To better understand the significant factors that affect the introduction, scale-up, and institutionalization of integrated community case management (iCCM) into national health systems in Malawi, Mali, and Rwanda, the perspectives of health system actors at various levels were explored and analyzed.

Key informants across all 3 countries viewed government ownership and integration within national systems as defining the status of iCCM institutionalization.

In each country, iCCM was described by key informants as being part of an overall wider country health agenda, which appeared to have supported a sense of ownership and advanced institutionalization within the countries.

Key informants emphasized the need to secure sufficient financing and increases in domestic funds not only for iCCM services but the national health system as a whole.

Advocates for iCCM should consider positioning iCCM within wider country agendas to advance iCCM institutionalization within a national health system.

Researchers should consider systematic document review, prospective analysis and complex adaptive systems approaches to further understanding of iCCM institutionalization processes and development of practical sensemaking models.

Since 2012, the World Health Organization (WHO) and UNICEF have recommended integrated Community Case Management (iCCM) of childhood illnesses as an intervention delivered by community health workers (CHWs) in areas with limited access to health facilities to increase access to lifesaving interventions for children younger than 5 years with malaria, pneumonia, or diarrhea. In recent years, the importance of institutionalizing iCCM and community health more broadly within national health systems has become increasingly recognized.

This qualitative study sought to identify and describe processes of iCCM institutionalization from the perspectives of health system actors. A total of 51 semistructured interviews were conducted with purposefully selected key informants in 3 countries: Malawi, Mali, and Rwanda. Thematic analysis of coded interview data was conducted, and country documentation was reviewed to provide contextual background for qualitative interpretation. The study was informed by a newly developed iCCM Institutionalization Framework, which conceptualizes the process of institutionalization through a maturity model of phases (i.e., awareness, experimentation, expansion, consolidation, and maturity) with 4 drivers: core values, leadership, resources, and policy.

According to key informant narrative descriptions, processes of iCCM institutionalization reflected a progression of maturity phases, which were iterative rather than linear in progression. All 4 drivers of institutionalization as conceptualized within the iCCM Institutionalization Framework were described by key informants as contributing to the advancement of iCCM institutionalization within their countries. Key informants emphasized the need to continually strengthen or reinforce iCCM institutionalization for it to be sustained within the context of wider health system dynamics.

Overall, key informants viewed government ownership and integration within national systems to define the status of iCCM institutionalization. Further development of the iCCM Institutionalization Framework and other practical sensemaking models could assist health system actors in advancing institutionalization of iCCM and other health interventions.

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