Open Access

Towards eliminating malaria in high endemic countries: the roles of community health workers and related cadres and their challenges in integrated community case management for malaria: a systematic review

  • Bruno F. Sunguya1Email author,
  • Linda B. Mlunde2,
  • Rakesh Ayer3 and
  • Masamine Jimba3
Malaria Journal201716:10

DOI: 10.1186/s12936-016-1667-x

Received: 8 October 2016

Accepted: 22 December 2016

Published: 3 January 2017

Abstract

Background

Human resource for health crisis has impaired global efforts against malaria in highly endemic countries. To address this, the World Health Organization (WHO) recommended scaling-up of community health workers (CHWs) and related cadres owing to their documented success in malaria and other disease prevention and management. Evidence is inconsistent on the roles and challenges they encounter in malaria interventions. This systematic review aims to summarize evidence on roles and challenges of CHWs and related cadres in integrated community case management for malaria (iCCM).

Methods

This systematic review retrieved evidence from PubMed, CINAHL, ISI Web of Knowledge, and WHO regional databases. Terms extracted from the Boolean phrase used for PubMed were also used in other databases. The review included studies with Randomized Control Trial, Quasi-experimental, Pre-post interventional, Longitudinal and cohort, Cross-sectional, Case study, and Secondary data analysis. Because of heterogeneity, only narrative synthesis was conducted for this review.

Results

A total of 66 articles were eligible for analysis out of 1380 studies retrieved. CHWs and related cadre roles in malaria interventions included: malaria case management, prevention including health surveillance and health promotion specific to malaria. Despite their documented success, CHWs and related cadres succumb to health system challenges. These are poor and unsustainable finance for iCCM, workforce related challenges, lack of and unsustainable supply of medicines and diagnostics, lack of information and research, service delivery and leadership challenges.

Conclusions

Community health workers and related cadres had important preventive, case management and promotive roles in malaria interventions. To enable their effective integration into the health systems, the identified challenges should be addressed. They include: introducing sustainable financing on iCCM programmes, tailoring their training to address the identified gaps, improving sustainable supply chain management of malaria drugs and diagnostics, and addressing regulatory challenges in the local contexts.

Keywords

Community health workers Malaria Community case management Malaria endemicity

Background

Mortality among children under 5 years old has fallen by more than 50% in the last decade [1]. However, the global burden of diseases and years of life lost are still high in low and middle-income countries owing to infectious diseases, including malaria [1]. Malaria burden remains high despite the knowledge of effective interventions [2]. Such interventions include community-based approaches for prevention and treatment of common illnesses responsible for high mortality and morbidity, such as malaria [35].

Community-based interventions call for individuals available in and originated from the respective communities to implement them. Community health workers (CHWs) have been effective in improving access to preventative, promotive and curative interventions in the communities they serve [6]. In malaria interventions, CHWs and related cadres have improved outcomes in disease control by tailoring interventions to local needs and regulations. The World Health Organization (WHO) has endorsed CHW-led interventions and encouraged its member states to embrace integrated community case management (iCCM) approaches and policies to address child mortality [7].

The iCCM approach using CHWs and related cadres has been effective in managing and preventing child deaths due to malaria in various contexts [6, 8]. Their use is cost-effective [9]. However, more than half a million children still die of malaria every year [1]. Drug resistance and mutation of the malaria parasite have presented significant hurdles in decreasing the persistently high mortality rates of malaria in children, particularly in highly endemic regions. Such complex factors in disease transmission and treatment present particularly difficult challenges for the iCCM approach, which relies on less-trained CHWs and related cadres who may have elementary skills and knowledge in malaria. They may not be able to manage more complex cases present to them.

Implementation of iCCM interventions has encountered various challenges. They have included shortages of drugs and supplies, poor quality of care, and lack of CHW incentives, training and supervision [8]. Such challenges continue to risk stalling positive outcomes obtained through iCCM interventions. In particular, they risk the establishment, scale-up and sustainability of iCCM interventions in reducing child mortality. In some settings, CHWs in iCCM programmes have been tasked with roles beyond what they are trained to do [7, 10]. Lack of health workers has influenced task-shifting from qualified medical personnel to CHWs for malaria case management as the only alternative. In other areas, where CHWs are the only personnel available, they have been used to deliver effective life-saving interventions [4].

Success of iCCM using CHWs and related cadres has been well documented. However, evidence of challenges and differing roles of CHWs and other lay health workers in various endemic regions has not been systematically examined. Challenges learnt from such varied implementation locations may help the process of adaptation of iCCM interventions in areas with similar characteristics. This systematic review was conducted to examine and summarize evidence on different roles of CHWs and related cadres in malaria prevention, case management and health promotion in malaria-endemic regions. This review also aimed to examine the challenges encountered by such health cadres in the implementation of iCCM.

Methods

This systematic review aimed to address two Population Intervention Comparator Outcome (PICO) questions: What is the role of CHWs and related cadres in malaria prevention, case management and health promotion in highly malaria-endemic regions? and, What are the challenges encountered while implementing iCCM for malaria using CHWs and related cadres?

In this review, the population of interest included CHWs and related cadres, such as village health volunteers and other lay health workers: home care providers and community medicine distributors. Qualified health cadres or those who had more formal and qualified training were excluded from this study. This also included mid-level providers and other official health workers employed to provide care in health facilities. Interventions of interest included iCCM, community case management of malaria (CCMm), seasonal malaria chemoprevention (SMC), and home-based management of fever. This review did not include a comparison group because of the nature of the two PICO questions.

The outcome of interest for this review was the roles and challenges faced by CHWs and related cadres. Challenges of CHWs and the related cadres were defined in line with the health system building blocks put forth by WHO [11]. They were grouped into financing, workforce, medical products, information and research, service delivery, and stewardship.

The developed protocol was registered in the PROSPERO database for systematic reviews (Registration number CRD42015027878). The current review is set to answer two of the four research objectives in the registered protocol. These are examining roles and challenges encountered by CHWs working in malaria interventions in malaria-endemic regions. Evidence search was conducted in PubMed, CINAHL, ISI Web of Knowledge, and WHO regional databases. A Boolean phrase was prepared and used for evidence search in PubMed, while search terms were used in other databases. Studies with the following designs were included: randomized control trial; quasi-experimental; pre-post interventional; longitudinal and cohort; cross-sectional; case study; and, secondary data analysis. Evidence in form of opinion papers, reviews, editorials, and reports was excluded in this review.

A total of 1394 articles were retrieved. Of them, 617 articles were identified from PubMed and 777 articles from all other databases (Fig. 1). A total of 1380 were screened after removal of 14 articles as duplicates. Of the remaining, 1245 articles were further excluded based on their titles and abstracts. Only 139 articles were eligible for full text assessment based on inclusion and exclusion criteria. On the full text assessment, a total of 72 articles were further excluded based on differences in objectives (n = 33), study design (n = 15), participants (n = 2), interventions (n = 6), outcomes (n = 5), and lack of the defined intervention (n = 11). Finally, a total of 68 articles were eligible for analysis. Excel spreadsheet was used to report the extracted data. Only a narrative synthesis on the included studies was conducted because of the differences in study designs and measurements of outcome variables.
Fig. 1

PRISMA flow chart through phases of systematic review

Results

Description of the selected studies

This review retrieved studies conducted in regions with high malaria endemicity (Table 1). These included Southeast Asia and sub-Saharan Africa regions. In the retrieved studies, CHWs were the commonest health cadre in 38 studies. Others included community health volunteers, village malaria workers, community medicine distributors, village health workers, home care providers, accredited social health activists, volunteer community-directed distributors, health surveillance assistants, village volunteers, community-owned resource persons, drug shop attendants, drug shop vendors, traditional birth attendants, community reproductive health workers, adolescent peer mobilizers, volunteer health workers, volunteer collaborators, women leaders, and mothers. In sub-Saharan Africa, the commonest cadre was CHW, while in Asia it was village malaria worker.
Table 1

Description of the studies included in the review

No

Citation

Country

Study design

Intervention

Cadre

1.

Rodriguez et al. [20]

Malawi

Case study

iCCM

Health surveillance assistants

2.

Chilundo et al. [21]

Mozambique

Qualitative study

iCCM

CHWs

3.

Yansaneh et al. [33]

Sierra Leone

Mixed methods: household survey, in-depth interviews, focus group discussions

Free healthcare initiative and iCCM

CHVs

4.

Witek-McManus et al. [34]

Malawi

Pre-post interventional study

Training programme for school teachers

CHWs

5.

Nanyonjo et al. [30]

Uganda

Cross-sectional study

iCCM

CHWs

6.

Heidkamp et al. [26]

Malawi

Cross-sectional study

iCCM

CHWs, called health surveillance assistants

7.

Linn et al. [19]

Senegal

Quasi-experimental study

ProAct model (iCCM in which CHWs proactively search for cases)

HCPs

8.

Druetz et al. [35]

Burkina Faso

Cross-sectional study

Community case management of malaria

CHWs

9.

Das et al. [36]

India

Pre-post interventional study

a. Supportive supervision of ASHA plus community mobilization

b. Community mobilization only

ASHA

10.

Yansaneh et al. [12]

Sierra Leone

Pre-post interventional study

Health for the poorest quintile, focussing on 3 diseases: diarrhoea, malaria, pneumonia.

CHWs

11.

Banek et al. [13]

Uganda

Mixed methods: cross-sectional, qualitative design

Home-base management of fever

CMDs

12.

Hamainza et al. [22]

Zambia

Longitudinal study

CHWs providing passive and active visits to households

CHWs

13.

Abbey et al. [24]

Ghana

Mixed method: cross-sectional, qualitative design

Community-based health intervention

CHWs

14.

Lwin et al. [37]

Myanmar

Community-base intervention study

Sun primary health community-based intervention

CHWs

15.

Tine et al. [14]

Senegal

Randomized controlled trial

CCMm and seasonal malaria chemoprevention

CHWs

16.

Tine et al. [29]

Senegal

Randomized controlled trial

Home-based management of malaria using RDT, ACT, rectal artesunate seasonal malaria chemoprevention delivered by CHWs

CHWs

17.

Nanyonjo et al. [18]

Uganda

Cross-sectional study

iCCM

CHWs:

Primary health facility workers (PFHWs)

18.

Siekmans et al. [38]

Kenya

Cross-sectional study

iCCM

CHWs

19.

Ndiaye et al. [39]

Senegal

Secondary data analysis

CCMm

CHWs

20.

Blanas et al. [28]

Senegal

Mixed-methods design

CCMm

CHWs

21.

Ohnmar et al. [40]

Myanmar

Randomized controlled trial

Training unpaid village volunteers in provision of RDT, ACT and supervision

Village volunteers

22.

Lim et al. [41]

Cambodia

Cross-sectional study

VMW vs health facility health worker intervention

VMW

23.

Kisia et al. [42]

Kenya

Cross-sectional study

CCMm

CHWs

24.

Counihan et al. [25]

Zambia

Longitudinal study

CHW intervention

CHWs

25.

Rutta et al. [43]

Tanzania

Pre-post intervention study

CORPs to provide early diagnosis and treatment of malaria

CORPs

26.

Ratsimbasoa et al. [44]

Madagascar

Mixed methods design

RDTs conducted by CHWs, compared to PCR and microscopy

CHWs

27.

Brenner et al. [23]

Uganda

Pre-post intervention study

Volunteer community health worker intervention

Community health volunteers

28.

Mukanga et al. [45]

Uganda

Qualitative study

Integrated malaria and pneumonia community case management

CHWs

29.

Thiam et al. [46]

Senegal

Secondary data analysis

Home-based management of malaria

HCPs

30.

Okeibunor et al. [15]

Nigeria

Pre-post intervention study

VCDDs intervention

VCDD

31.

Lemma et al. [47]

Ethiopia

Pre-post intervention study

Training of CHWs

CHWs

32.

Patouillard et al. [16]

Ghana

Randomized controlled trial

Intermittent preventive treatment of malaria in children (IPTc)

Community health volunteers

33.

Chanda et al. [48]

Zambia

Cross-sectional study

HMM

CHWs

34.

Chanda et al. [49]

Zambia

Prospective study

CHWs intervention

CHWs

35

Ngasala et al. [50]

Tanzania

Prospective study

Delivery of artemether–lumefantrine by community health workers

CHWs

36.

Phommanivong et al. [51]

Lao PDR

Prospective study

Training of village health volunteers

Village health workers

37.

Yeboah-Antwi et al. [52]

Zambia

Cluster randomized controlled trial

CHW intervention

CHWs

38.

Mukanga et al. [53]

Uganda

Qualitative study

CHW intervention

CMDs

39.

Yasuoka et al. [17]

Cambodia

Cross-sectional study

VMW intervention

VMW

40.

Hawkes et al. [54]

Democratic Republic of Congo

Prospective cohort study

Training of CHWs

CHWs

41.

Eke et al. [55]

Nigeria

Prospective cohort study

CHW intervention

CHWs

42.

Awor et al. [56]

Uganda

Quasi-experimental study

iCCM

Drug shop attendants

43.

Cox et al. [57]

Cambodia

Mixed methods study

Community-based surveillance systems

VMW

44.

Hamainza et al. [22]

Zambia

Cross-sectional study

Mobile phone SMS vs register book

CHWs

45.

Ndiaye et al. [58]

Senegal

Prospective cohort study

Paediatric kit containing quinine, purified water, syringe

CHWs

46.

Das et al. [59]

India

Longitudinal study

Community-based presumptive chloroquine treatment

Volunteers

47.

Mbonye et al. [60]

Uganda

Intervention study

Community-based IPTp

Drug shop vendors, traditional birth attendants, community reproductive health worker, adolescent peer mobilizer

48.

Vanek et al. [61]

Tanzania

Cross-sectional study

Community-based surveillance

CORPs

49.

Cho-Min-Naing et al. [62]

Myanmar

Cross-sectional study

Rapid on-site immunochromatographic test

Volunteer health workers

50.

Kelly et al. [63]

Kenya

Cross-sectional study

Community initiatives for child survival

CHWs

51.

Ruebush et al. [64]

Guatemala

Intervention study

Community-based malaria case detection system—Volunteer collaboration network (VCN)

Volunteer collaborators

52.

Aung et al. [65]

Myanmar

Pre-post intervention study

Training of CHWs

CHWs

53.

Gidebo et al. [66]

Ethiopia

Mixed-methods study

Health extension programme

CHWs

54.

Kalyango et al. [67]

Uganda

Mixed methods study

iCCM of childhood illnesses

CHWs

55.

Hamer et al. [68]

Zambia

Cluster randomized controlled trial

Training of CHWs

CHWs

56.

Mubi et al. [10]

Tanzania

Randomized cross-over trial

Training of CHWs

CHWs

57.

Harvey et al. [69]

Zambia

Quasi-experimental study

Training of CHWs

CHWs

58.

Delacollette et al. [70]

Zaire

Prospective cohort study

Training of CHWs

CHWs

59.

Eriksen et al. [71]

Tanzania

Randomized controlled trial

Training of community women leaders

Women leaders

60.

Kouyaté et al. [72]

Burkina Faso

Randomized controlled trial

Training of women group leaders by health workers

Lay community women leaders

61.

Onwujekwe et al. [73]

Nigeria

Prospective study

Training of CHWs

CHWs

62.

Mayxay et al. [74]

Laos PDR

Longitudinal study

Training of VHVs

VHVs

63.

Hii et al. [75]

Malaysia

Cross-sectional study

Community participation health programme (Sukarelawan Penjagaan Kesihatan Primer (SPKP))

VHVs

64.

Spencer et al. [76]

Kenya

Cross-sectional study

Community-based malaria control programme

Volunteer community health workers

65.

Ajayi et al. [77]

Nigeria

Pre-post intervention study

Training of mother trainers

CHWs

66.

Kweku et al. [78]

Ghana

Randomized controlled trial

IPTc

Community volunteers vs health workers in health facilities

iCCM integrated community case management, CHWs community health workers, ASHA accredited social health activist, HCPs home care providers, CMDs community medicine distributors, VMWs village malaria workers, CORPs community-owned resource persons, CCDD volunteer community-directed distributor, VHVs village health volunteers, CHVs community health volunteers

Role of CHWs and related cadres in malaria interventions

Table 2 shows the different roles of CHWs and related cadres on malaria interventions. This review classified their roles into three main categories: malaria case management, prevention including health surveillance and health promotion specific to malaria. Such roles were reported in a total of 40 articles.
Table 2

Roles of CHWs, VMWs and lay personnel working on malaria

SN

Citation

Cadre

Roles

1.

Rodriguez et al. [20]

Health surveillance assistants

Treatment with ACT

Disease surveillance

Health promotion

2.

Chilundo et al. [21]

CHWs:

Agentes Polivalentes Elementares (APEs)

Prescription of anti-malarial

Management of malaria cases

3.

Yansaneh et al. [33]

Community health volunteers

Malaria treatment

Health promotion

Referral of critical patients or those with danger signs

Accompanies malaria-sick patients to health facilities

4.

Witek-McManus et al. [34]

CHWs

Diagnosis using RDT

Treatment using ACT

5.

Nanyonjo et al. [30]

CHWs

Diagnosis

Patients’ referral

6.

Linn et al. [19]

HCPs

Home visitation and health promotion

7.

Druetz et al. [35]

CHWs

Patients consultations

Prescription and treatment

8.

Das et al. [36]

ASHA

Patients consultations

Prescription and treatment

9.

Yansaneh et al. [12]

Community health volunteers

Malaria treatment

Disease prevention

10.

Banek et al. [13]

(CMDs)

Home-based treatment of malaria

11.

Hamainza et al. [22]

CHWs

Malaria treatment

Diagnosis using RDT

12.

Abbey et al. [24]

CHWs

Health promotion

13.

Tine et al. [14]

CHWs

Malaria treatment

Health promotion

14.

Tine et al. [29]

CHWs

Home-based treatment and diagnosis

15.

Nanyonjo et al. [18]

Primary health facility workers (PFHWs)

Facility treatment

Health promotion and prevention

16.

Siekmans et al. [38]

CHWs

Home-based treatment and diagnosis

17.

Ndiaye et al. [39]

CHWs

Consultations

Treatment using ACT

Patients’ referrals

Diagnosis using RDT

18.

Blanas et al. [28]

CHWs

Treatment and prescription of ACT

Diagnosis with RDT

Selling anti-malarials at government prices

19.

Ohnmar et al. [40]

Village volunteers

Treatment and prescription of ACT

Diagnosis with RDT

20.

Lim et al. [41]

Village malaria workers

Diagnosis

21.

Kisia et al. [42]

CHWs

Treatment and prescription of ACT

22.

Counihan et al. [25]

CHWs

Diagnosis using RDT

23.

Rutta et al. [43]

CORPs

Diagnosis using RDT

Treatment using ACT

Referral of malaria cases

24.

Ratsimbasoa et al. [44]

CHWs

Diagnosis using RDT

25.

Brenner et al. [23]

Community health volunteers

Diagnosis using RDT

Treatment using ACT

26.

Mukanga et al. [45]

CHWs

Patients’ consultation: taking history

Diagnosis with RDT

Patient’s classification

27.

Thiam et al. [46]

HCPs

Patients’ consultation: taking history

Diagnosis with RDT

Treatment

28.

Okeibunor et al. [15]

CDDs

Distribution of ITNs

Provision of IPTp drugs

Counselling services on prevention among pregnant women

29.

Lemma et al. [47]

CHWs

Diagnosis using RDT

Treatment of malaria

30.

Patouillard et al. [16]

Community health volunteers

Intermittent preventive treatment in children (IPTc)

31.

Chanda et al. [48]

CHWs

Diagnosis

32.

Chanda et al. [49]

CHWs

Treatment using anti-malarials

33.

Ngasala et al. [50]

CHWs

Treatment using anti-malarials (ACT)

34.

Phommanivong et al. [51]

Village health workers

Diagnosis using RDT

Treatment of malaria

35.

Yeboah-Antwi et al. [52]

CHWs

Diagnosis using RDT

Treatment using ACT

36.

Mukanga et al. [53]

CMDs

Diagnosis using RDT

37.

Yasuoka et al. [17]

Village malaria workers

Diagnosis with RDTs

Prescribing anti-malarials

Active detection

Explanations about compliance

Follow-up of patients

38.

Hawkes et al. [54]

CHWs

Diagnosis using RDT

Treatment of febrile conditions/malaria

39.

Eke et al. [55]

CHWs

Diagnosis using RDT

40.

Tipke et al.

Volunteer community health workers

Treatment using modern medicine

41.

Awor et al. [56]

Drug shop attendants

Malaria testing with RTD

Malaria treatment with ACT

42.

Cox et al. [57]

Village malaria workers

Surveillance of day 3-positive Plasmodium falciparum cases

43.

Hamainza et al. [22]

CHWs

Diagnosis using RDT

44.

Ndiaye et al. [58]

CHWs

Use of paediatric kit containing quinine, purified water, syringe

45.

Das et al. [59]

Volunteers

Cases of fever treated during the 3-year period

46.

Mbonye et al. [60]

Drug shop vendors, traditional birth attendants, community reproductive health worker, adolescent peer mobilizer

Delivery of SP doses to pregnant women

47.

Vanek et al. [61]

CORPs

Number of malaria vector larval habitats

48.

Cho-Min-Naing et al. [62]

Volunteer health workers

Sensitivities of malaria parasites tests

49.

Kelly et al. [63]

CHWs

Treatment

50.

Ruebush et al. [64]

Volunteer collaborators

Number of patients treated

51.

Aung et al. [65]

CHWs

Diagnosis and treatment of paediatric malaria

52.

Gidebo et al. [66]

CHWs

Diagnosis and treatment

53.

Kalyango et al. [67]

CHWs

Treatment

54.

Hamer et al. [68]

CHWs

Use of RDT

55.

Mubi et al. [10]

CHWs

Provision of ACT

56.

Harvey et al. [69]

CHWs

Use of RDT

57.

Delacollette et al. [70]

CHWs

Treatment

58.

Phommanivong et al. [51]

Village health volunteers

Use of RDT

Provision of ACT

59.

Eriksen et al. [71]

Women leaders

Role of women leaders in recognizing symptoms and providing first-line treatment for uncomplicated malaria

60.

Kouyaté et al. [72]

Lay community women leaders

Malaria case management

61.

Onwujekwe et al. [73]

CHWs

Malaria treatment

62.

Mayxay et al. [74]

Village health volunteers

Use of RDT

63.

Hii et al. [75]

Village health volunteers

Treatment

64.

Spencer et al. [76]

Volunteer community health workers

Treatment with chloroquine

65.

Ajayi et al. [77]

CHWs

Health promotion

Treatment of malaria

66.

Kweku et al. [78]

Community volunteers vs health workers in health facilities

Administration of amodiaquine plus SP

CHWs community health workers, ASHA accredited social health activist, HCPs home care providers, CMDs community medicine distributors, VMWs village malaria workers, CORPs community-owned resource persons, CCDD volunteer community-directed distributor, VHVs village health volunteers

In malaria case management, CHWs and related cadres were involved in the diagnosis of malaria using rapid diagnostic tests (RDT). They were also involved in management of fever and the treatment of malaria using artemisinin combination therapy (ACT). In some studies, CHWs and related cadres were involved in prescription of anti-malarial drugs, delivery of anti-malarial drugs for home-based care and treatment or referral of complicated cases to the health facilities. In some cases they were the vital person in the community to accompany community members to seek care [12], or to provide home-based visitations for follow-up [13, 14] (Table 2).

Community health workers and related cadres were also involved in malaria preventive roles as shown in a few selected studies. Such roles included provision of intermittent preventive treatment for pregnant women (IPTp) [15] and for children (IPTc) [16]. CHWs and related cadres were also involved in distribution of insecticide-treated bed nets as one of the malaria prevention strategies [15].

The reviewed evidence also suggested that CHWs and the related cadres took part in a number of health promotion activities for malaria in various contexts [14, 15, 1719]. Examples of such roles included counselling for malaria prevention, early treatment and improving health-seeking behaviour. They provided health education about malaria and related complications, prevention and treatment.

Challenges of CHWs and related cadres in malaria interventions

Table 3 enumerates challenges and barriers CHWs and related cadres faced while implementing iCCM interventions. CHWs and related cadres faced health care financing challenges while implementing their roles in malaria interventions. This primarily included lack of sustainable sources of funds [20, 21]. As a result, CHWs and related cadres often suffered from poor or no remuneration [12, 22] and lack of incentives. Because the majority work on a voluntary basis, there has been no accountability when they are absent from the workplace [23].
Table 3

Challenges of CHWs, VMWs and lay personnel working on malaria

SN

Citation

Cadre

Challenges

1.

Rodriguez et al. [20]

Health surveillance assistants

Short training not in-keeping with medical regulation standards for prescription

Lack of resources to lengthen training

Poor supervision and overburden with patients

Most are found in remote and hard-to-reach areas where frequent supervision is not routine

Job description keeps changing with more introduction of community interventions

Financial instability and poor sustainability because of donor dependence and other unreliable sources

2.

Chilundo et al. [21]

CHWs

Policy conflicts on prescription. Authority does not allow personnel with short-term training to prescribe

Stock out of supplies especially anti-malarials

Poor supervision especially in the hard to reach areas

Funding instability. The programme is donor funded and subjected to delays in funding disbursement

Lack of community involvement and ownership

No evidence yet on impact and no evaluation strategy

APEs are not paid

3.

Yansaneh et al. [33]

CHVs

CHVs are not remunerated and have to do other income generating activities

Not available when needed as they are not paid for their service

4.

Nanyonjo et al. [30]

CHWs

Patients may not complete referrals

5.

Heidkamp et al. [26]

CHWs

Stock-out of essential supplies

Poor supervision from higher cadres

6.

Druetz et al. [35]

CHWs

Community preference on qualified health workers

CHWs not known to people

Medicine stock-out

Long distance to CHWs

7.

Banek et al. [13]

CMDs

Patients overload

Lack of supervision

Limited malaria knowledge

Tensions with community members

Lack of remuneration from the government

8.

Hamainza et al. [22]

CHWs

Lack of remuneration

Negative attitudes to care given by CHWs

Weak social responsibilities

9.

Abbey et al. [24]

CHWs

High attrition rate of CHWs especially in hard-to-reach areas

10.

Tine et al. [14]

CHWs

Medicine and RDT stock-out

11.

Ndiaye et al. [39]

CHWs

Medicine and supply RDT stock-out (ACT, RDT, gloves, case files, patients forms)

12.

Blanas et al. [28]

CHWs

ACT and other supplies stock-outs

Expired medicines or unavailable in villages

Scepticism from villages

Transport problems, poor infrastructure and long distances for referrals

13.

Counihan et al. [25]

CHWs

RDT and other medical supply stock-outs after initial supplies finished

Lack of supervision

Sustainability

14.

Brenner et al. [23]

CHVs

Low turn-over of CHVs

Low motivation

Inconsistent supplies of medicine and supplies

15.

Gidebo et al. [66]

CHWs

Shortage of chloroquine,

Patient pressure to take coartem

16.

Delacollette et al. [70]

CHWs

CHWs’ position remains ambiguous in the healthcare system.

Non-comprehensive care may have negative effect on the sustainability of programme

17.

Ajayi et al. [77]

CHWs

Challenges in their promotion/training activities

 The community members were not in support of the project.

 Some community members felt trainers were wasting their time

 Trainers could not conduct training all the time because of their domestic needs

CHWs community health workers, ASHA accredited social health activist, HCPs home care providers, CMDs community medicine distributors, VMWs village malaria workers, CORPs community-owned resource persons, CCDD volunteer community-directed distributor, VHVs village health volunteers

Community health workers and related cadres have been facing similar health workforce challenges to other cadres working in malaria-related interventions. There has been a widespread lack of in-service training and other forms of continuous professional development [20]. Other related challenges include high turnover due to high attrition rates, especially for those working in hard-to-reach or remote areas [24], lack of incentives [23] and lack of motivation to continue with their work [12, 21].

Stewardship challenges also affected the role of CHWs and related cadres in malaria interventions. For example, in Malawi, abbreviated CHW training did not meet medical regulation standards for prescription resulting in CHWs not being allowed to prescribe anti-malarials [20]. Lack of supervision from qualified health workers and poor coordination from the existing health infrastructure affected implementation of CHWs’ role in iCCM [20, 21, 25, 26].

Lack of necessary medical supplies and medicine affected CHWs role in iCCM. Most studies mentioned stock-outs of ACT and other anti-malarials [21, 26, 27], test kits for malaria [13, 14, 25, 28] and gloves, among others [29].

Service delivery by CHWs working in malaria was impaired by a number of factors. First, CHWs and related cadres were not trusted to have adequate knowledge to care and treat malaria cases in some communities [21, 22, 27]. As a result, people who had symptoms of malaria still had to travel long distances to seek similar care in health facilities [27]. Second, distances from where they were stationed to households in need affected their service delivery [13], and the referral of their patients [30]. Third, lack of transport and poor roads caused delays in service delivery in some studies [13, 28].

Some of the iCCM and roles of CHWs and related cadres have not been evaluated [21]. This poses a challenge in scaling up this intervention to wider areas. Information and research are needed for understanding the challenges, lessons and areas for improvement when scaling up.

Discussion

The current study is the first systematic review that summarizes evidence on the roles and challenges of CHWs and related cadres working on malaria interventions. In this review, CHWs and related cadres were already tasked with different roles in malaria interventions. They included prevention, malaria case management and health promotion related to malaria.

Community health workers and related cadres constitute the majority of potential health workforce for malaria and many other health-related interventions. Within the realm of malaria, understanding the breadth of their potential roles is an essential first step in order to best utilize the abundant pool of CHWs and related cadres. Their importance is augmented in the setting of human resource health crises, an overwhelming problem in most malaria-burdened countries due to their low-income country status [31]. The potential of utilizing CHWs and related cadres brings new hope in addressing both malaria and human resources for health challenges in such countries. This alternative resource can fill the gap if carefully tailored to suit the context [6] in order that efforts to control malaria and reduce morbidity and mortality can be achieved [7, 27].

Evidence presented shows a number of health system challenges [11] that CHWs and related cadres face. Such challenges have also been experienced in different settings with implementation of malaria interventions using other qualified cadres. The financial challenge is lack of stable funding to implement iCCM. In most settings of high malaria endemicity, malaria projects have been operating in donor-driven programmes that run vertically and were not integrated into the existing health system to ensure efficacy, timely delivery and to cut down bureaucracy. They have been expensive to run and lack sustainability beyond a project’s duration [32]. To ensure sustainability, CHWs and related cadres should be integrated into the health system infrastructure.

Short-term and focused training for CHWs and related cadres is a strength of iCCM. However, its cost effectiveness is a challenge in the implementation of malaria intervention, in particular, medical prescription and treatment [21]. It conflicts with other policies and regulations that require prescribers to have a minimum of training which is longer than that given to CHWs for iCCM [20, 32]. Short-term training reduces the community’s confidence in CHWs and related health cadres, which affects their utilization [22]. Tailor-made curricula for CHWs and related cadres should address conflicting policies and involve key stakeholders to ameliorate lack of confidence by the community.

Health workforce challenges are common among CHWs and related cadres. They include low or no remuneration, lack of recognition from some of the public health system, lack of incentives, and poor transport to remote areas. These are not uncommon causes of attrition, even among qualified medical and other health cadres. Addressing such challenges will help to deploy and retain CHWs and related cadres in hard-to-reach areas and solve the health workforce crisis in malaria-endemic areas.

Ensuring constant supply of anti-malarial and diagnostic tools, such as RDT and other supplies, is vital to implementation of iCCM. This review found that stock-outs were a common challenge. In some studies, the first consignment given after training of CHWs was never replaced when it ran out. To ensure reliable supply, health systems should incorporate CHWs and related cadres in malaria interventions as part of its strategy.

The evidence presented should be interpreted carefully owing to the following two limitations. First, meta-analysis could not be conducted on the retrieved evidence owing to differences in study designs and differences in outcome measures. However, the narrative synthesis was more suitable to this study to take advantage of different experiences and challenges encountered. Second, all lay health workers were included and combined together. Such health workers’ levels of knowledge, training duration, and context differed from one region to another. However, evidence generated has consistently shown similar roles and challenges of these cadres in malaria interventions.

Conclusions

Community health workers and related cadres have been taking roles similar to those of more qualified health workers. They are important actors in malaria control and elimination but suffer from the health system challenges including financing, logistics, human resource management, and stewardship. To meet targets in sustainable development in health and to save countless lives and morbidity, CHWs and related cadres must be well resourced and sustained.

Declarations

Authors’ contributions

BFS conceived the research questions, prepare and registered the review protocol, conducted the literature search, analysed the data, and prepared the first draft of the manuscript. LBM conducted the literature search, analysed the data, and prepared the first draft of the manuscript. RA conducted the literature search, and analysed the data. MJ conceived the research questions, supervised the research team on protocol development and registration, analyses and manuscript preparation. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

All the articles used for the analyses are listed in Tables 1 and 2.

Ethics approval and consent to participate

Efforts was made to ensure that all included articled adhered to the ethical standards and obtained ethical approval beforehand.

Funding

Authors did not receive any grant for this systematic review.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Community Health, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences
(2)
Management for Development and Health
(3)
Department of Community and Global Health, The University of Tokyo

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