH Madagascar’), grade 10 junior certificate (‘MOH Malawi’, ‘Save Malawi’), minimal literacy with basic numerical competence (‘MOH Mozambique’, ‘PSI Cameroon CIDA’, ‘PSI DRC CIDA’, ‘Save Mozambique’) or even it might not be required any level of literacy (‘IRC Sierra Leone’).Occasionally, eligibility criteria could include already being a CHW, Traditional Birth Attendant (TBA), drug distributors or alike, in order to become member of Villages Health Teams (‘MOH Uganda’). In ‘Concern Rwanda KabehoMwana’ CHW selected themselves a cell coordinator. More rarely, CHW were staff from the MOH (eg, PSI Malawi CIDA, where the lowest rank of MOH employees are eligible).

CHW were selected by community members (10 programmes), community leaders (4 programmes), by the MOH (2 programmes), or by governments (1 programme) or NGOs (1 programme). In detail, CHW were selected by: MOH (‘MOH Malawi’), communities (Community Based Distributors in ‘IRC Sierra Leone’; ‘MC South Sudan’; ‘Save South Sudan’; by popular vote in ‘MOH Uganda’), both (‘PSI Cameroon CIDA’; in this case, though, the choice was made by their peers; ‘Save Mozambique’), government (‘Save Malawi’), or MOH and a local NGO (‘PSI DRC CIDA’, the final selection being made by the head nurse in collaboration with community leaders). In ‘MOH Madagascar’ most CHW were selected by their communities with some involvement of the traditional chieftaincy or the Community Health Committee. Involvement of villagers and chieftaincy was also reported in ‘PSI Madagascar’ and in ‘PSI South Sudan’. In ‘PSI Myanmar SPH Franchise’ CHW were recruited among auxiliary midwives, already existing CHW, farmers, or from other areas of activity. Additional criteria included being residents in the villages they were meant to serve (‘PSI Cameroon CIDA’, ‘PSI DRC CIDA’, ‘Save Malawi’, ‘Save Mozambique’) or being married (‘PSI DRC CIDA’). Interestingly, there was some information on exclusion criteria (ie, candidates who were NOT eligible); eg, political leaders or those imposed by political leadership (‘MOH Uganda’).

The number of CHW involved was difficult to assess because depended on the time–span of the programme, the degree of scaling up and the different types of health care workers reached. Table 3 shows the approximate number of CHW involved in the programmes, when available in the source documents (median 1441, interquartile range 732 to 2582).

Disaggregation by CHW gender was only possible for a few programmes. For example, in ‘IRC Sierra Leone’ (26% females and 74% males of 2207 trained CHW), ‘MOH Ethiopia’ and ‘Save Mozambique’ (all females in both programmes, 137 and 273, respectively), ‘MOH Madagascar’ (half females and half males, of 4800), ‘PSI DRC CIDA’ (4% females and 96% males of 748 CHW), and in ‘Save Malawi’ (25% females and 75% males of 838 CHW).

Programme documents described several types of incentives. The majority of incentives were goods and even work equipment and tools (9 of the 17 programmes with data, 53%). Only in Malawi did CHW receive proper salaries. Incentives also included intangibles such as recognition and reputation. In detail:

• ‘incentives architecture’, similar to a career path (‘CHW Backpack plus’);

• reputation and recognition: ‘MOH Madagascar’, ‘PSI DRC CIDA’; increase in client flow using services (‘PSI Uganda Five & Alive Franchise’);

• performance–based financing mechanisms (‘Concern Rwanda KabehoMwana’, ‘PSI Myanmar SPH Franchise’);

• goods: soaps and batteries (‘IRC Sierra Leone’); T–shirt (‘Living Goods Uganda’); cap, T–shirt, torch, jerry cans, certificates, soap (‘MC Sudan South’); bicycles and T–shirts (‘MC Uganda’); bicycles, uniforms, T–shirts (‘PSI Malawi CIDA’); cellphone (‘PSI Mali CIDA’); sugar, salt, soap, bicycles, gumboots, clear bags and rain jackets (‘PSI South Sudan’); cycles, stainless steel spoons, medicine cups, water cups, plastic medicine bags, basins and a water container (‘Save Malawi’); soap, jugs, spoons, jerry cans, pair of scissors, medicine bag, pens, lunch and transport during refresher trainings (‘Save South Sudan’);

• percentage of benefits: loan start–up bag with US$ 60 worth of merchandise and 15% to 20% percent of whatever they sell (‘Living Goods Uganda’);

• per diem and allowances: for training (‘MOH Madagascar’); for reporting (‘PSI Cameroon CIDA’); travel allowance (‘PSI DRC CIDA’);

• cash: 1575 to 3150 South–Sudan pounds for staff; ‘MOH Madagascar’ (some CHW); ‘PSI South Sudan’; ‘Save Mozambique’;

• salaries: ‘MOH Malawi’, ‘Save Malawi’.

Besides, in some programmes, the training itself (‘PSI Malawi CIDA’) or certificates (‘PSI Madagascar’), supervision (‘PSI DRC CIDA’), supplies and working tools were mentioned as motivators or incentives to improve CHW performance (‘MOH Uganda’, ‘PSI Madagascar’).

Training and supervision

Training schedules, length and approaches varied greatly across programmes. Table 4 details the length of training for those programmes which had this information available. Median training length was 2 weeks (interquartile range from 6 to 43 days), depending on the contents and competences to be achieved.

Training was mainly formal in 8 out of 15 programmes (53%) with information on this area. Other approaches were present in 1 or 2 programmes as detailed below: formal training courses or refreshments (eg, annual in Concern Rwanda KabehoMwana and IRC Sierra Leone; biannual in ‘PSI Cameroon CIDA’; monthly in ‘PSI DRC CIDA’; ‘MC Uganda’, ‘Save Mozambique’, ‘MOH Ethiopia’ or ‘Save South Sudan’), mentorship programmes (‘MOH Madagascar’), including both theory and practical on–the–job training (e,g. ‘CHW Backpack plus’). Other approaches included (‘Concern Burundi’): interactive lessons where CHW learned to fill the tools and used their experience, exercises, demonstrations and role plays; similarly in ‘MC South Sudan’, ‘PSI DRC CIDA’; or even practical cases in in–patient health facilities (‘MOH Malawi’, ‘Save Malawi’). Only in ‘PSI DRC CIDA’ and ‘PSI Mali CIDA’ documentation it was mentioned that training was conducted using local languages as well.

Training focused on CHW but included other personnel as well (eg, health facility staff and district–level officials in ‘Concern Niger’; caregivers in individual households in ‘CORE–Malawi’); and might have the active involvement of supervisors in the training (USAID BASICS DRC). A cascade training approach was implemented in ‘Concern Burundi’ where MOH staff trained programme staff and the District Health Team, and then those trained CHW and health centre staff. In ‘MC Sudan South’, ‘MOH Uganda’ and ‘PSI DRC CIDA’ a cascade training was also implemented.

The contents of the training were mainly around clinical care; for example: to assess, classify, refer or treat sick children; to counsel the caretaker on home management follow up; to recognize and treat sick children aged 2 to 59 months with fever, diarrhoea, and pneumonia; to refer children to health facilities if they were less than 2 months, if they presented with illnesses other than fever, diarrhoea or pneumonia or if they showed any “danger signs”; if there were stock–outs, or if after treatment, the child’s condition failed to improve or worsened (IRC Sierra Leone). Similar skills were targeted in other programmes. Training included also the use of equipment (eg, respiratory timers in ‘MC Uganda’), Behaviour Change Communication (‘Concern Rwanda KabehoMwana’), reproductive health and family planning (‘MOH Madagascar’), managerial competences and supplies management (‘MOH Uganda’, ‘PSI Cameroon CIDA’, ‘PSI Malawi CIDA’) or gender based violence (‘PSI Malawi CIDA’).

Tools used in the training initiatives included full curriculums for clinical care, trainers–of–trainers manuals, facilitators’ guides, job aids, algorithms or lists of supplies. Two programmes explicitly reported that materials were based on WHO/UNICEF or MOH materials which were adapted to local situations (eg, ‘MC Sudan South’, ‘MOH Malawi’).

Supervision was designated or assimilated to several human resources management strategies (eg, managerial supervision, clinical supervision, mentorship). In some programmes, several cadres could be responsible for CHW supervision: for example, in ‘Concern Burundi’ supervisors included Concern staff, District Health Teams and health centre staff; in ‘MC Uganda’ included health centres’ staff, Community Development Officers, Health Assistants or Health Inspectors; senior CHW, environmental officer or community nurses (‘MOH Malawi’);community based Health Area focal points and Animateurs District CCM focal points (‘PSI Cameroon); senior CHW, Environmental Health Officers or Health Facility Staff (mentors) (‘PSI Malawi’); senior CHW (routine supervision) and health centres’ clinical staff (clinical mentors) (‘Save Malawi’)

In other programmes, supervision was assigned to a single cadre: a community health in–charge (‘Concern Rwanda KabehoMwana’), a senior CHW (‘CORE Malawi’), health centre staff (‘IRC Sierra Leone’), programme officers (‘MC South Sudan’), nursing holders of health areas (‘PSI DRC’), or even community members (‘MOH Uganda’); centre technical director (‘PSI Mali’); field leader of township (‘PSI Myanmar’); CHW supervisors (‘PSI South Sudan’, ‘Save South Sudan’); chief nurse (or medical technician) (‘Save Mozambique’, ‘USAID BASICS DRC’). No information data was available regarding the gender mix of supervisors.

Supervisors undertook a specific training, which ranged from two to nine days, in the six programmes where this information was available. Tools used included guidelines, checklists and training manuals.

The supervisors: CHW ratios varied: 1:2 (‘PSI Malawi’), 1:6 (‘PSI DRC’), 1:6 to 7 (‘Save Mozambique’), 1:8 to 16 (‘IRC Sierra Leone’), 1:10 (‘PSI Cameroon’), 1:11 (‘Save Malawi’) or 1:18 (‘Save South Sudan’).

The frequency of supervisory visits ranged from once a year to three times a month (‘PSI South Sudan’); although in some cases there are reports of CHW not having received a single supervisory visit (eg, ‘MOH Madagascar’). Meetings were also mentioned as supervision–like strategies in seven programmes (37% of the 19 programmes with this information available) (eg, ‘MOH Ethiopia’ with biannual meetings; ‘PSI DRC’ monthly monitoring meetings).

Supervision activities could include any mix of the following areas of work: clinical skills, submission of reports, analysis of reports and feedback, medical supplies, logistics, site management, relations with the community, recommendations or corrective actions.

Interestingly, there were programmes where CHW were working within a more or less formal network of CHW and other providers. For example, teams and team–work was heavily emphasised in ‘Save Zambia’; ‘Care Group Volunteers’ were reported by ‘Concern Burundi’; and peer support groups based on the Care Group model were implemented by ‘Concern Rwanda KabehoMwana’.

Several tools were identified across the documents, sometimes clearly highlighted in programmes reports and some other times identified by the reviewers as potentially innovative or particularly important programme components. A total of 114 tools have been identified across the whole set of programmes. In summary, they included equipment (eg, a backpack and storage box, a drug calculator, supplies, as complements to CHW activities and to support motivation as well); guides (describing procedures or tasks, such as clinical tasks, assessments or supervision); job aids (eg, home–based management; peer–support groups; case management; counselling cards, mother reminder cards); templates for reporting (eg, register and referral forms; CCM register; CCM supervision form; follow–up visit form; medication stock management form); communication tools (eg, home and community boards; flip charts). Other tools included an integrated analogue and digital mobile phone application for real–time stock tracking and reporting or an integrated toolkit map to facilitate the planning of activities within the catchment area of CHW.

Quality of care

Eventually all programmes implemented IMCI care protocols in one way or another, which served as an overreaching framework for a number of activities with the main components being guidelines, expansion and training of CHW, supervision and often supplies.

Programmes were not uniform in their underlying ‘quality of care’ concept or framework, which was in most cases implicit. Therefore, ‘quality of care’ was approached under different perspectives and dimensions of care across programmes. We extracted information on a limited number of outcomes related to access (ie, utilisation, coverage), appropriateness of care (eg, adherence to guidelines) and health outcomes. Programmes reported very different outcomes and there was no full consistency in measurements and reporting approaches.

As shown in Table 5 , we extracted and grouped reports on outcomes, selecting those that seemed to be better related to quality of care indicators and better reported. 43% were categorised as qualitative (‘+’), 30% as quantitative (‘++’) and 26% as quantitative with some estimation of statistical significance.

The synthesis of effects on quality of care suggested that there were positive effects for those strategies that involved policy change (‘CORE Cameroon’), organisational change (eg, C–IMCI framework ‘CORE Cameroon’), standardisation (‘Concern Rwanda’), integration with existing health care services and alignment with other programmes which may ease implementation and scaling up (‘CORE Malawi’, ‘PSI Mali’).

Quality changes seemed more remarkable in large multi–component programmes which included training of CHW, strengthened supervision and improvement of supply change management. Improvements in monitoring and evaluation procedures seemed to have had positive effects on utilisation rates (‘MOH Ethiopia’). Interestingly, access improved in most programmes, yet achievements were moderate in absolute terms or compared with formal health care (‘Save Malawi’). Geographic and effective access to care increased (‘Save Malawi’). A programme with a component of improvements of information transmission through mobile telephones seemed to have increased utilisation of CHW and more prompt management of illnesses.

Other strategies aimed at reinforcing the relations between CHW either with peers or supervisors. Peer–support groups provided a platform for more effective human resources interventions (eg, supervision, trust, accountability; ‘Concern Rwanda’); social franchising (‘PSI Myanmar’) seemed to strengthen networking of providers, alongside an increase in reputation of CHW. Micro–franchising seemed to achieve affordable improvements in the availability of good quality medical products (‘Living Goods Uganda’). Social franchising increased the availability of services at equal or lower costs than regular formal services and supplies with specific data on Oral Rehydration Salts (ORS) distribution (‘PSI Myanmar’). Equity (differentials in access from different economic strata) was reported in terms of access to CHW, Artemisinin–based Combination Therapy (ACT) and treatments of diarrhoea (‘PSI Cameroon’); social franchising also seemed to improve equity, focusing on the most vulnerable populations (‘PSI Myanmar’, ‘PSI Uganda’).Yet, at least one programme (‘Save Malawi’) could not find differences in accessing CHW according to wealth.

Effects on caregivers seemed positive, with increases in knowledge, changes in care seeking behaviour (‘PSI Malawi’, ‘PSI Mali’) and caregivers’ basic disease management (‘Concern Rwanda’); clients’ satisfaction with availability of medicines and care increased (‘PSI Cameroon’); and there were some indications that community ownership and accountability were strengthened.

Effects of iCCM interventions may not be sustained over time everywhere since there were examples of declining coverage of services (‘PSI Cameroon’) with time. Social franchising showed examples where coverage of services did not seem to increase (‘PSI Uganda’).

In contrast, some of the poor outcomes (eg, clinical management) were related to the shift of care seeking between different types of providers; for example, from formal governmental services to CHW community based care. Training large numbers of CHW led to the reduction in the use of traditional healers, although this was seen as a positive effect of the programme (‘CORE Malawi’). Introduction of an iCCM programme in an area where care seeking appeared generally high resulted in shifting of care from government health centres, private health facilities and shops to village health clinics.

Although the aims of this review did not include reporting on mortality, it is worth noting that reductions in mortality were occasionally reported with findings suggesting reductions in some geographical areas but not in others, within the same programme (‘PSI Cameroon’), or not statistically significant reductions (‘IRC Sierra Leone’).