Conclusions
Despite limitations of the currently available evidence, several recommendations can be made for the design and implementation of CCMm. It is most important that CHWs receive a training in which they have enough opportunity to practice the difficult steps and interpretation of RDTs to ensure adequate execution and interpretation of the tests and consequently ensure the most optimal test performance. Furthermore, the risks derived from potentially lower specificity may be outweighed if iCCM is implemented. A job aid, repeated training and supervision can subsequently enhance the overall performance of CHWs, including adherence to test results. Again, further improvement in adherence can be obtained by implementing iCCM. Community sensitization is needed to ensure comprehension of the intervention and trust in the skills of the CHW. Furthermore, it might stimulate adherence to treatment and referral advice. The stock management system needs to be elucidated and stock management training should be an integrated part in the CHW and health centre staff training.
Finally, since factors influencing cost-effectiveness are abundant and variable in different malaria-endemic areas and because the scarce number of studies available lack the inclusion of important benefits, an individual cost-effectiveness analysis is still needed for each area preparing for RDT-based CCMm implementation.
The implications raised in this review can be used to draft RDT-based CCMm or iCCM programmes and research projects, even for risk groups not explicitly addressed in most RDT-based CCMm studies, such as pregnant women. However, specific considerations would be in place depending on malaria pathogenesis, transmission dynamics, the existing healthcare structure and the local culture and social setting.