Open Access Open Badges Research

Performance of community health workers under integrated community case management of childhood illnesses in eastern Uganda

Joan N Kalyango123*, Elizeus Rutebemberwa4, Tobias Alfven15, Sarah Ssali6, Stefan Peterson147 and Charles Karamagi28

Author Affiliations

1 Department of Public Health Sciences, Division of Global Health (IHCAR), Karolinska Institutet, SE 17177, Stockholm, Sweden

2 Clinical Epidemiology Unit, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda

3 Department of Pharmacy, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda

4 Department of Health Policy, Planning and Management, School of Public Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda

5 Department of Paediatrics, Sach’s Children’s Hospital, Södersjukhuset, Stockholm, Sweden

6 Department of Gender and Women Studies, Makerere University, P.O. Box 7072, Kampala, Uganda

7 International Maternal and Child Health, Department of Women and Children’s Health, Uppsala University, Uppsala, Sweden

8 Department of Paediatrics and Child Health, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda

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Malaria Journal 2012, 11:282  doi:10.1186/1475-2875-11-282

Published: 20 August 2012



Curative interventions delivered by community health workers (CHWs) were introduced to increase access to health services for children less than five years and have previously targeted single illnesses. However, CHWs in the integrated community case management of childhood illnesses strategy adopted in Uganda in 2010 will manage multiple illnesses. There is little documentation about the performance of CHWs in the management of multiple illnesses. This study compared the performance of CHWs managing malaria and pneumonia with performance of CHWs managing malaria alone in eastern Uganda and the factors influencing performance.


A mixed methods study was conducted among 125 CHWs providing either dual malaria and pneumonia management or malaria management alone for children aged four to 59 months. Performance was assessed using knowledge tests, case scenarios of sick children, review of CHWs’ registers, and observation of CHWs in the dual management arm assessing respiratory symptoms. Four focus group discussions with CHWs were also conducted.


CHWs in the dual- and single-illness management arms had similar performance with respect to: overall knowledge of malaria (dual 72%, single 70%); eliciting malaria signs and symptoms (50% in both groups); prescribing anti-malarials based on case scenarios (82% dual, 80% single); and correct prescription of anti-malarials from record reviews (dual 99%, single 100%). In the dual-illness arm, scores for malaria and pneumonia differed on overall knowledge (72% vs 40%, p < 0.001); and correct doses of medicines from records (100% vs 96%, p < 0.001). According to records, 82% of the children with fast breathing had received an antibiotic. From observations 49% of CHWs counted respiratory rates within five breaths of the physician (gold standard) and 75% correctly classified the children. The factors perceived to influence CHWs’ performance were: community support and confidence, continued training, availability of drugs and other necessary supplies, and cooperation from formal health workers.


CHWs providing dual-illness management handled malaria cases as well as CHWs providing single-illness management, and also performed reasonably well in the management of pneumonia. With appropriate training that emphasizes pneumonia assessment, adequate supervision, and provision of drugs and necessary supplies, CHWs can provide integrated treatment for malaria and pneumonia.

CHW; ICCM; Health system research; Performance; Malaria; Pneumonia; Children; CMDs