DISCUSSION
diarrhoea, pneumonia, illness, fatigue, fever, malaria, cough, ’ improved illness, febrile
DISEASE, SECONDARY, PNEUMONIA, MALARIA
Early access to health sector treatment more than doubled for sick children when study communities received care from professional CHWs and upgraded primary care clinics without user fees. In 2018, the Mali DHS found that only 21% and 55% of children under five with fever in the Mopti region received any prompt treatment and any care, respectively [Proactive CHW service delivery improved early health sector treatment further, compared to the fixed approach, after 12 months, but not after 24 or 36 months of implementation. These findings suggest that home visits were most important during the first year after launching the redesigned CHW-led health system, possibly by mobilising care-seeking, reinforcing the importance of prompt treatment, or building trust in the health system. After more than a year of experiencing accessible, high-quality care without fees, control communities with fixed CHWs may have themselves mobilised, adopted rapid care-seeking, and gained trust in the system, though not as quickly. There was some evidence that, over all three years, proactive CHW service delivery improved access to health sector evaluation and any care, suggesting that home visits may have helped to overcome persistent indirect cost, distance, or social barriers to care, even where fixed CHW services were available without fees. Subgroup estimates suggested that proactive home visits may improve child access to care best in smaller communities, where a CHW can achieve greater home visit coverage, in those farther from a PHC, where utilisation was lowest at baseline [For maternal health care, our analysis of other secondary trial endpoints (reported elsewhere) [CHW adherence to the proactive workflow protocol, as reported at survey time points by respondents, reached only half of sick children in the intervention arm and waned over time. This could be intervention fatigue or the conflict making the proactive workflow difficult to deliver. This likely biased ITT intervention effect estimates towards the null, as per-protocol subgroup analyses showed stronger magnitudes and significance of effects across children’s utilisation outcomes at 12 months and during the trial overall. These findings suggest that had households in the intervention arm received a proactive CHW home visit at least once every two weeks throughout the trial period, home visits may have had more effect on children’s health care utilisation.The proactive service delivery intervention effects found in this trial should be understood within the context of the co-interventions in both trial arms, including user fee removal, professional CHWs, and upgraded primary care clinics. Proactive CHW home visits’ effects may be different in other health system or social contexts. Our forthcoming process evaluation paper used mixed methods to elucidate the implementation, mechanisms, and context of the proactive home visits and co-interventions in both arms and to help to explain these trial outcome results (unpublished data).Child morbidity, measured as disease prevalence, did not decrease over time or more so in the intervention arm as we expected it to. Rather, reported prevalence of all four illnesses increased during the trial period compared to baseline (descriptive), and cough and suspected pneumonia increased statistically at 12 months in intervention compared to control clusters. These increases could reflect mothers’ improved illness recognition given CHW care and, additionally, home visits. Mothers who received routine counselling during home visits on disease prevention, illness recognition, and rapid care-seeking may have been more likely during the first year than their control arm counterparts to recognise cough as an illness and fast breathing as an alert, and thus report it during a survey. Our study did not measure progression or severity of disease, which may link health care utilisation to survival in the pathway of change, and this is a limitation. In Ghana, home visits by volunteer CHWs focusing on health education, but who also tested febrile children for malaria and treated childhood diarrhoea with ORS, had no effect on the prevalence of these illnesses (primary outcomes) or case detection/management, compared to no volunteer CHWs [With its randomised design, large number of clusters, and rigorous, baseline, and repeated outcome measurement, this trial addressed common risks of bias found in studies in this domain [