title: The 'community' in community case management of childhood illnesses in Malawi.
abstract: BACKGROUND
  Malawi has achieved a remarkable feat in reducing its under-5 mortality in time to meet its MDG 4 target despite high levels of poverty, low female literacy rates, recurrent economic crises, a severe shortage of human resources for health, and poor health infrastructure. The country's community-based delivery platform (largely headed by Health Surveillance Assistants, or HSAs) has been well established since the 1960s, although their tasks and responsibilities have evolved from surveillance to health promotion and prevention, and more recently to include curative services. However, the role of and the form that community involvement takes in community-based service delivery in Malawi is unclear.
  
  
  METHODS
  A qualitative rapid appraisal approach was utilised to explore the role of community involvement in the HSA programme in Malawi to better understand how the various community providers intersect to support the delivery of integrated community case management by HSAs. Twelve focus group discussions and 10 individual interviews were conducted with HSAs, HSA supervisors, mothers, members of village health committees (VHCs), senior Ministry of Health officials, district health teams, and implementing partners.
  
  
  RESULTS
  Our findings reveal that HSAs are often deployed to areas outside of their village of residence as communities are not involved in selecting their own HSAs in Malawi. Despite this lack of involvement in selection, the high acceptance of the HSAs by community members and community accountability structures such as VHCs provide the programme with legitimacy and credibility.
  
  
  CONCLUSIONS
  This study provides insight into how community involvement plays out in the context of a government-managed professionalised community service delivery platform. It points to the need for further research to look at the impact of removing the role of HSA selection and deployment from the community and placing it at the central level.
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa; wanga.zembe@mrc.ac.za.
authors.forename: Wanga Z
authors.initials: WZ
authors.lastname: Zembe-Mkabile
authors.affiliation: School of Public Health, University of the Western Cape, Bellville, South Africa.|Knowledge Management & Implementation Research Unit, UNICEF, New York, USA.
authors.forename: Debra
authors.initials: D
authors.lastname: Jackson
authors.affiliation: School of Public Health, University of the Western Cape, Bellville, South Africa.|School of Child and Adolescent Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
authors.forename: David
authors.initials: D
authors.lastname: Sanders
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
authors.forename: Donela
authors.initials: D
authors.lastname: Besada
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
authors.forename: Karen
authors.initials: K
authors.lastname: Daniels
authors.affiliation: UNICEF, Malawi Country Office, Lilongwe, Malawi.
authors.forename: Texas
authors.initials: T
authors.lastname: Zamasiya
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.|School of Public Health, University of the Western Cape, Bellville, South Africa.|School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Tanya
authors.initials: T
authors.lastname: Doherty
mesh_terms: D019090:Case Management / Q000458:organization & administration*; D002648:Child; D002662:Child Health Services / Q000458:organization & administration*; D003153:Community Health Services / Q000379:methods / Q000458:organization & administration* / Q000592:standards; D003150:Community Health Workers / Q000458:organization & administration* / Q000592:standards; D003906:Developing Countries; D005260:Female; D017144:Focus Groups; D006078:Government Programs; D006293:Health Promotion; D006801:Humans; D007407:Interviews as Topic; D008295:Malawi; D008297:Male; D036301:Qualitative Research
keywords: Malawi; community health workers; community involvement
references.citation: Nurse Educ Today. 2004 Feb;24(2):105-12
references.pmid: 14769454
references.citation: Health Policy. 2005 Jul;73(1):92-103
references.pmid: 15911060
references.citation: Aust J Prim Health. 2010;16(1):4-16
references.pmid: 21133292
references.citation: Health Policy Plan. 2012 Jul;27 Suppl 3:iii88-103
references.pmid: 22692419
references.citation: Am J Trop Med Hyg. 2012 Nov;87(5 Suppl):6-10
references.pmid: 23136272
references.citation: Am J Trop Med Hyg. 2012 Nov;87(5 Suppl):54-60
references.pmid: 23136278
references.citation: Am J Trop Med Hyg. 2012 Nov;87(5 Suppl):61-8
references.pmid: 23136279
references.citation: BMC Health Serv Res. 2012;12:328
references.pmid: 22995125
references.citation: Health Policy Plan. 2013 Sep;28(6):573-85
references.pmid: 23065598
references.citation: J Glob Health. 2015 Dec;5(2):020412
references.pmid: 26649176