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Across both arms, sick children\u2019s 24-hour treatment and pregnant women\u2019s four or more antenatal visits doubled, and under-5 mortality halved, over 3 years compared with baseline. In the intervention arm, proactive CHW home visits had modest effects on children\u2019s curative and women\u2019s antenatal care utilization, but no effect on under-5 mortality, compared with the control arm. We aimed to explain these results by examining implementation, mechanisms and context in both arms We conducted a process evaluation with a mixed method convergent design that included 79 in-depth interviews with providers and participants over two time-points, surveys with 195 providers and secondary analyses of clinical data. We embedded realist approaches in novel ways to test, refine and consolidate theories about how ProCCM worked, generating three context-intervention-actor-mechanism-outcome nodes that unfolded in a cascade. First, removing user fees and deploying professional CHWs in every cluster enabled participants to seek health sector care promptly and created a context of facilitated access. Second, health systems support to all CHWs and PHCs enabled equitable, respectful, quality healthcare, which motivated increased, rapid utilization. Third, proactive CHW home visits facilitated CHWs and participants to deliver and seek care, and build relationships, trust and expectations, but these mechanisms were also activated in both arms. Addressing multiple structural barriers to care, user fee removal, professional CHWs and upgraded clinics interacted with providers\u2019 and patients\u2019 agency to achieve rapid care and child survival in both arms. Proactive home visits expedited or compounded mechanisms that were activated and changed the context across arms.<\/jats:p>","DOI":"10.1093\/heapol\/czae066","type":"journal-article","created":{"date-parts":[[2024,7,27]],"date-time":"2024-07-27T00:57:47Z","timestamp":1722041867000},"page":"864-877","source":"Crossref","is-referenced-by-count":9,"title":["Community case management to accelerate access to healthcare in Mali: a realist process evaluation nested within a cluster randomized trial"],"prefix":"10.1093","volume":"39","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0570-4632","authenticated-orcid":false,"given":"Caroline","family":"Whidden","sequence":"first","affiliation":[{"name":"Department of Disease Control, London School of Hygiene and Tropical Medicine , Keppel Street, London WC1E 7HT, United Kingdom"},{"name":"Department of Research, Monitoring & Evaluation, Muso , SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amadou Beydi","family":"Ciss\u00e9","sequence":"additional","affiliation":[{"name":"Muso , SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Faith","family":"Cole","sequence":"additional","affiliation":[{"name":"Department of Anthropology, University of California , 375 Portola Plaza, Los Angeles, CA 90095, United States"},{"name":"Institute for Social Research, University of Michigan , 426 Thompson Street, Ann Arbor, MI 48103, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Saibou","family":"Doumbia","sequence":"additional","affiliation":[{"name":"Department of Research, Monitoring & Evaluation, Muso , SEMA Route de 501 Logements, Bamako H3M8+VJC, Mali"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdoulaye","family":"Guindo","sequence":"additional","affiliation":[{"name":"Facult\u00e9 des Sciences de l\u2019\u00c9ducation et des Sciences Humaines, Universit\u00e9 des Lettres et des Sciences Humaines de Bamako , Rue 627 Porte 83, Bamako BP E 2528, Mali"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Youssouf","family":"Karamb\u00e9","sequence":"additional","affiliation":[{"name":"Institut National de la Jeunesse et des Sports , Bamako J35J+CJF, Mali"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily","family":"Treleaven","sequence":"additional","affiliation":[{"name":"Institute for Social Research, University of Michigan , 426 Thompson Street, Ann Arbor, MI 48103, United States"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jenny","family":"Liu","sequence":"additional","affiliation":[{"name":"Institute for Health & Aging, University of California , 490 Illinois Street, San Francisco, CA 94158, United 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