Community Case Management of Malaria: Exploring Support, Capacity and Motivation of Community Medicine Distributors in Uganda

To increase access to effective antimalarial treatment in Africa, the World Health Organization (WHO) advocates for community-based case management of malaria, where community members are selected to provide treatment for febrile children. Shifting tasks from health workers to community members is rooted in the philosophy endorsed in WHO's 1978 Alta Ata Declaration, which promoted equity, universal primary health care, and "bringing health care as close as possible to where people live and work." In the home-based management of fever (HBMF) programme, which was introduced in Uganda in 2002, volunteer community medicine distributors (CMDs) were trained to distribute pre-packaged chloroquine plus sulfadoxine-pyrimethamine (CQ + SP, branded HOMAPAK) free of cost. Since then, community services for febrile children have been expanding from presumptive treatment of fever with anti-malarials through the HBMF programme to include treatment for malaria (e.g., through artemisinin-based combination therapy, or ACT), diarrhoea, and pneumonia through integrated community case management (ICCM). To understand the level of support available and the capacity and motivation of community health workers to deliver these expanded services, researchers from the ACT Consortium interviewed community medicine distributors (CMDs), who had been involved in the HBMF programme in Tororo district, shortly before ICCM was adopted.

Specifically, between October 2009 and April 2010, 100 CMDs were recruited to participate by convenience sampling. Just over half of the CMDs were women, and two-thirds were between 30 and 45 years of age. The survey included questionnaires to gather information about the CMDs' work experience and to assess knowledge of fever case management, as well as in-depth interviews to discuss experiences as CMDs including motivation, supervision, and relationships with the community. Summary contact sheets were made for each of the 100 interviews; 35 were chosen for full transcription and analysis.

All interviewees had been part of the government's HBMF programme, which was stalled at the time of the interviews, and many CMDs said they were actively working within a community-based programme at the time of the survey, including other Ministry of Health (MoH) and non-governmental organisation (NGO) programmes. CMDs reported working on a number of non-malaria initiatives including family planning, prevention of mother to child transmission of HIV, and circumcision programmes. When the HBMF programme was active, the CMDs reported receiving 20 patients per week, including approximately 15 patients with suspected malaria, and 5 non-malaria patients. CMDs reported that patients sought care at all times of day and night; they were not provided with a torch or paraffin for lamps (meaning that they were unable to examine patients, distribute drugs, or complete records at night). CMDs reported that lack of antimalarial drugs severely compromised their work. CMDs were not provided with any form of transport by the MoH, such as a bicycle, or an allowance to cover the costs of transporting themselves and/or patients. CMDs listed many other supplies they were lacking, including boxes or containers to store drugs, bags to transport drugs from the health centre to their homes, boots and rain gear, and pens and stationery to keep patient records.

In addition, researchers found that CMDs faced challenges related to communication, such as:

• Limited knowledge and supervision - Overall, the CMDs performed poorly on the malaria knowledge questionnaire. When asked to define malaria, one-quarter of CMDs mentioned "fever or high temperature or hot body", but only one mentioned "disease caused by a parasite". Fewer than half of CMDs reported that malaria was transmitted through the bite of a mosquito, and few said that the female mosquito was responsible. Knowledge of danger signs of severe disease was limited. No CMD correctly identified all danger signs, although "convulsions" and "unable to sit/stand due to weakness" were mentioned by one-third of respondents, respectively. Just over half (57%) of CMDs reported that children with uncomplicated malaria should be treated with CQ + SP. One-third of CMDs did mention artemether/lumefantrine (AL), the first-line recommended antimalarial treatment; few knew the correct dosing or timing for administration. Only one-quarter stated that the child should be referred if they had not improved after 2 days. Sixty-one CMDs had received training in management of malaria with AL in the past 2 years, in addition to their initial HBMF training. One-third of the CMDs reported receiving some additional training on management of children with fever within the past 2 years. The training was most commonly provided by members of the district health team, or health workers from local health centres Health Centre III (HCIII) and Health Centre IV (HCIV). The lack of drug supplies and lapse in the HBMF programme meant that CMDs were unable to put their training into practice, which may have adversely impacted on their ability to recall information and their performance on the knowledge questionnaires. Only 4 CMDs reported that they had been supervised in the previous 6 months. Some CMDs reported that they had never been supervised in their home village; others said that the only form of supervision they received was from health workers who reviewed their patient registers when they collected drugs from the health centre. However, these types of supervision activities were dictated by the availability of drugs and health workers.
• Unrealistic expectations of community members - CMDs reported that community members often accused them of selling drugs when treatment was not available and to interpret a CMD's inability to provide treatment as a personal slight rather than the result of a stock-out. Some respondents were concerned that community members mistakenly believed that the CMDs were getting paid for their work and in some cases had expectations for services beyond drug provision.
• Differing motivations - CMDs described being motivated to volunteer for altruistic reasons; however, the main benefits of their work appeared related to "becoming someone important". Almost all respondents spoke of the benefit of working as a CMD for their social status. This involved "getting many friends", including with health workers at formal facilities, an opportunity they recognised as important for increasing their exposure to different ideas as well as to a wider social circle that linked them to other benefits. It also involved "becoming known" as someone who can help with health issues locally, often being called musawo, "health worker". Being well known held many benefits, including social recognition at community functions such as funerals, as well as the possibility for accruing reciprocal favours from others. Respondents described other programmes they had been able to work with, including immunisation, mass drug administration and bednet distribution, each with different benefits for participation. A larger proportion of women than men perceived working as a CMD as a way to secure future employment and/or to benefit them personally. An immediate advantage of the training and access to supplies of malaria medicines was to help family members, specifically children, by having an enhanced understanding of malaria and ability to treat swiftly.
• Lack of respect - The CMDs reported that without uniforms, they could not be distinguished as community health workers. In part, the desire for compensation for their work as a CMD for the government-sponsored HBMF programme appeared to relate to expectations built up from experiences with other programmes or organizations that provided various incentives, such as T-shirts or bicycles, as well as some financial incentives such as generous transport refunds. The dissatisfaction with lack of respect represented by pay was underscored when the HBMF programme stalled due to lack of drugs, when CMDs felt that they may have been forgotten, and were concerned about losing their position and the status associated with being a CMD.

At the time of the survey, over half of CMDs felt demotivated due to limited support from communities and the health system, lack of supervision, unrealistic expectations of caregivers, limited drugs and supplies, and lack of compensation. "Our analysis suggested a disconnect between what is expected from a CMD and how the CMD expects to benefit from volunteering, leading to feelings of disappointment, low motivation and isolation when these expectations are not met.... If community interventions, in increasingly complex forms, are to become the solution to improve access to primary health care, greater importance needs to be placed on the sustainability of community health volunteer programmes, in particular individual motivation and greater support to the wider health systems to which they belong."

The ACT Consortium is funded through a grant from the Bill & Melinda Gates Foundation to the London School of Hygiene & Tropical Medicine.