Assessing Bottlenecks, Mitigation Strategies and Lessons for the Liberia Malaria in Pregnancy Programming

On April 5th 2011 the Johns Hopkins Bloomberg School of Public Health observed Global Health Day. A key event was a series of poster presentations by students who had won global health grants to undertake field projects. Today we are sharing a second presentation about malaria in pregnancy in Liberia. The results from this Case Study in Liberia feature IPT Uptake.

Contributors: Liz Posey, MPH Candidate, Johns Hopkins Bloomberg School of Public Health and Ngozi Enwerem, MPH Candidate, Johns Hopkins Bloomberg School of Public Health

Liberia is a target country for the President’s Malaria Initiative (PMI) with the goal of reducing related mortality by 70%. To achieve this, the country must reach 85% coverage, with proven therapeutic interventions, of the two most vulnerable groups, children under 5 and pregnant women. Despite concerted efforts to increase the number of women who receive two or more doses of intermittent preventive treatment (IPT) with the recommended antimalarial drug during antenatal care visits (ANC); the Global Fund August 2011 grant report which uses the Health Management Information Systems (HMIS) data for 2011 documents a trend of IPT uptake for pregnant women that is consistently 28-50% below target for every reporting period. Additionally, the Liberia Malaria Indicator Survey (LMIS) 2009 reported that 54% of pregnant women did not take the two or more doses of IPT as recommended during ANC visits. A case study was conducted using a tool created by JHPIEGO and WHO to identify the gaps, challenges and strengths of the Malaria in Pregnancy Program.

img_2254-ngozi.jpgIdentified Gaps and Challenges Surrounding Low IPT 2 Uptake Include:

  • Issues with recording and transferring antenatal attendance and IPT recipient data, arise as a result of overworked health care workers who are simultaneously responsible for administration, reporting , antenatal care and treatment, and prevention education which leads to underreporting of IPT distribution (Photo at right shows Ngozi reviewing clinic records with staff to learn more about IPT recording).
  • The number of women that receive IPT 1 is always higher in all facilities. Pregnant women face logistical challenges in returning to receive the second dose or as a result of women arriving for appointments too late in their pregnancy to receive the second dose. Accurately Tracking IPT use is a challenge because patients migrate from county to county based on the perceived quality of care received at a health care facility.
  • The health facilities are not consistently communicating the need for pregnant women  to return for a second dose due to understaffing and lack of communication and behavior change messaging and strategy addressing IPT 1 and 2.

img_2267-both.jpgOpportunities to Leverage Strengths to Address Challenges:

  • Unparalleled collaboration and integration in programming, monitoring and evaluation and policy development between partners, funders, and the MOH which provides a ripe opportunity to align resources and strategy to address existing challenges (Photo at right shows Ngozi and Liz at one health facility where observations were made).
  • Rich history with the revitalized general community health volunteers system in Liberia. Strong structures in place that can be further strengthened through strategies to address compensation, motivation, community buy-in/perception.
  • Strong track record of success using communication and behavior change messaging to increase use of long lasting insecticide treated nets, this can be similarly leveraged to improve IPT 2 uptake.
  • Strong trained traditional midwives network that can be increasingly leveraged to promote early ANC visits and adherence to IPT 1 and 2 in coordination with a strong IEC/BCC campaign.
  • Efforts underway to build a warehouse and strengthen the supply chain management system at all levels.
  • Integrated monitoring and evaluation system utilized by all partners. Plans in place to address data accuracy. These efforts also include potential plans to pilot mobile health platforms to address issues with tracking.

These findings will guide the national malaria and reproductive health programs in serving pregnant women better and protecting them from malaria.

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