Low- and middle-income countries face many unmet social needs, including healthcare. These gaps are largely due to a lack of human resources [1] [2] . As part of a global effort to address these issues, primary healthcare [3] , which was designed to bring services closer to the community [4] , has been promoted since the 1980s. Several countries, including Burkina Faso, have adopted this approach [5] [6] . Community health development is considered one of the best options for achieving consistent progress at lower costs [7] . The strategy has evolved to involve community members, known as community health workers (CHWs), to provide affordable and accessible care [8] - [11] . Various formats have been implemented, particularly in sub-Saharan Africa [12] . After adopting primary healthcare in 1979, Burkina Faso experimented with several initiatives to involve the community in healthcare [13] - [16] . Strategic plans from 2008 and 2018, with the latest version adopted in 2024, have largely incorporated this approach. The implementation of these plans has been system-driven and strengthened in 2010 for the integrated community management of childhood illnesses [17] . Integrated Community Management of Childhood Illness (iCCM) is a strategy to reduce morbidity and mortality in children under five by providing high-quality services through volunteer or paid Community Health Workers (CHWs) to hard-to-reach groups. It focuses on managing deadly childhood diseases such as malaria, diarrhoea, and pneumonia [18] . Numerous pilot projects [15] [19] - [21] have been conducted to develop this profile of informal players (community health workers or community relays) to evolve towards a more institutionalised status known as community-based health workers [8] [22] [23] . These community health workers, recruited from within the community and trained in basic healthcare administration [24] , were to offer a package of preventive, curative, and promotional care in the community [22] [25] [26] . While their contribution has been essential in improving access to healthcare in several countries [10] [27] , bottlenecks or shortcomings have sometimes been reported regarding the level of education [13] , the supervision or availability of healthcare products [28] , and the involvement of managers in implementation, leading to differences in application levels [20] . This sometimes leads to poor results and low uptake of community-based care, with an unsatisfactory reduction in infant mortality in particular [29] [30] . The role of these CHWs will be crucial if developing countries are to move towards universal health coverage [7] [12] . These observations motivated us to conduct this study to explore the services offered by these actors and gather their views on improving health coverage by focusing on the integrated management of childhood illnesses in the community. The aim of this study was to assess the knowledge and practices of community-based health workers compared to the guidelines for implementing this curative aspect of community health and to analyse the implications for access to the services offered to communities.

The study involved 960 caregivers of children under the age of five. They lived an average distance of 7.3 km from the health center and were 78.1% female. The household respondents had a median age of 34 years (range: 16 to 80) and were mostly farmers (50.7%) or housewives (35%), with no schooling (64.8%).

Of the CHWs (n = 183) included in the study, 52.5% were male, with a median age of 35 (range 17 - 63). A total of 95.7% had a primary school certificate, 56.3% were farmers, and 12.6% were traders, most of whom were married. In 86.8% of cases, these CHWs had been working for at least 3 years.

This study assessed the CHWs’ implementation of activities. The service package offered consisted largely of preventive and curative care. The CHWs had a good knowledge of the symptoms of the diseases targeted by the iCCM but were not sufficiently familiar with the complications.

Our results show that household members surveyed have a good understanding of malaria frequency but are less aware of the significance of diarrhoea and pneumonia in child morbidity. This knowledge gap is even more pronounced for malnutrition, which was considered in this part of our study. However, according to CHW reports, communication activities are conducted, though some techniques, such as advocacy, are underutilised. These gaps in household knowledge raise questions about the effectiveness of CHW-led communication activities, which should enable better prioritization of iCCM target diseases in community care-seeking and may be related to the inadequacies of our CHWs. Some studies [31] recommend retraining community health workers. Strengthening the quality of supervision, training, and improving communication between different levels of the health system are aspects that have been shown [32] to improve the performance of CHWs. We recommend retraining our CHWs in community transformative communication techniques and methods. Precise communication activities enable early referrals and help reduce healthcare costs [33] .

The types of care provided are broadly consistent with the package recommended by national guidelines. CHWs provided oral treatments. This aligns with the Burkina Faso national reference framework describing the profile of CHWs and the iCCM guidelines [22] . Compliance with national guidelines was reported in a study conducted in Uganda [34] . However, a lack of knowledge about some complications was reported. This has led to fears that serious cases will be managed by CHWs, resulting in unfortunate consequences for both patients and the reputation of CHWs. Poor understanding of the definitions of complications could negatively impact continuity of care due to a lack of referrals. Consequently, the quality of care could be inadequate, reducing household confidence in the services provided by these CHWs. A study conducted in Ethiopia reported that around half of the children in the study were screened for danger signs, and less than half were referred according to guidelines. This lack of adherence to guidelines was identified as a risk for misdiagnosis and a lack of potentially life-saving treatment [35] . To solve such problems, we can learn from successful experiences in other countries. In Liberia, the performance of CHWs has improved by using a consensual clinical instrument to validate the quality of their services. This has enhanced the quality of CHW services [36] . In the digital age, designing a self-training capsule with a minimum grid for checking CHW skills through remote clinical units is a credible way to improve the services offered by CHWs.

Care is accessible according to the surveyed households. The services offered by the iCCM have also been accessible in other countries. In a study on community engagement and resource mobilization in Nigeria, some authors found communities satisfied with malaria management by CHWs, who were considered accessible, diligent, and effective [37] . However, this access is relative, as our study showed some CHWs lacked drugs to treat the three iCCM target diseases. The drug stock-outs identified may be due to inadequate supply in a context where free care is being extended to the community level [38] . They could also be explained by supply difficulties, particularly in the transport sector, reported by 47.5% (87/183) of CHWs. Most travelled by bicycle and had difficulty transporting their inputs. Some lacked the medicines needed for treatment. Community-based management programs for childhood illnesses face similar difficulties in other countries, as reported in other studies [37] [39] . These logistical aspects are essential in researching the effects of applying the iCCM [23] . The surveyed household members called for support for CHWs. Several points in the results align with the matrix proposed by Smisha Agarwal et al. [40] for measuring CHW performance. Community healthcare access could be further reduced. Our results showed that CHWs work in the commercial sector (12%) amidst irregular payment of financial incentives, which could lead to low availability for service provision to households in need. A study on time uses by community health workers in three rural districts of Tanzania found that their investment in community health activities was low, reducing community access to services [41] . Previous studies have shown low uptake of CHW services in Burkina Faso [30] [42] . Efforts must be made to avoid a deterioration in access to quality services and to ensure effective use of the community-based care offered by CHWs. To achieve this, iCCMs need strong support, based on confidence in the quality of the care provided [43] . This low uptake needs to be countered by effective communication about the iCCM. Prescribing drugs outside the iCCM generates income and negatively affects perceptions of community care quality, impacting community uptake. This issue is exacerbated by a funding mechanism that favours hospital care, resulting in insufficient resource allocation for iCCM implementation [44] . Efforts must be made to change the funding paradigm to improve service delivery through community health workers (CHWs) recruited and distributed throughout the country if Burkina Faso is to seize the opportunity offered by their introduction to achieve universal health coverage [12] [45] [46] .

Our study reported that CHWs experienced delays in financial motivation. Given their importance and the operational challenges involved, programs to strengthen community care using CHWs as new human resources deserve special attention from policymakers and health system managers [19] . A study on delegating immunization tasks to CHWs in the Sahel region of Burkina Faso also noted irregular motivational payments to CHWs [47] . These motivational issues could reduce CHWs’ commitment to their work. The regularity of financial incentive payments needs improvement to ensure CHWs remain committed to their work [37] .

In terms of the implications of this research for community health programmes, particularly for the management of CHWs, the researchers have proposed a redesign of the system architecture to provide research and development support services. Basic and advanced levels of technical capacity, within a two-kilometer radius of the village, could improve CHW performance in areas like quality of care, commitment, and community initiatives. By the end of this study, improvements in communication methods for better community empowerment on iCCM target diseases, retraining of CHWs, and the introduction of continuous self-training tutorials supported by revised and more effective supervision arrangements should be considered. Additionally, the introduction of clinical devices for skill validation, leveraging digital technology, are important aspects for CHW management programs to achieve better results and satisfactory community use.

Our study has some limitations. The sample size of community relays does not allow for generalization. Additionally, household responses may be biased when assessing CHW services because they live in the same community. Finally, recall bias may affect the responses of those who have not recently seen their child.

This study allowed us to revisit the role of CHWs in the context of free community health care in two health districts implementing iCCM. The health system benefits from the services offered by CHWs, but major shortcomings that existed before the implementation of free health care have not been resolved by extending free health care to community care for children. Efforts have been made to institutionalise CHWs and to establish a community health financing scheme. Nevertheless, the delay in motivating CHWs and the lack of medicines among them indicate that the resources allocated to implementing this strategy are insufficient to meet the challenges. Access to services, confirmed by the parents of children under five interviewed, is a source of satisfaction. However, the battle for effective use of these services remains unresolved and can only be won if the issues of motivating CHWs and the availability of medicines are addressed.

In its quest to achieve universal health coverage, Burkina Faso should review the funding paradigm of its health system by increasing the share of funding allocated to community health in the Ministry of Health’s budget. This would relieve the burden on health facilities and allow investment in economies of scale to improve their technical facilities.

We would like to thank the staff of the regional health and public hygiene directorates of the Centre Nord and the Plateau Central, the management teams of the health districts of Boussé and Boussouma, the teams of the central structures of the Ministry of Health of Burkina Faso, as well as the local authorities and data collectors for their administrative support throughout the preparation and collection of data.

“Informed consent was obtained from all subjects involved in the study”.

The data produced has been transmitted to the additional files.