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

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.


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 [3][4][5].
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 lesstrained 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 PROS-PERO 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.

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   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.

Role of CHWs and related cadres in malaria interventions
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,[17][18][19]. 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. 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].

Challenges of CHWs and related cadres in malaria interventions
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 hardto-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].
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 stockouts 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.