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Decentralised programmes depend on the dedication of clinic-based staff, who deserve encouragement, regular clinical updates and feedback about the successes, not only the difficulties, of the programme.
Interviews and focus groups broadly covered the following areas: objectives of the CHWs programme, view of the programme's progress in the reality of the districts where it was implemented, positive aspects, critical points and difficulties of the programme (or of the CHWs' work), and perspectives about the continuity or suggestions to improve the programme.
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"We have access to some of the most senior people in the business, so before we design a programme we take it out to the industry to make sure we've got it right and it's relevant," says principal Gavin Shreeve who says he makes no apology for the rigour and difficulty of the programme.
The programme included some progressions whereby the intensity and difficulty of the programme varied, beginning with less strenuous tasks and progressing in difficulty.
Carers volunteered an array of anticipated difficulties with the programme contextualized within their own personal circumstances.
Despite the difficulties of identifying specific programme effects, it is unlikely that the contribution of large-scale programmes such as Matching Michigan to the 'rising tide' is trivial.
Only 5 participants reported difficulties with accessing the programme because of either a reluctance to use a computer or issues surrounding arrangements to access a computer.
The available financial support had not been used to a great extent to cover the extra expenses for the vaccinations, and therefore it was not surprising that nurses reported difficulties in implementing the programme because of time constraints.
It appears clear that utilization increased where free care was effectively available, but implementation difficulties, most notably under-funding of the programme, implied that effective free care (at least as judged by users) was not sustained, with the implication that higher rates of utilization also could not be sustained.
Technological difficulties in accessing the programme or dislike of computers, however, were not reported as barriers, which may reflect increasing familiarity with technology.
The difficulties of transferring programmes across cultures and populations were apparent from the systematic review.
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