Health workers' and managers' perceptions of the integrated community case management program for childhood illness in Malawi: The importance of expanding access to child health services

Community case management (CCM) is a promising task-shifting strategy for expanding treatment of childhood illness that is increasingly adopted by low-income countries. Its success depends in part on how the strategy is perceived by those responsible for its implementation. This study uses qualitative methods to explore health workers' and managers' perceptions about CCM provided by health surveillance assistants (HSAs) during the program's first year in Malawi. Managers and HSAs agreed that CCM contributed beneficially by expanding access to the underserved and reducing caseloads at health facilities. Managers differed among themselves in their endorsements of CCM, most offered constrained endorsement, and a few had stronger justifications for CCM. In addition, HSAs uniformly wanted continued expansion of their clinical role, while managers preferred to view CCM as a limited mandate. The HSAs also reported motivating factors and frustrations related to system constraints and community pressures related to CCM. The impact of CCM on motivation and workload of HSAs is noted and deserves further attention.