All posts by Bill Brieger

Acceptance of the Contribution of Community-Based Health Workers (CBHWs) to Improving Prevention of Malaria in Pregnancy in Burkina Faso by Health Center Staff

Efforts are underway to test the a community-based system for providing IPTp to pregnant women in Burkina Faso as a means of increasing coverage. Justin Tiendrebeogo, Ousmane Badolo, Mathurin Dodo, Yacouba Savadogo, Danielle Burke, Susan Youll, and William Brieger share a formative study among health staff concerning their perceptions of the ability of Community Based Health Workers to provide increased doses. This was presented at the 7th Multilateral Initiative for Malaria Conference in Dakar. Below are the findings.

The Burkina Faso Ministry of Health, with support from its partners, initiated a study on the feasibility of increasing provision of intermittent preventive malaria treatment in pregnant women (IPTp) with sulfadoxine-pyrimethamine (SP). Existing community-based health workers (CBHWs) were enlisted to deliver the third and fourth doses recommended by the World Health Organization. Currently, only facility-based health care providers give SP, and women in rural areas have trouble accessing health facilities for the medicine.

Using CBHWs has the potential to reach more women with a greater number of doses of IPTp-SP. Direct training and supervision of CBHWs is the responsibility of frontline health care staff, including antenatal care (ANC) providers. Therefore, to ensure a successful rollout of community delivery of IPTp, it is crucial that these staff accept the new roles of CBHWs. This baseline study was conducted to learn the frontline staff’s views about existing and proposed CBHW activities.

Study’s Geographic Areas. Three districts (Batié, Pô, and Ouargaye) in the southern part of Burkina Faso. Twelve centre de santé et de promotion sociale (health and social promotion centers [CSPS]) were selected in Ouargaye, Pô, and Batié Health Districts. In each district, two CSPS were randomly assigned as intervention catchment areas, for a total of six centers. Then using matching criteria, the remaining six CSPS were designated as control sites.

Health Worker Interviews were conducted among a total of 35 CSPS staff: 23 were men, and 12 were women. Semi-structured interview guides were used in this formative study. Open-ended questions sought the views of ANC providers and CBHW supervisors about the current work of CBHWs and the feasibility of using this health cadre to administer IPTp to pregnant women. The Study sought to understand provider opinions to design an IPTp-SP intervention involving CBHWs.

Qualitative analysis identified common themes in the open-ended responses. Providers like the CBHW program, noting that “CBHWs come from the community” and help with language barriers. However, CBHWs are not always available or move frequently from one community to another. A few male providers noted issues with timely payment of stipends to CBHWs.

Most providers were open to CBHWs providing IPTp-SP to pregnant women: “It will reduce [our] workload.” Unlike female providers, some male providers stressed the need for CBHWs to be “well trained.”

Providers commented that CBHWs were needed and could contribute. For example CBHWs could increase the uptake of IPTp-SP, prevent deaths and malaria, educate women and the community, and prevent stock-outs of SP. While CBHWs do not currently provide IPTp-SP, several providers noted that CBHWs already conduct community education sessions with pregnant women on taking IPTp-SP.

A few noted that CBHWs already monitor adherence to IPTp-SP doses and send women to the health facility when doses are needed. Providers expressed the importance of including information on malaria prevention and treatment, IPTp-SP administration, stock management, and data collection in the CBHW training.

The findings guided discussions and planning with both district and CSPS staff in the design of the CBHW training and IPTp-SP intervention. The results led to development of the training-of-trainers process that started with the district health team, who then trained CSPS staff—the CSPS staff then trained CBHWs.

Gaining the frontline staff’s acceptance of and perceptions about CBHWs—and building on them—will hopefully lead to greater ownership and better management of project implementation at the community level.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID, PMI, or the United States Government.

Improved Malaria Case Management of Children under Age 5: The Experience of the MCSP Restoration of Health Services Liberia Project

Catherine Gbozee, Birhanu Getahun, Topian Zikeh, Anne Fiedler, and Allyson Nelson of the Maternal and Child Survival Program (Jhpiego and John Snow, Inc.) have presented experiences on improving malaria case management for children in Liberia at the 7th Multilateral Initiative for Malaria Conference in Dakar. Below are their findings.

In malaria-endemic countries, malaria is the second leading cause of mortality for children under the age of 5 years. In Liberia Mortality rate for children under the age of 5 years was 94 per 1,000 in 2013. Malaria accounts for 31% of outpatient mortality for children under the age of 5 years and 51% of all outpatient consultations. Malaria among children under the age of 5 years accounts for 20.5% of all outpatient consultations in Liberia Health services weakened by the epidemic of Ebola virus disease. Over 40% of children under the age of 5 years have tested positive for malaria using malaria rapid diagnostic tests (mRDTs) since 2009 (see Figure 1)

Maternal and Child Survival Program (MCSP) Restoration of Health Services (RHS) Project Objectives for malaria include prevention at facilities, Strengthen infection prevention and control (IPC) practices at 77 health facilities through training, intensive supportive supervision, triage, improvement of waste management, and provision of essential IPC commodities and supplies, Increased utilization of and demand for maternal and child health services—Restore delivery of quality primary health care services through implementation of integrated reproductive, maternal, newborn, child, and adolescent health as part of the Essential Package of Health Services in 77 facilities.

MCSP RHS supported health facilities in three counties

  • Grand Bassa: 30 (91% of health facilities in county)
  • Lofa: 17 (27% of health facilities in county)
  • Nimba: 30 (46% of health facilities in county)
  • Population coverage: 900,000 (20% of total population)

Liberia Malaria Indicator Survey 20164 showed that mRDT was done for only 43% and 44% of children with fever in North Central and South Central regions, respectively. Treatment with artemisinin-based combination therapy (ACT) improved from 43% to 81% from 2013 to 2016. Intervention approaches are outlined at the left.

Scores for all technical areas, including malaria, improved
from baseline to endline (see Figure 2). Median facility scores for adherence to malaria clinical standards improved by 75% between baseline and endline in half of MCSP facilities sampled (see Figures 3 and 4). Percent of malaria cases in children under 5 years of age receiving ACT for malaria in MCSP-supported facilities improved from 76% to 82%, despite sporadic stock-outs of ACT (see Figure 5)

Challenges included Frequent stock-outs of mRDTs and ACT. There were Bad roads and broken bridges challenging for supportive supervision, malaria commodity distribution, and facility accessibility to users.

Lessons Learned included Task-shifting and comprehensive hands-on health workforce improvement approaches are essential for revamping and improving quality care provision in post-disaster settings such as Liberia. Uninterrupted and sustained supplies of mRDTs, ACT, and malaria commodities are key for quality malaria case management.

References

1. World Health Organization (WHO). 2015. MCEE-WHO methods and data sources for child causes of death 2000–2015. WHO website.
http://www.who.int/healthinfo/global_burden_disease/ChildCOD_method_2000_2015.pdf. Accessed April 2, 2018.

2. Liberia Institute of Statistics and Geo-Information Services (LISGIS), Ministry of Health and Social Welfare Liberia, National AIDS Control Program Liberia, et al. 2014.
Liberia demographic and health survey 2013. Demographic and Health Surveys Program website. https://dhsprogram.com/pubs/pdf/fr291/fr291.pdf. Accessed April 2, 2018.

3. Liberia Ministry of Health. Liberia Ministry of Health Annual Report 2015. Monrovia, Liberia: Ministry of Health.

4. National Malaria Control Program, Liberia Institute of Statistics and Geo-Information Services, and The DHS Program. 2017. Liberia Malaria Indicator Survey 2016.
The Demographic and Health Surveys Program website. http://dhsprogram.com/pubs/pdf/MIS27/MIS27.pdf. Accessed April 2, 2018.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

Community-Based Health Workers in Burkina Faso: Are they ready to take on a larger role to prevent malaria in pregnancy?

Community Based Health Worker (CBHW) opinions were sought prior to establishing community delivery of intermittent preventive treatment of malaria in pr4egnancy in Burkina Faso. Bill Brieger, Danielle Burke, Justin Tiendrebeogo, Ousmane Badolo, Mathurin Dodo, Yacouba Savadogo, and Susan Youll report on the findings from the CBHWs at the 7th Multilateral Initiative for Malaria Meeting in Dakar.

In 2012 and 2013, World Health Organization recommended that a minimum of three doses—rather than two doses—of intermittent preventive treatment of malaria in pregnancy (IPTp). This three-dose recommendation has made it more challenging to achieve the 85% national coverage target in Burkina Faso. Existing health services in other endemic countries have also had difficulty achieving the two-dose target. Using a formative approach, this study tested if the 85% target could be achieved by having IPTp delivered to the community through trained community-based health workers (CBHWs) who are supervised by the health system.

Existing training materials for these CBHWs outline a basic role in promoting antenatal care (ANC) and guiding communities to use curative and preventive malaria services. The question was to what extent are the CBHWs practicing what they were taught, and could training in community delivery of IPTp build on their existing roles.

Because of continuous malaria transmission, these three districts in the southern part of Burkina Faso were chosen for the intervention study: Batie, Po, and Ouargaye. Also in these three districts, community health workers have been involved in the implementation of other programs, such as immunization, malaria, nutrition, and family planning.

As part of this formative study to design the community-based IPTp intervention, semi-structured interviews were conducted with CBHWs in three health districts (Batie, Po, and Ouargaye) with a high malaria burden. In general, the Directorate of Health Promotion in the Ministry of Health encourages communities to select one male and one female CBHW, although the actual CBHWs chosen would depend on availability and literacy of the CBHW.

In each district, four centre de santé et de promotion sociale (health and social promotion centers [CSPS] were selected, and their catchment areas were divided among intervention and control groups. Effort was made to reach all CBHWs currently practicing in these 12 catchment areas. Numerical and narrative data were entered in a database and analyzed by gender based on major themes relating to ANC, pregnancy, and malaria services. Interview transcripts were manually reviewed for themes.

Of the CBHWs interviewed, a total of 62 were male and 42 were female.  Both female and male CBHWs provide advice and education to women in their villages, which may include advising women to go to the CSPS for pregnancy or ANC, family planning, immunization, or illness. Some CBHWs stated that they remind women about follow-up ANC appointments. As one female CBHW explained, “on their return [from CSPS for care], I ask [the pregnant woman] what has been said and I shall ensure they practice this.”

A male CBHW noted that he “direct[s] women, in case of amenorrhea, [to] go to CSPS to check for pregnancy, to [receive] follow[-up] care, and be in good health.” Many male CBHWs were likely to mention malaria-related activities, including education about causes and prevention of malaria. A few male CBHWs talked about helping people recognize malaria, seek treatment, and comply with recommended medicine regimens.

A few male and female CBHWs specifically mentioned encouraging women to take sulfadoxine-pyrimethamine for IPTp. Some reported involvement in distributing bed nets. In contrast to the male CBHWs, some female CBHWs may even accompany women to ANC to ensure that the women receive services.

Some challenges were faced by CBHWs. At least a third of the CBHWs noted difficulties in carrying out their work, but they also had encouragements: “Acceptance by the community of my activities facilitates the task.” “Nothing is easy, but with the understanding of people, there are no problems.” While officially, CBHWs were to receive a stipend, one CBHW explained that “nothing is easy, especially that I am not paid for all these activities.” Others also noted that “for the moment, there is nothing that is easy as we lack the tools [for the job].”

CBHWs report being active in promoting the health of pregnant women and encouraging women and the community to prevent and treat malaria. Although their training stresses postnatal care, this area was not mentioned during interviews. Likewise, CBHWs did not address the danger signs of malaria in pregnancy during the interviews, which is in their training. Female CBHWs were more likely to encourage pregnant women to attend ANC at CSPS and follow up with them after the visit, while the male CBHWs were more focused on providing health information. Logistical challenges and payment of stipends need to be addressed before adding more duties for the CBHW to complete. Overall, CBHWs are positioned to deliver IPTp under the supervision of CSPS staff.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID, PMI, or the United States Government.

Ministry of Health’s Effort in Developing and Implementing a Quality Assurance Plan for Global Fund-Supported Antimalarial Drugs: A Case Study of Nepal in the Context of Malaria Elimination

Prakash Raj Pant and Bhim Acharya of the USAID Supported Maternal and Child Survival Program/Jhpiego (MCSP)and the Epidemiology and Disease Division, Ministry of Health, Nepal presented their case study of developing a quality assurance approach for the Global Fund supported provision of antimalarial drugs at the 7th Multilateral Initiative for Malaria Conference in Dakar. Below are their experiences.

Nepal is in the malaria elimination phase, with a target of 2026 through the Global Fund (GF) malaria grant in process for 2018–2021. The Maternal and Child Survival Program (MCSP) also supported GF HIV/AIDS, TB, and malaria grant implementation.

Quality assured antimalarials are a prerequisite for malaria elimination. This is Mandated by GF quality control policies on pharmaceuticals National Malaria Strategic Plan 2016 states: “quality assured antimalarials should be available at all points of service delivery”. Nepal National Drug Regulation Agency (NDRA) does not have a written quality assurance (QA) policy for GF pharmaceuticals

Developing and Implementing a Successful QAP requires the following Key considerations:

  • Effective coordination of National Malaria Control Program (NMCP) and stakeholders with NDRA
  • Approval of QAP by ministry of health (MOH) and GF
  • Presence of laboratories in the region that are prequalified by the World Health Organization or certified by ISO 17025
  • Advocacy among high-level MOH officials
  • Intersectoral collaboration among implementing partners
  • NDRA’s active role in scheduling inspections
  • Building the capacity of government entities by bilateral agencies (e.g., WHO, United States Agency for International Development) in the initial phase of QAP implementation
  • Budgeting for QA activities in grant funds

Next Steps in QAP Implementation start with identifying GF-approved laboratories in region for quality control testing of existing grant-funded products. Then partners must strengthen national medicine testing capacities, and seek accreditation of government laboratories by international bodies in 2–3 years. It is important to Mainstream grant-funded QA activities into the NDRA

Challenges in Resource-constrained countries like Nepal include weak pharmaceutical QA testing capacity of domestic laboratories with no accreditation from international bodies. There is inadequate attention of decision-makers in implementing QA policies.

Take-Home Messages from the experience in Nepal include the fact that QA of pharmaceuticals is a mandatory but often neglected area in many GF grant recipient countries. There is need to integrate QA measures into country’s mainstream drug regulation. Coordination with in-country stakeholders is critical.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of PMI, USAID, or the United States Government.

Application d’un audit de la qualité des données (DQA) du paludisme dans le district sanitaire de Kribi, Cameroun

Kodjo Morgah, Naibei Mbaïbardoum, Mathurin Dodo, et Eric Tchinda from Jhpiego share their experiences in improving malaria data quality in Kribi District, Cameroon. The project was funded by the ExxonMobil Foundation. Their findings are presented below.

Les indicateurs clés du paludisme En 2015 dans le district sanitaire de Kribi, Cameroun, le mortalité palustre était 19% et le morbidité palustre était 29%. En outre, le couverture du premier traitement de TPI était 76% et 55% pour le deuxième.

Les interventions du projet Amélioration de la qualité des services de contrôle du paludisme au Tchad et au Cameroun sont montrés dans le diagramme ci-joint.

Les activités DQA ont commencé en 2012. Au début du projet, les formations sanitaires de Kribi ne disposaient pas d’une gestion des données suffisante en termes de fiabilité, de complétude et de promptitude des registres des formations sanitaires et des rapports soumis. En 2013 nous avons formé des prestataires de Kribi en prévention et traitement du paludisme, y compris la collecte et la gestion des données, et collaboration avec l’équipe cadre de district (ECD) du Ministère de la Santé Publique (MSP) pour institutionnaliser les réunions mensuelles de vérification et de validation des données. Puis en 2015 nous avons développé et diffusé d’affiches de suivi des données pour aider les formations sanitaires à suivre les indicateurs clés du paludisme afin de soutenir une prise de décision efficace. L’année passe, en 2017, le DQA est réalisé.

Objectifs du DQA sont d’améliorer la qualité des données du paludisme dans le district de Kribi; identifier les erreurs systématiques; apprécier les sous-déclarations et/ou sur-déclarations; mesurer la concordance des données rapportées; apprécier la précision, la validité, la fiabilité, et la complétude des données collectées; et renforcer les capacités des ECD et du PNLP.

Pour mettre en œuvre du DQA, nous avons sélectionné huit indicateurs du paludisme et un indicateur général. Le projet a adapté des outils de collecte des données développés par le projet MEASURE Evaluation financé par l’USAID. Puis, il a facilité le constitution et orientation des équipes d’évaluateurs des données composées du personnel de Jhpiego et des membres de l’ECD. Apres ça, les équipes commencent le réalisation du DQA dans des sites sélectionnés

Modalités :

  • Aucun problème de qualité des données, si la mDA est comprise entre 100% et 90%
  • Problèmes mineurs de qualité des données, si la mDA est comprise entre 89% et 70%
  • Problèmes majeurs de qualité des données, si la mDA est inférieure à 70%

Conclusions: Le DQA a réussi à identifier les problèmes qui ont affecté la qualité des données dans les formations sanitaires de Kribi. Il a aussi révélé une meilleure qualité des données dans les formations sanitaires rurales que dans les formations sanitaires urbaines. Dans l’ensemble, la qualité des données du paludisme est acceptable dans la majorité des formations sanitaires soutenues par le projet.

L’équipe de projet doit soutenir le personnel et les formations sanitaires du MS du district dans l’intégration des recommandations du DQA pour continuer à améliorer la qualité des données.

Recommendations: Il est necessaire de renforcer les capacités des prestataires dans la collecte des données à travers la supervision formative. Dans l’outil de supervision de district, il est utile d’intégrer la vérification et le contrôle des données. Une Aide-mémoire sur la vérification, le contrôle et la validation des données du paludisme devrait être disponible.

Febrile Illness Case Management in Madagascar: Lessons from a Facility Provider Case Scenario Assessment

Rachel Favero, Jean Pierre Rakotovao, Lalanirina Ravony, Reena Sethi, Katherine Wolf, Barbara Rawlins, Eliane Razafimandimby, Andrianandraina Ralaivaomisa, Toky Rakotondrainibe, Mamy Razafimahatratra, Thierry Franchard, Sedera Mioramalala, Joss Razafindrakoto, and Catherine Dentinger of the Maternal and Child Survival Program/Jhpiego, the National Malaria Control Programme and the United States Agency for International Development/Madagascar examine malaria care seeking in Madagascar. Their findings were presented at the 7th Multilateral Initiative for Malaria Conference in Dakar and are shared below.

In 2016, malaria accounted for 5.9% of outpatient visits and 6.7% of all deaths in Madagascar. Care is often delayed and the recommended treatment protocols for management of febrile illness are not systematically applied. Children and adults do not always receive medication for febrile illness and when they do, it is not always the correct medication or dosage, as noted in MEDALI (Mission d’Etude des Déterminants de l’Accès aux Méthodes de Lutte antipaludique et de leur Impact) Quantitative and Qualitative 2014.

Study Goals aimed to Identify gaps, attitudes, and practices that may Prevent timely care seeking for febrile illness (within 24 hours after onset of fever) in the formal health system and Lead to nonadherence to national guidelines for malaria treatment. Key assessment questions included What strategies could be adopted to encourage pregnant women and caregivers of children under age 15 to use the formal health system as their primary resource for treatment of febrile illness? The study also asked What are the reasons that health providers do not systematically apply national malaria treatment guidelines?

Study districts were sampled from eight malaria operational zones. In-depth interviews with the following groups (N = 90). Facility health care providers, both public and private were included as were Community health workers and Caregivers of children under age 15 and pregnant women. Focus group discussions were held with caregivers of children
under the age of 15 years, including pregnant women (N = 16).

A Case scenario was reviewed with facility providers (N = 15). A case scenario is a description of a made-up situation involving a decision to be made or a problem to be solved. The case scenario used was febrile illness in children and pregnant women. This scenario allowed the study team to understand provider response. Provider responses to the scenarios are seen below.

 

From the review of case studies one could see that Facility provider diagnosis and treatment of malaria does not always conform to national protocol. Therefore, Targeted efforts to improve provider knowledge and practice are needed. Effort must be made to Ensure that standards/protocols are available in the health facilities and that providers have received guidance on the standards/protocols. Finally, Supportive supervision should be provided to address gaps in knowledge and practice.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID, PMI, or the United States Government.

Improved IPTp Uptake: MCSP Restoration of Health Services Experience in Liberia

Nyapu D.Taylor, Birhanu Getahun,Topian Zikeh, Anne Fiedler, and Allyson Nelson of the USAID supported Maternal and Child Survival Program/Jhpiego in Liberia are presenting their project aimed at strengthening health services in Liberia to improve uptake of Intermittent preventive treatment of malaria in pregnancy at the 7th Multilateral Initiative for Malaria in Dakar this week. Below are a description of their work and their main findings.

Mother and baby in Liberian Government Hospital, Grand Bassa County, Liberia. Photo by Kate Holt, Jhpiego.

In Liberia more than 170,000 pregnancies occur each year. Provision of two or more doses of SP for IPTp (IPTp2+) merely increased from 50% 2016. Provision of the three or more doses of

IPTp (IPTp3+) remains at 22%.Liberia adopted WHO’s IPTp3+ guideline but it is not practiced all over the country. There is a gap in the competency of the health care workforce. There are recurring stock-outs of SP.The Maternal and Child Survival Program (MCSP) Restoration of Health Services (RHS) intended to address these challenges. Project

Objectives included Prevention at facilities by strengthening infection prevention and control (IPC) practices at 77 health facilities through training, intensive supportive supervision, triage, improvement of waste management, and provision of essential IPC commodities and supplies.  Also the project aimed to Increase utilization of and demand for maternal and child health services bu restoring delivery of quality primary health care services through implementation of integrated reproductive, maternal, newborn, child, and adolescent health as part of the Essential Package of Health Services in 77 facilities.

MCSP RHS supported health facilities in three counties:

  • Grand Bassa: 30 (91% of health facilities in county)
  • Lofa: 17 (27% of health facilities in county)
  • Nimba: 30 (46% of health facilities in county)

Population coverage was 900,000 or 20% of population. This included 45,000 pregnancies per year. The Project timeline is September 2015–June 2018. The quality improvement process used in the project is seen in the attached diagram.

Several achievements were documented. Adherence to malaria clinical standards improved from 25% at baseline to 100% at endline in 39 MCSP-supported facilities—sampled at endline (see Figure 1). Adherence to malaria clinical standards improved substantially from baseline to endline in 39 MCSP-supported facilities—sampled at endline (see Figure 2). Increasing uptake of IPT2+ in the 77 RHS facilities has been observed since the inception of the project (see Figure 3).

The project met and dealt with several challenges. Health facilities were sporadically stocked with SP and mosquito nets (another component of malaria in pregnancy services). Bad roads prevented travel to field during rainy seasons. This affected distribution of malaria supplies and provision of mentorship and supervision for quality service. Clients had huge difficulty accessing health facilities.

Among the lessons learned were that close collaboration and involvement of key actors, especially MOH (National Malaria Control Program) and country health team at all levels, is an effective and efficient approach for project implementation. Regular mentorship and coaching during supportive supervision improves the quality of care provided for malaria in pregnancy. Ensuring availability of IPTp drugs and long-lasting insecticidal nets at health facilities are key to preventing malaria in pregnancy.

In conclusion the project met IPC objectives and achieved 80% Safe, Quality, Health Services score. Thus there was improved service delivery utilization.

The poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

Community Health Volunteers Contribute to Improved Malaria Prevention and Management in Kribi, Cameroon

Kodjo Morgah, Eric Tchinda, and Naibei Mbaïbardoum of Jhpiego (a Johns Hopkins University Affiliate) in Cameroon are presenting a poster at the Multilateral Initiative for Malaria Conference in Dakar this week. Their findings, seen below, show how community health volunteers can contribute to improving the quality of malaria control services in Chad and Cameroon.

CHV Lilian Kubeh preparing to administer a rapid diagnostic test. Photo by Karen Kasmauski.

Project objectives focused overall on contributing to the reduction of malaria-related morbidity and mortality in Cameroon and Chad. It also aimed to strengthen community-based interventions through the use of community health volunteers (CHVs) to manage simple cases of malaria and conduct awareness-raising activities. The geographic scope of the project was Kribi District in the south of Cameroon. Thirty-two health facilities are supported by Jhpiego. Kribi District has an estimated population of 134,876.

Reports from the National Malaria Control Program show that malaria is the leading cause of morbidity in Cameroon—an estimated 1,500,000 cases occur each year. In 2016, it was the leading reason for medical consultations (23.6% of all medical consultations) and hospitalizations (46% of all hospitalizations). Among children under 5 years of age, malaria accounted for 41% of all medical consultations and 55% of all hospitalizations. Malaria is also a leading cause of mortality. In 2016, Cameroon had 2,639 deaths caused by malaria—12% of all deaths across all age groups and 28% of all deaths among children under 5 years of age were attributed to malaria.

Project intervention strategies target the four levels of the health system. The CHV intervention was mobilized to support the strategy at the community level as seen in the attached diagram. In 2012 and 2014, 38 CHVs were selected by the community and received training to support areas in the district more than 10 km from a health center. (Note: 10 km was the measurement tool used to determine the geographic scope of each CHV for this project.) An initial donation of medications, data collection tools, and small equipment was made available to CHVs using funding from ExxonMobil Foundation.  An evaluation of the training intervention was conducted by an external consultant in April 2016.

CHV Daniel Ze conducting an individual educational session on IPTp. Photo by Karen Kasmauski.

CHVs conduct outreach activities in their communities—via home visits and community education sessions—to provide health education on malaria transmission and prevention, use of long-lasting insecticidal nets, the importance of intermittent preventive treatment in pregnancy (IPTp), and the importance of promptly seeking medical care for suspected cases of malaria. CHVs also support national health campaigns and health promotion events, including World Malaria Day. In Cameroon, where CHVs are also able to test and treat patients, they administer rapid diagnostic tests (RDTs) and treat cases of uncomplicated malaria.

Motivation of CHVs included ongoing training and technical updates, regular replenishment of materials, CHVs are recognized and respected community leaders, provision of per diem and transport costs, and continued advocacy targeting district officials to provide CHV stipends to ensure sustainability. Attached are details of the supervisory activities that provided continual technical support to the CHVs to ensure that they retain knowledge and skills to carry out their activities and track their data.

Between 2013 and 2016 CHVs in these communities were able to reach nearly 20,000 people with a variety of malaria services as seen in the attached table. The project paid close attention to data quality, which was reviewed with the CHVs on a regular basis, resulting in improved data quality.  CHVs improved the accessibility of malaria prevention and care services for communities living in remote areas. Results from April 2016 external evaluation show these results. Knowledge of malaria prevention is significantly higher in households that did not receive CHV support (p = 0.001). Use of long-lasting insecticide-treated nets is higher in households that benefitted from CHV support (88%) than in households that did not benefit from CHV support (73%) (p = 0.023). There was an increase in the delivery of IPTp2, from 60% in 2012 to 70% in 2016.

In conclusion CHVs have increased their communities’ access to health centers through referrals, health education on malaria prevention, IPTp, and treatment for simple and severe cases of malaria. Regular supervision of CHVs by their supervisors (the health zone managers) is essential to maintaining and strengthening CHV performance and motivation. Continuing advocacy efforts with local authorities is necessary to ensure that CHV activities are sustainable. The project team aims to establish a mechanism to improve documentation of its activities to better measure the impact on indicators at the community, facility, and district levels, and provide evidence for advocacy to sustain these efforts.

Malaria and Primary Health Care: 40 Years after Alma Ata

The Concept of Primary Health Care (PHC) was formalized in 1978 when The World Health Organization and UNICEF convened a major conference in the then Alma Ata in Kazakhstan. The resulting Alma Ata Declaration resulted in advocacy for Health for All, which had evolved into Universal Health Coverage. The Declaration outlined important principles such as community participation in health care planning and delivery, promotion of scientifically sound and acceptable health interventions, the use of community-based health workers (CHWs), and addressing the common endemic health problems in each community. One of those endemic problems common to a majority of communities in Africa is malaria. Now in 2018, 40 years after the Alma Ata Declaration we explore how malaria has progressed within the context of PHC.

The Roll Back Malaria Partnership (RBM) began in 1998, 20 years after Alma Ata. When RBM convened a meeting of African Heads of State in 2000 the resulting Abuja Declaration set targets for major malaria interventions of 80% coverage by 2010. The Abuja Declaration reflected principles of Alma Ata when it called on all member states to undertake health systems reforms which will:

  1. Promote community participation in joint ownership and control of Roll Back Malaria actions to enhance their sustainability.
  2. Make diagnosis and treatment of malaria available as far peripherally as possible including home treatment.
  3. Make appropriate treatment available and accessible to the poorest groups in the community.

By 2011 reality intervened. WHO reported that “In the 10 years that has passed since the Abuja Declaration, there has been progress towards increasing the availability of financial resources for health at least in terms of dollar values. However, there has not been appreciable progress in terms of the commitments the Africa Union governments make to health, or in terms of the proportion of GNI the rich countries devote to Overseas Development Assistance.” Since that time funding from international and bilateral donors has leveled, such that there is even greater need for malaria endemic countries to step forward and guarantee access to malaria prevention and treatment services are available through PHC at the grassroots. Such access needs to move beyond removing barriers to making malaria interventions attractive to the community.

Community Health Workers in Nigeria are trained to provide malaria community case management

Christopher and colleagues looked to the community and examined how response to malaria and other childhood illnesses were faring 30 years since Alma Ata. After they reviewed seven studies of community health workers they concluded that “CHWs in national programmes achieved large mortality reductions of 63% and 36% respectively, when insecticide-treated nets and anti-malarial chemoprophylaxis were delivered, in addition to curative interventions.” (They found little evidence of the effectiveness of these community interventions on pneumonia and diarrhoea.) The challenge they saw was the ability of countries to move beyond successful studies to scale up and sustain community malaria control interventions to the national level and thereby reap the full promises and benefits of PHC.

Others continue to advocate for a community role in achieving malaria goals through PHC. Malaria Consortium has looked at the position of malaria control within the context of Community Based PHC (CBPHC) and the use of CHWs as a means for revisiting Health for All.

Community donates a house in Western Region Ghana to serve as CHPS Compound where malaria services are provided to the community

Ghana’s community-based health planning and services (CHPS) program aims to make primary care accessible at the grass roots. CHPS compounds are small clinics in space usually donated by the community, staffed by community health officers who oversee community based agents (CBAs) and other community volunteers who treat and prevent malaria through integrated community case management. Countries have also build on the community directed intervention approach pioneered by the African Program for Onchocerciasis Control to ensure malaria interventions are delivered through community community planning and action.

Controlling and eventually eliminating malaria will certainly go a long way toward helping achieve Health for All. On this 40th Anniversary year of Alma Ata it is time to ensure that all malaria endemic countries and malaria donors revisit the basic philosophy of community action and participation and ensure that these principals guide us to accessible and sustainable malaria programming by the community “Through their Full Participation.”

(This posting has been extracted from a full article appearing in the April 2018 Issue of Africa Health. Also please join the discussion about Alma Ata at 40 on the forum created by colleagues at the Johns Hopkins Bloomberg School of Public Health.)

Multilateral Initiative for Malaria (MIM) – Jhpiego Presents in Dakar

The 7th Pan African Malaria Conference holds from 15-20 April 2017, Dakar, Senegal. The conference celebrates 20 years since the initial establishment of the Multilateral Initiative on Malaria (MIM) by the Tropical Disease Research Program and partners.

During the conference next week, staff from Jhpiego malaria projects in Burkina Faso, Liberia, Nepal, Madagascar and Cameroon will share oral and poster presentations to highlight their work. Below is a list along with the location numbers.

  • Application d’un Audit de la Qualité des données (DQA) du paludisme dans le District Sanitaire de Kribi, Cameroun, SS-13 Oral
  • Contribution des Agent de Santé Communautaire (ASC) à l’amélioration de la prévention et la prise en charge du paludisme dans le district de Kribi, Cameroun, B-40 Poster
  • MOH’s effort in developing and implementing Quality Assurance plan (QAP) for Global Fund-supported antimalarial drugs: A case study of Nepal in the context of malaria elimination, C-107 Poster
  • Community-Based Health Workers in Burkina Faso: Are they ready to take on a larger role to prevent malaria in pregnancy? D-115 Poster
  • Contribution of Community-Based Health Workers (CBHWs) to Improving Prevention of Malaria in Pregnancy in Burkina Faso: Review of health worker perceptions from the baseline study D-118 Poster
  • Malaria in Pregnancy: The Experience of MCSP in Liberia, D-140 Poster
  • Improved Malaria Case Management of Under-Five Children: The Experience of MCSP-Restoration of Health Liberia project D-141 Poster
  • Experiences and perceptions of care seeking for febrile illness among caregivers, pregnant women and health providers in eight districts of Madagascar D-142 Poster

Abstracts will be shared here on the day of each presentation for those unable to attend MIM. Also check Jhpiego at Exhibit Booth 148.