There has been a substantial increase in publications and interest in community health workers (CHWs) in low- and middle-income countries (LMIC) over the last years This paper examines the growth, geographical distribution and programmatic orientations of the indexed literature on CHWs in LMIC over a 10-year period A scoping review of publications on CHWs from 2005 to 2014 was conducted Using an inclusive list of terms, we searched seven databases (including MEDLINE, CINAHL, Cochrane) for all English-language publications on CHWs in LMIC Two authors independently screened titles/abstracts, downloading full-text publications meeting inclusion criteria These were coded in an Excel spreadsheet by year, type of publication (eg review, empirical), country, region, programmatic orientation (eg maternal-child health, HIV/AIDS, comprehensive) and CHW roles (eg prevention, treatment) and further analysed in Stata14 Drawing principally on the subset of review articles, specific roles within programme areas were identified and grouped Six hundred seventy-eight publications from 46 countries on CHWs were inventoried over the 10-year period There was a sevenfold increase in annual number of publications from 23 in 2005 to 156 in 2014 Half the publications were reporting on initiatives in Africa, a third from Asia and 11 % from the Americas (mostly Brazil) The largest single focus and driver of the growth in publications was on CHW roles in meeting the Millennium Development Goals of maternal, child and neonatal survival (35 % of total), followed by HIV/AIDS (16 %), reproductive health (6 %), non-communicable diseases (4 %) and mental health (4 %) Only 17 % of the publications approached CHW roles in an integrated fashion There were also distinct regional (and sometimes country) profiles, reflecting different histories and programme traditions The growth in literature on CHWs provides empirical evidence of ever-increasing expectations for addressing health burdens through community-based action This literature has a strong disease- or programme-specific orientation, raising important questions for the design and sustainable delivery of integrated national programmes

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The global pendulum swing towards community health workers in low- and middle-income countries: A scoping review of trends, geographical distribution and programmatic orientations, 2005 to 2014

The World Health Organization recommends parasitological confirmation of malaria prior to treatment Malaria rapid diagnostic tests (RDTs) represent one diagnostic method that is used in a variety of contexts to overcome limitations of other diagnostic techniques Malaria RDTs increase the availability and feasibility of accurate diagnosis and may result in improved quality of care Though RDTs are used in a variety of contexts, no studies have compared how well or effectively RDTs are used across these contexts This review assesses the diagnostic use of RDTs in four different contexts: health facilities, the community, drug shops and schools A comprehensive search of the Pubmed database was conducted to evaluate RDT execution, test accuracy, or adherence to test results in sub-Saharan Africa Original RDT and Plasmodium falciparum focused studies conducted in formal health care facilities, drug shops, schools, or by CHWs between the year 2000 and December 2016 were included Studies were excluded if they were conducted exclusively in a research laboratory setting, where staff from the study team conducted RDTs, or in settings outside of sub-Saharan Africa The literature search identified 757 reports A total of 52 studies were included in the analysis Overall, RDTs were performed safely and effectively by community health workers provided they receive proper training Analogous information was largely absent for formal health care workers Tests were generally accurate across contexts, except for in drug shops where lower specificities were observed Adherence to RDT results was higher among drug shop vendors and community health workers, while adherence was more variable among formal health care workers, most notably with negative test results Malaria RDTs are generally used well, though compliance with test results is variable – especially in the formal health care sector If low adherence rates are extrapolated, thousands of patients may be incorrectly diagnosed and receive inappropriate treatment resulting in a low quality of care and unnecessary drug use Multidisciplinary research should continue to explore determinants of good RDT use, and seek to better understand how to support and sustain the correct use of this diagnostic tool

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Use of malaria RDTs in various health contexts across sub-Saharan Africa: a systematic review.

Policy researchers have used various categories of variables to explain why policies change, including those related to institutions, interests and ideas. Recent research has paid growing attention to the role of policy networks-the actors involved in policy-making, their relationships with each other, and the structure formed by those relationships-in policy reform across settings and issues; however, this literature has largely ignored the theoretical integration of networks with other policy theories, including the '3Is' of institutions, interests and ideas. This article proposes a conceptual framework integrating these variables and tests it on three cases of policy change in Burkina Faso, addressing the need for theoretical integration with networks as well as the broader aim of theory-driven health policy analysis research in low- and middle-income countries. We use historical process tracing, a type of comparative case study, to interpret and compare documents and in-depth interview data within and between cases. We found that while network changes were indeed associated with policy reform, this relationship was mediated by one or more of institutions, interests and ideas. In a context of high donor dependency, new donor rules affected the composition and structure of actors in the networks, which enabled the entry and dissemination of new ideas and shifts in the overall balance of interest power ultimately leading to policy change. The case of strategic networking occurred in only one case, by civil society actors, suggesting that network change is rarely the spark that initiates the process towards policy change. This analysis highlights the important role of changes in institutions and ideas to drive policymaking, but hints that network change is a necessary intermediate step in these processes.

Why do policies change? Institutions, interests, ideas and networks in three cases of policy reform

BACKGROUND: Community case management (CCM) involves training supporting and supplying community health workers (CHWs) to assess classify and manage sick children with limited access to care at health facilities in their communities. This paper aims to provide an overview of the status in 2013 of CCM policy and implementation in sub-Saharan African countries. METHODS: We undertook a cross-sectional descriptive quantitative survey amongst technical officers in Ministries of Health and UNICEF offices in 2013. The survey aim was to describe CCM policy and implementation in 45 countries in sub-Saharan Africa focusing on: CHW profile CHW activities and financing. RESULTS: 42 countries responded. 35 countries in sub-Saharan Africa reported implementing CCM for diarrhoea 33 for malaria 28 for pneumonia 6 for neonatal sepsis 31 for malnutrition and 28 for integrated CCM (treatment of 3 conditions: diarrhoea malaria and pneumonia) - an increase since 2010. In 27 countries volunteers were providing CCM compared to 14 countries with paid CHWs. User fees persisted for CCM in 6 countries and mark-ups on commodities in 10 countries. Most countries had a national policy memo or written guidelines for CCM implementation for diarrhoea malaria and pneumonia with 20 countries having this for neonatal sepsis. Most countries plan gradual expansion of CCM but many countries plans were dependent on development partners. A large group of countries had no plans for CCM for neonatal sepsis. CONCLUSION: 28 countries in sub-Saharan Africa now report implementing CCM for pneumonia diarrhoea and malaria or "iCCM". Most countries have developed some sort of written basis for CCM activities yet the scale of implementation varies widely so a focus on implementation is now required including monitoring and evaluation of performance quality and impact. There is also scope for expansion for newborn care. Key issues include financing and sustainability (with development partners still providing most funding) gaps in data on CCM activities and the persistence of user fees and mark-ups in several countries. National health management information systems should also incorporate CCM activities.

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Community case management of childhood illness in sub-Saharan Africa - findings from a cross-sectional survey on policy and implementation.

This strategic review provides direction to the global child health community on how to better assist countries to deliver the best possible strategies to help each child survive and thrive. Over the past quarter century child mortality has more than halved dropping from 91 to 43 deaths per 1000 live births between 1990 and 2015. Yet in 2015 an estimated 5.9 million children still died before reaching their fifth birthday most from conditions that are readily preventable or treatable with proven cost-effective interventions. The review took as its departure point the implementation of Integrated Management of Childhood Illness (IMCI) developed by WHO and UNICEF in 1995 as a premier strategy to promote health and provide preventive and curative services for children under five in countries with greater than 40 deaths per 1000 live births. It includes contributions from over 90 countries and hundreds of experts in child health and related areas with 32 specifically commissioned pieces of analysis. The final product represents a collaboration of child health experts worldwide working together to examine past lessons and propose an agenda to stimulate momentum for improving care for children.

Towards a grand convergence for child survival and health: A strategic review of options for the future building on lessons learnt from IMNCI.

Objective: To report an in-depth analysis of policy change for integrated community case management of childhood illness (iCCM) in six sub-Saharan African countries. We analysed how iCCM policies developed and the barriers and facilitators to policy change. Methods: Qualitative retrospective case studies drawing from document reviews semi-structured interviews and in-country validation workshops were conducted in Burkina Faso Kenya Malawi Mali Mozambique and Niger. These countries were selected to maximise variation in iCCM policy status community health worker (CHW) models and different African regions. Results: Country iCCM policies evolved in an ad hoc fashion but were substantially influenced by the history of primary health care and the nature of CHW programmes. Technical officers within Ministries of Health led iCCM policy change with support from international donors but neither communities nor political leadership was mobilised. Concerns about achieving the Millennium Development Goals together with recognition of the shortcomings of existing child health programmes led to the adoption of iCCM policies. Availability of external financing played a critical role in facilitating policy change. Conclusions: iCCM policy change has been promoted by international agencies but national governments have struggled to align iCCM with country health systems. Greater investment is needed in tailoring global policy initiatives to match country needs. High-level political ownership of iCCM policies could facilitate policy change as could clearer strategies for ensuring the long-term sustainability of such policies.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/tmi.12319

Mamadou Konate

Papers

Policy challenges facing integrated community case management in Sub-Saharan Africa.