Impact of the Severe Malaria "Champions Program" on the Management of Severe Malaria Cases in 12 Hospitals of the North and Far North Regions of Cameroon.

Malaria remains a main cause of morbidity and mortality in Cameroon. Since 2021, the U.S. President's Malaria Initiative Impact Malaria Project has supported the National Malaria Control Program to develop the Champions program in two northern regions. We assessed this program's preliminary effectiveness on the performance of hospitals in the management of severe malaria and reduction of malaria-related deaths. We conducted a secondary analysis of Outreach Training and Supportive Supervision (OTSS) data from four rounds (one round pre-Champions program and three rounds post-Champions program and 2020-2022 malaria-related mortality data for 12 hospitals). Using linear regressions, we measured changes in hospital readiness and competency of health workers in the management of severe malaria between baseline and subsequent rounds. There were statistically significant improvements in overall management of severe malaria scores in post-Champions OTSS rounds, with post-Champions round 3 exhibiting an increase of +14% (P = 0.013) over baseline. Overall health facility readiness scores exhibited an increase of +7% (P = 0.006) from baseline to post-Champions round 3. There were no statistically significant findings associated with providing the right treatment, as nearly all patients hospitalized with severe malaria were treated with a recommended severe malaria treatment. Reported inpatient malaria deaths and case fatality rates trended downward from 2020 to 2022, but these differences were not statistically significant. The Champions program resulted in significant improvements in quality of inpatient care for severe malaria. The downward trends in malaria deaths and case fatality rate will require further monitoring to determine whether the Champions program is having the desired impact of reducing inpatient deaths from malaria.

Outreach Training and Supportive Supervision for Quality Malaria Service Delivery: A Qualitative Evaluation in 11 Sub-Saharan African Countries.

Quality improvement of malaria services aims to ensure that more patients receive accurate diagnosis, appropriate treatment, and referral. The Outreach Training and Supportive Supervision Plus (OTSS+) approach seeks to improve health facility readiness and provider competency through onsite supportive supervision, troubleshooting, and on-the-job training. As part of a multicomponent evaluation, qualitative research was conducted to understand the value of the OTSS+ approach for malaria quality improvement. Semistructured key informant interviews, focus group discussions, and structured health facility-based interviews were used to gather stakeholder perspectives at subnational, national, and global levels. Data were collected globally and in 11 countries implementing OTSS+; in-depth data collection was done in four: Cameroon, Ghana, Niger, and Zambia. Study sites and participants were selected purposively. Verbatim transcripts were analyzed thematically, following the Framework approach. A total of 262 participants were included in the analysis; 98 (37.4%) were supervisees, 99 (37.8%) were supervisors, and 65 (24.8%) were other stakeholders. The OTSS+ approach was perceived to improve provider knowledge and skills in malaria service delivery and to improve data and supply management indirectly. Improvements were attributed to a combination of factors. Participants valued the relevance, adaptation, and digitization of supervision checklists; the quality and amount of contact with problem-solving supervisors; and the joint identification of problems and solutions, and development of action plans. Opportunities for improvement were digitized checklist refinement, assurance of a sufficient pool of supervisors, prioritization of health facilities, action plan dissemination and follow-up, and data review and use. The OTSS+ approach was perceived to be a useful quality improvement approach for malaria services.

Experiences in Improving the Quality of Community-Based Fever Management from Three Malaria-Endemic African Countries.

The WHO affirms that trained, supervised, and supported community health workers (CHWs) can deliver high-quality health services effectively and has called for documentation of enabling factors, needs, and implementation strategies of successful CHW programs. In response, the U.S. President's Malaria Initiative Impact Malaria Project conducted a study to document implementation approaches, best practices, and lessons learned for quality improvement (QI) of community-based fever management in Madagascar, Malawi, and Mali. The team conducted 10 key informant interviews (KIIs) with individuals at national, regional, and district levels using an open-ended interview guide tailored to each level, and a desk review of documents and materials related to community-based QI. Each country's community health landscape and QI approaches were summarized into four categories identified during the KIIs (training, supervision, coaching/mentoring, and review meetings) and compared. Results found that Madagascar, Malawi, and Mali all had well-defined community health strategies that include QI, but countries could not extend their full package of community-based QI approaches to all CHWs as a result of limited human and financial resources. Vertical funding for health programs limits the scope and coverage of QI approaches, especially at the community level. Recommendations from key informants for strengthening community-based QI included integrating QI approaches to improve cost efficiency, to define roles and responsibilities more clearly, to engage communities and all health system levels in implementation, and to digitize QI tools. Increased financial and skilled human resources are needed for community-based QI activities to achieve their intended effect.

Access to healthcare services and confidence in healthcare professionals' management of malaria: the views of Francophone sub-Saharan African Immigrants living in western Canada.

BACKGROUND: There is a paucity of knowledge about the healthcare attitudes and practices of French-speaking immigrants originating from Sub-Saharan Africa (FISSA) living in minority settings. The purpose of this study was to characterize FISSA healthcare experiences and confidence in the malaria-related knowledge of health professionals in Edmonton. METHODS: A structured survey was used to examine a cohort of 382 FISSA (48% female; 52% male) living in Edmonton. FISSA general healthcare attitudes, experiences and satisfaction with the Canadian healthcare system were studied. Healthcare Competency Perception (HCP) was characterized by using an index score. Statistical analyses were performed to evaluate the impact of healthcare experiences and other outcomes. RESULTS: Intriguingly, while only 42% of FISSA had a French-speaking family physician, 83% (197/238) of those who had received health care services in Alberta found that access to medical treatment was easy, and 77% (188/243) were satisfied with received care. Although 70% (171/243) of FISSA did not receive services in French, 82% (199/243) surprisingly reported having good levels of comprehension during their visits. Satisfaction with care was associated with having a family physician (p = 0.018) and having health insurance (p = 0.041). Nevertheless, confidence in the healthcare system's ability to treat malaria effectively was significantly lower, with only 39% (148/382) receiving a positive score on the HCP index. CONCLUSION: This study provides an important insight into FISSA experience with and perception of the Alberta's healthcare system.

Malaria treatment health seeking behaviors among international students at the University of Ghana Legon.

INTRODUCTION: Appropriate management of malaria demands early health seeking behaviour upon suspicion of malaria-like symptoms. This study examined malaria treatment seeking behaviour and associated factors among international students at University of Ghana. METHODS: The study used a cross-sectional and quantitative approach. Data collection was undertaken using a structured questionnaire administered on a random sample of 264 international students. Data obtained on malaria treatment and factors influencing treatment behaviors were analyzed using IBM, SPSS Statistics version 22. Associations between individual characteristics and Malaria treatment seeking behavior was assessed by Pearson Chi-square(X2) test of independence. Binary logistic regression model was built using a backwards Wald approach, with variables retained at Wald p-value <0.05. RESULTS: The findings show that 35% of the respondents obtained self-prescribed antimalarial at their utmost first choice of Malaria treatment. At bivariate level, a significant relationship between Malaria health-care seeking behaviour and:- Respondents continent, X2(1, N = 264) = 7.936, p = .005; Service accessibility, X2(1, N = 264) = 7.624, p = .006; Wait time, X2(1, N = 264) = 22.514, p <0.001; Treatment cost, X2(1, N = 264) = 97.160, p <0.001; Health insurance, X2(1, N = 264) = 5.837, p = 0.016, and Perceived staff attitude, X2(1, N = 264) = 18.557, p < 0.001. At multivariable analysis, inappropriate malaria health seeking behaviours was associated with low perceived service accessibility as (≥30mins) (aOR = 6.67; p<0.001), perceived long wait time (≥30mins), (aOR = 5.94; p = 0.015), perceived treatment cost affordability (<15 GHC) (aOR = 19.88; p<0.001) and age group: -34-41years (aOR = 8.83; p<0.001). CONCLUSION: There were widespread inappropriate health-care seeking behavior for Malaria treatment among international students. Improving accessibility to malaria treatment services, reducing wait time at health facilities and the treatment cost will address inappropriate malaria treatment health seeking behaviours among the international students.

A novel approach to estimate the impact of health workforce investments on health outcomes through increased coverage of HIV, TB and malaria services.

BACKGROUND: Globally, HIV, TB and malaria account for an estimated three million deaths annually. The Global Fund partnered with the World Health Organization to assist countries with health workforce planning in these areas through the development of an integrated health workforce investment impact tool. Our study illustrates the development of a user-friendly tool (with two MS Excel calculator subcomponents) that computes associations between human resources for health (HRH) investment inputs and reduced morbidity and mortality from HIV, TB, and malaria via increased coverage of effective treatment services. METHODS: We retrieved from the peer-reviewed literature quantitative estimates of the relation among HRH inputs and HRH employment and productivity. We converted these values to additional full-time-equivalent doctors, nurses and midwives (DNMs). We used log-linear regression to estimate the relation between DNMs and treatment service coverage outcomes for HIV, TB, and malaria. We then retrieved treatment effectiveness parameters from the literature to calculate lives saved due to expanded treatment coverage for HIV, TB, and malaria. After integrating these estimates into the tool, we piloted it in four countries. RESULTS: In most countries with a considerable burden of HIV, TB, and malaria, the health workforce investments include a mix of pre-service education, full remuneration of new hires, various forms of incentives and in-service training. These investments were associated with elevated HIV, TB and malaria treatment service coverage and additional lives saved. The country case studies we developed in addition, indicate the feasibility and utility of the tool for a variety of international and local actors interested in HRH planning. CONCLUSIONS: The modelled estimates developed for illustrative purposes and tested through country case studies suggest that HRH investments result in lives saved across HIV, TB, and malaria. Furthermore, findings show that attainment of high targets of specific treatment coverage indicators would require a substantially greater health workforce than what is currently available in most LMICs. The open access tool can assist with future HRH planning efforts, particularly in LMICs.

Extracellular Vesicles Derived from Plasmodium-infected Hosts as Stimuli of "Trained" Innate Immunity.

Although the burden of malaria has been successfully controlled globally, this disease remains a major public health issue. To date, neither existing drugs nor vaccines against malaria are sufficient in eliminating malaria worldwide. To achieve the eradication of malaria by 2040, effective interventions targeting all Plasmodium species are urgently needed. As the cornerstone of vaccine design, immune memory serves a significant role in the host's defense against Plasmodium infections. It has long been considered that innate immunity is non-specific and lacks immunologic memory. However, emerging evidence has suggested that innate immunity can be trained following exposure of the body to infectious agents, such as Plasmodium or its products, which, in turn, promotes the onset of a type of memory in innate immune cells. The above "trained" innate immune cells, whose phenotype is modified in response to epigenetic modifications, metabolic recombination, or cytokine secretion, exhibit differential pathophysiology after the exposure of the body to a pathogen. In addition, Plasmodium-infected red blood cells and other host cells can secrete exosomes that contain conserved parasite-specific information, such as proteins, RNA, non-coding RNA molecules, and nucleic acids. These molecules can act as stimuli for promoting the establishment of "trained" innate immunity against malaria, thereby altering the onset and progression of the parasitic disease. A deeper understanding of the role of exosomes in the development of "trained" innate immunity during Plasmodium infection could provide novel therapeutic and prevention strategies against malaria infections.

Economic Burdens of Uncomplicated Malaria in Primary Health Care (PHC) Facilities of Plateau State, Nigeria: Patients' Perspectives.

OBJECTIVES: This study aims at evaluating the costs incurred by patients in Primary Healthcare facilities of Plateau State, Nigeria, due to uncomplicated malaria management. METHODS: Patients' information on resources used and absence from the labour market due to uncomplicated malaria illness were collected using the self-reported cost of illness instruments across 24 selected Primary Health Care (PHC) facilities in Plateau State. The collated data were used to estimate the direct medical and non-medical costs incurred by patients through the summation of the various costs paid out of pocket for the services; while the indirect cost was estimated using the human capital theory. All analyses were conducted through Microsoft Excel and IBM Statistical Package for Social Sciences (SPSS®) version 23 software. RESULTS: The average direct cost per episode of uncomplicated malaria was estimated at NGN 2808.37/USD 7.39, while the indirect average money equivalence of the time lost due to the ailment was estimated at NGN 2717/USD 7.55, giving an average cost of treating uncomplicated malaria borne by patients in Plateau State per episode to be NGN 5525.37/USD 14.94. The projected annual cost of the disease was NGN 9, 921,671,307.22 (USD 27, 560,198.08). CONCLUSIONS: The study showed substantial financial costs borne by patients due to uncomplicated malaria in Plateau State, comprising 50.83% of direct cost and 49.17% of the indirect cost of medications.

When Knowledge Is Not Enough: Applying a Behavioral Design Approach to Improve Fever Case Management in Nigeria.

BACKGROUND: We sought to encourage health care providers to adhere to national malaria case management guidelines. This requires them to conduct malaria parasite tests for every patient presenting with a fever and provide malaria treatment only to those who test positive for malaria. Our goal was to make it easier for providers to follow guidelines by addressing drivers of nonadherence uncovered through facility observations and interviews with staff and clients. IMPLEMENTATION AND MONITORING: The case management interventions were piloted in 12 public health facilities in Akwa Ibom, Kebbi, and Nasarawa states in Nigeria between October and December 2019. Participating facilities included 1 hospital and 3 primary health centers in each state. Relevant changes included the following: (1) providers at each facility participated in facilitated discussions to correct misconceptions about the reliability of malaria test kits; (2) testing procedures were integrated into existing triage systems; (3) treatment algorithms were integrated into medical record forms; (4) providers were issued pictorial brochures outlining danger signs to share with clients, together with instructions for when to seek further care; and (5) a process was created for facilities to monitor their own adherence to guidelines. LESSONS LEARNED: The lessons learned include: (1) disentangling the drivers of behavior allows for more targeted solutions, (2) solutions that streamline processes for overburdened providers allow them to redirect their attention and efforts where they can be most impactful, and (3) changing staff perceptions of workplace norms can support a holistic and sustained approach to behavior change.

The effect of an integrated electronic medical record system on malaria out-patient case management in a Ugandan health facility.

BACKGROUND: Malaria contributes 20% of outpatient cases in health facilities in Uganda. Data also show that there is a severe shortage of skilled health care personnel in sub-Saharan Africa. Electronic Medical Record (EMR) systems have been shown to provide benefits to health care providers and patients alike, making them important for low resourced settings. METHODS: A comparative study was performed from March 2018 to March 2019 in which an integrated EMR system was implemented with treatment guidelines for malaria, and its effect was evaluated on malaria outpatient case management in one Ugandan health facility. Another health facility was used as a control site. RESULTS: Malaria outpatient visits were 1.3 h shorter in the EMR group (p < .0001), and 80% more participants in the EMR group had age and weight information available to clinicians at the point of prescribing (p < .0001). Fewer participants in the EMR group had recurring malaria with no statistical significance (p = .097). Malaria surveillance reporting was significantly more accurate at the EMR intervention site (p < .05). CONCLUSION: The EMR system probably improved malaria outpatient case management by reducing outpatient visit durations, improving the availability of patient age and weight information to inform prescribing and improving the accuracy of malaria surveillance reporting.

Costs of treating childhood malaria, diarrhoea and pneumonia in rural Mozambique and Uganda.

BACKGROUND: Globally, nearly half of all deaths among children under the age of 5 years can be attributed to malaria, diarrhoea, and pneumonia. A significant proportion of these deaths occur in sub-Saharan Africa. Despite several programmes implemented in sub-Saharan Africa, the burden of these illnesses remains persistently high. To mobilise resources for such programmes it is necessary to evaluate their costs, costs-effectiveness, and affordability. This study aimed to estimate the provider costs of treating malaria, diarrhoea, and pneumonia among children under the age of 5 years in routine settings at the health facility level in rural Uganda and Mozambique. METHODS: Service and cost data was collected from health facilities in midwestern Uganda and Inhambane province, Mozambique from private and public health facilities. Financial and economic costs of providing care for childhood illnesses were investigated from the provider perspective by combining a top-down and bottom-up approach to estimate unit costs and annual total costs for different types of visits for these illnesses. All costs were collected in Ugandan shillings and Mozambican meticais. Costs are presented in 2021 US dollars. RESULTS: In Uganda, the highest number of outpatient visits were for children with uncomplicated malaria and of inpatient admissions were for respiratory infections, including pneumonia. The highest unit cost for outpatient visits was for pneumonia (and other respiratory infections) and ranged from $0.5 to 2.3, while the highest unit cost for inpatient admissions was for malaria ($19.6). In Mozambique, the highest numbers of outpatient and inpatient admissions visits were for malaria. The highest unit costs were for malaria too, ranging from $2.5 to 4.2 for outpatient visits and $3.8 for inpatient admissions. The greatest contributors to costs in both countries were drugs and diagnostics, followed by staff. CONCLUSIONS: The findings highlighted the intensive resource use in the treatment of malaria and pneumonia for outpatient and inpatient cases, particularly at higher level health facilities. Timely treatment to prevent severe complications associated with these illnesses can also avoid high costs to health providers, and households. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT01972321.

The effect of health financing reforms on incidence and management of childhood infections in Ghana: a matching difference in differences impact evaluation.

INTRODUCTION: In 2003, Ghana abolished direct out of pockets payments and implemented health financing reforms including the national health insurance scheme in 2004. Treatment of childhood infections is a key component of services covered under this scheme, yet, outcomes on incidence and treatment of these infections after introducing these reforms have not been covered in evaluation studies. This study fills this gap by assessing the impact on the reforms on the two most dominant childhood infections; fever (malaria) and diarrhoea. METHODS: Nigeria was used as the control country with pre-intervention period of 1990 and 2003 and 1993 and 1998 in Ghana. Post-intervention period was 2008 and 2014 in Ghana and 2008 and 2018 in Nigeria. Data was acquired from demographic health surveys in both countries and propensity score matching was calculated based on background socioeconomic covariates. Following matching, difference in difference analysis was conducted to estimate average treatment on the treated effects. All analysis were conducted in STATA (psmatch2, psgraph and pstest) and statistical significance was considered when p-value ≤ 0.05. RESULTS: After matching, it was determined that health reforms significantly increased general medical care for children with diarrhoea (25 percentage points) and fever (40 percentage points). Also for those receiving care specifically in government managed facilities for diarrhoea (14 percentage points) and fever (24 percentage points). CONCLUSIONS: Introduction of health financing reforms in Ghana had positive effects on childhood infections (malaria and diarrhoea).

Psychosocial factors associated with malaria care-seeking in rural Ethiopia.

BACKGROUND: Ethiopia's National Malaria Control and Elimination Program aims to diagnose all suspected malaria cases within 24 h of fever onset and provide prompt treatment for confirmed cases. This study explored psychosocial factors associated with no-, delayed- and prompt- care-seeking among female caregivers of children under five years with fever in rural Ethiopia. METHODS: Household surveys were conducted from 2016-2019 among female caregivers (N = 479) of children under five years old with fever in Oromia; Amhara; Southern Nations, Nationalities, and Peoples Region (SNNPR); and Tigray. Prompt and delayed care-seeking were defined as seeking treatment within ≤ 24 h or > 24 h of symptom onset respectively. Contextual factors explored included sociodemographic factors, household supply of bed nets, exposure to health messages, and household vulnerability (a measure of financial access to food, shelter, schooling, and medical treatment). Ideational factors included psychosocial factors related to care-seeking (knowledge, self-efficacy, response efficacy, attitudes, involvement in decision-making, and household social support). RESULTS: The prevalence of fever among children under five years was 18% (ranging from 9% in Tigray to 34% in SNNPR. Overall, 45% of caregivers of children with fever sought care promptly, while 23% delayed care-seeking and 32% sought no care. Prompt care-seeking rates were higher among caregivers with positive attitudes toward prompt care-seeking (48%), involved in decision-making (48%) or perceived equitable gender norms in the community (65%). Caregivers with a high care-seeking ideation had increased odds of prompt care-seeking (aOR: 2.65; 95% CI: 1.74-4.02). Significant contextual factors included residence in the Oromia region (aOR: 2.99; 95% CI:1.40-6.41), caregivers age 35-49 years (aOR: 0.49; 95% CI: 0.26-0.95), residence in vulnerable households (aOR: 2.01; 95% CI: 1.28-3.18). CONCLUSIONS: Among this rural Ethiopian population, prompt care-seeking was low but positively influenced by both ideational and contextual psychosocial factors occurring at the caregiver level. Multi-sectoral interventions at the individual, community, and health facility levels are needed to improve prompt care-seeking. These include social behavior change interventions to improve ideation, complemented by health facility interventions to ensure provision of high-quality services and structural interventions to increase educational attainment in these rural settings.

The Unmeasured Burden of Febrile, Respiratory, and Diarrheal Illnesses Identified Through Active Household Surveillance in a Low Malaria Transmission Setting in Southern Zambia.

Malaria incidence has declined in southern Zambia over recent decades, leading to efforts to achieve and sustain malaria elimination. Understanding the remaining disease burden is key to providing optimal health care. A longitudinal study conducted in a rural area of Choma District, Southern Province, Zambia, assessed the prevalence of and factors associated with symptoms of non-malarial illnesses and treatment-seeking behavior. We analyzed data collected monthly between October 2018 through September 2020 from 1,174 individuals from 189 households. No incident malaria cases were detected by rapid diagnostic tests among febrile participants. Mixed-effects logistic regression identified factors associated with cough, fever, diarrhea, and treatment-seeking. Incidence rates of cough (192 of 1,000 person-months), fever (87 of 1,000 person-months), and fever with cough (37 of 1,000 person-months) were highest among adults older than 65 years. Diarrhea incidence (37 of 1,000 person-months) was highest among children younger than 5 years. For every additional symptomatic household member, one's odds of experiencing symptoms increased: cough by 47% (95% CI, 40-55), fever by 31% (95% CI, 23-40), diarrhea by 31% (95% CI, 17-46), and fever with cough by 112% (95% CI, 90-137), consistent with household clustering of illnesses. However, between 35% and 75% of participants did not seek treatment for their symptoms. Treatment-seeking was most common for children 5 to 9 years old experiencing diarrhea (adjusted odds ratio, 3.61; 95% CI, 1.42-9.18). As malaria prevalence reduces, respiratory and diarrheal infections persist, particularly among young children but, notably, also among adults older than 65 years. Increasing awareness of the disease burden and treatment-seeking behavior are important for guiding resource re-allocation as malaria prevalence declines in this region.

Active case detection and treatment of malaria in pregnancy using LAMP technology (LAMPREG): a pragmatic randomised diagnostic outcomes trial-study protocol.

INTRODUCTION: Malaria is one of the major public health problems in sub-Saharan Africa. It contributes significantly to maternal and fetal morbidity and mortality in affected countries. This study aims to evaluate the impact of enhanced case detection using molecular testing called loop-mediated isothermal amplification (LAMP) on birth outcomes in a prospective study design. METHODS AND ANALYSIS: A pragmatic randomised diagnostic outcomes trial will be conducted in several health institutes in different Ethiopian regions. Women (n=2583) in their first and second trimesters of pregnancy will be included in the study and individually randomised to the standard of care or enhanced case detection arms, and followed until delivery. Enrolment will encompass the malaria peak transmission seasons. In the standard of care arm, a venous blood sample will be collected for malaria diagnosis only in symptomatic patients. In contrast, in the intervention arm, mothers will be tested by a commercially available Conformité Européene (CE)-approved LAMP malaria test, microscopy and rapid diagnostic test for malaria regardless of their symptoms at each antenatal care visit. The primary outcome of the study is to measure birth weight. ETHICS AND DISSEMINATION: The study was approved by the following ethical research boards: Armauer Hansen Research Institute/ALERT Ethics Review Committee (FORM AF-10-015.1, Protocol number PO/05/20), the Ethiopia Ministry of Science and Higher Education National Research Ethics Review Committee (approval SRA/11.7/7115/20), the Ethiopia Food and Drug Administration (approval 02/25/33/I), UCalgary Conjoint Health Research Ethics Board (REB21-0234). The study results will be shared with the institutions and stakeholders such as the Ethiopia Ministry of Health, the Foundation for Innovative Diagnostics, WHO's Multilateral initiative on Malaria - Tropical Diseases Research (TDR-MIM), Roll Back Malaria and the Malaria in Pregnancy Consortium. The study results will also be published in peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBER: NCT03754322.

Long-term quality of integrated community case management care for children in Bugoye Subcounty, Uganda: a retrospective observational study.

OBJECTIVE: Integrated community case management (iCCM) of childhood illness in Uganda involves protocol-based care of malaria, pneumonia and diarrhoea for children under 5 years old. This study assessed volunteer village health workers' (VHW) ability to provide correct iCCM care according to the national protocol and change in their performance over time since initial training. SETTING: VHWs affiliated with the Ugandan national programme provide community-based care in eight villages in Bugoye Subcounty, a rural area in Kasese District. The first cohort of VHWs began providing iCCM care in March 2013, the second cohort in July 2016. PARTICIPANTS: All children receiving iCCM care in 18 430 clinical encounters occurring between April 2014 and December 2018. PRIMARY AND SECONDARY OUTCOME MEASURES: The descriptive primary outcome measure was the proportion of patients receiving overall correct care, defined as adherence to the iCCM protocol for the presenting condition (hereafter quality of care). The analytic primary outcome was change in the odds of receiving correct care over time, assessed using logistic regression models with generalised estimating equations. Secondary outcome measures included a set of binary measures of adherence to specific elements of the iCCM protocol. Preplanned and final measures were the same. RESULTS: Overall, VHWs provided correct care in 74% of clinical encounters. For the first cohort of VHWs, regression modelling demonstrated a modest increase in quality of care until approximately 3 years after their initial iCCM training (OR 1.022 per month elapsed, 95% CI 1.005 to 1.038), followed by a modest decrease thereafter (OR 0.978 per month, 95% CI 0.970 to 0.986). For the second cohort, quality of care was essentially constant over time (OR 1.007 per month, 95% CI 0.989 to 1.025). CONCLUSION: Quality of care was relatively constant over time, though the trend towards decreasing quality of care after 3 years of providing iCCM care requires further monitoring.