Book Review: “Scaling up Integrated Community Case Management: Lessons from the Rapid Access Expansion (RAcE) Programme in Five Sub-Saharan African Countries”

Scaling up Integrated Community Case Management: Lessons from the Rapid Access Expansion (RAcE) Programme in Five Sub-Saharan African Countries, edited by Salim Sadruddin, is an important contribution to the literature on global child health and health systems strengthening. The book documents the experiences, evidence, and lessons learned from one of the most ambitious operational programmes designed to expand access to life-saving treatments for children living in remote and underserved communities in Africa. Drawing on implementation research conducted across five countries, which include Democratic Republic of Congo, Malawi, Mozambique, Niger, and Nigeria, the volume offers a rich account of how integrated community case management (iCCM) can be scaled up within national health systems to address the persistent burden of childhood mortality.

At its core, the book addresses one of the most pressing challenges in global health: how to deliver effective medical care to populations that live far from health facilities. In many low-income settings, geographical distance, weak infrastructure, and shortages of trained medical personnel prevent children from receiving timely treatment for common, but potentially fatal illnesses such as malaria, pneumonia, and diarrhoea. Integrated community case management was developed as a response to this challenge. By training community health workers (CHWs) to diagnose and treat these illnesses within communities, the strategy seeks to bring essential care closer to families who would otherwise face significant barriers to accessing health services.

The Rapid Access Expansion (RAcE) programme, launched by the World Health Organization’s Global Malaria Programme with financial support from Global Affairs Canada, represented a major effort to operationalize and scale up this strategy. Beginning in 2013, the programme supported the training and deployment of more than 8,000 community health workers across the participating countries and facilitated access to treatment for over 1.4 million children living in hard-to-reach areas. Over four years of implementation, community health workers diagnosed and treated more than eight million cases of malaria, pneumonia, and diarrhoea, demonstrating the potential of community-based care to significantly expand treatment coverage in underserved populations.

The book is structured as a collection of research articles and programmatic reflections that together provide a comprehensive examination of the RAcE programme. The chapters explore several major themes, including the impact of iCCM on child mortality, strategies for ensuring sustainability of community health programmes, the challenges of monitoring and data quality, and innovations designed to improve the quality of care delivered by community health workers. By bringing together perspectives from policymakers, programme implementers, and researchers, the book offers a multidimensional understanding of how large-scale public health initiatives operate in complex real-world environments.

One of the most compelling sections of the book examines the evidence for the impact of iCCM on child survival. Using modelling approaches such as the Lives Saved Tool (LiST), the authors estimate the potential reductions in child mortality resulting from improved coverage of treatment for malaria, pneumonia, and diarrhoea. Across the six RAcE programme sites, under-five mortality declined by approximately ten percent during the implementation period. The modelling suggests that around 6,200 child deaths were averted through improved treatment coverage, with roughly three-quarters of these lives saved through services provided by community health workers themselves. These findings provide persuasive evidence that community-based delivery of basic health interventions can make a measurable contribution to reducing child mortality in settings where access to facility-based care remains limited.

Interestingly, the book does not present the RAcE programme as an unqualified success story. One of its strengths lies in its willingness to engage critically with the operational challenges encountered during implementation. The chapters repeatedly emphasize that scaling up community health programmes requires far more than training community health workers and providing them with diagnostic tools and medicines. Effective implementation depends on strong health systems, reliable supply chains, supportive supervision structures, and sustained political commitment. Where these elements are weak, even well-designed programmes may struggle to achieve their full potential.

The experience of Mozambique illustrates this point particularly clearly. In contrast to the other programme sites, the modelling results suggested minimal impact on child mortality in Mozambique, largely because widespread stockouts of essential medicines limited the ability of community health workers to provide treatment. This example highlights a fundamental lesson of the book: community health strategies cannot function effectively in isolation from the broader health system. Without reliable supplies, referral mechanisms, and institutional support, even the most dedicated community health workers cannot deliver life-saving care.

Another important theme explored throughout the volume is sustainability. Many global health programmes rely heavily on donor funding and external technical support during their initial phases, raising concerns about what will happen once these resources diminish. Several chapters describe efforts undertaken within the RAcE programme to develop sustainability roadmaps that would gradually transfer ownership of iCCM programmes to national health systems. These planning processes involved ministries of health, international organizations, and implementing partners working together to identify priorities such as strengthening health information systems, integrating community health workers into national workforce structures, and securing domestic financing for programme continuation.

The book also sheds light on the complex dynamics of community engagement. Successful community health programmes depend not only on trained personnel and medical supplies, but also on the trust and participation of the communities they serve. Several case studies from Nigeria demonstrate how community mobilisation efforts increased care-seeking behaviour and improved acceptance of community health workers as trusted providers of medical care. These experiences suggest that community health interventions are most effective when they are embedded within broader social and institutional relationships that encourage communities to take ownership of health initiatives.

Monitoring and data quality constitute another critical focus of the volume. As iCCM programmes expand, governments and international partners must be able to track their performance and evaluate their impact. The authors describe innovative approaches to assessing the quality of reporting systems used by community health programmes and to strengthening health management information systems at national and subnational levels. These efforts underscore the importance of reliable data not only for accountability, but also for continuous programme improvement.

In addition to examining programme implementation, the book also explores technological innovations designed to improve the quality of care delivered by community health workers. Several studies investigate the use of mobile health applications that guide health workers through diagnostic protocols and treatment algorithms. These digital tools were found to improve adherence to clinical guidelines when assessing sick children, although their effects on treatment practices were more limited. The authors note that, while such technologies hold promise, their adoption must be carefully evaluated in light of costs, logistical challenges, and the capacity of national health systems to maintain them over time.

From a methodological perspective, the book demonstrates the growing importance of implementation research in global health. Rather than focusing solely on whether interventions work under ideal conditions, the authors examine how programmes function within real health systems and communities. This approach generates insights that are directly relevant to policymakers and programme managers seeking to scale up effective interventions. The integration of operational research within the RAcE programme allowed implementers to adapt strategies in response to emerging challenges and to generate valuable evidence for future initiatives.

The volume’s collaborative nature is another notable strength. The chapters are authored by researchers and practitioners from a wide range of institutions, including ministries of health, international organizations, non-governmental organizations, and academic institutions. This diversity of perspectives reflects the inherently collaborative nature of large-scale public health programmes and enriches the analysis presented throughout the book.

Perhaps the most enduring contribution of the Scaling up Integrated Community Case Management book lies in its demonstration that improving child survival requires both technical innovation and institutional commitment. Community health workers can play a transformative role in delivering essential care to underserved populations, but their effectiveness depends on the strength of the systems that support them. Training, supervision, supply chains, data systems, and community engagement must all function together as parts of an integrated health system. The lessons documented in this book are particularly relevant as global health efforts increasingly emphasize universal health coverage and equitable access to care. Millions of children still die each year from preventable and treatable diseases, many of them in communities that remain beyond the reach of conventional health services. Strategies such as integrated community case management offer a practical pathway toward closing this gap by extending basic health services to the most vulnerable populations.

In conclusion, Scaling up Integrated Community Case Management book provides an insightful and carefully documented account of a major international effort to expand access to life-saving care for children. By combining rigorous analysis with practical reflections from programme implementers, the book offers valuable guidance for policymakers, researchers, and health practitioners seeking to strengthen community health systems. Its central message, which states that community-based health care can significantly improve child survival when supported by strong health systems, remains highly relevant for the future of global health.

Citation: Salim Sadruddin (Ed): Scaling up Integrated Community Case Management: Lessons from the Rapid Access Expansion (RAcE) Programme in Five Sub-Saharan African Countries. Inishmore, Edinburgh, 2019. ISBN 978-1-9999564-2-4