Tropical Health Matters

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Over the past few years everyone has been worried about the willingness and ability for donor nations to provide continued support for malaria control efforts – either multilaterally through Global Fund contributions, or bilaterally.  Recent changes at the Global Fund itself reinforced these financial fears.  What may have been overlooked is the financial health of recipient countries themselves.

Donor support for malaria control provides major assistance for commodities, but usually is not expected to support the running of the basic health system from which those commodities are delivered to people in need of prevention or treatment services.  Recent news from two malaria endemic countries in southern Africa call into question the basic ability of governments to provide basic human and material health infrastructure.

The BBC reports that, “Britain is calling for urgent action to prevent a Greece-style financial crisis in Malawi, one of the world’s poorest countries, where recent political turmoil, a suspension of foreign aid, and an abrupt currency devaluation have conspired to leave the new government with a gaping hole in its budget.”

The new president believes that there is less need to worry because of existing pledges for cash that suspended last year because of the increasingly autocratic behavior of her predecessor.  But it is often easier to turn off the financial tap than turn it back on.  Donors become wary and wait and see.

Likewise the behavior of political elites is causing concern in Swaziland. According to IRIN the International Monetary Fund is withdrawing support from the country where government spending currently exceeds its revenue. While there has been a revenue from the Southern African Customs Union since 2008, a more proximate cause of financial woes is “The spending habits of King Mswati III – sub-Saharan Africa’s last absolute monarch – and the royal household are routinely splashed across newspapers, from the overseas shopping trips of his 13 wives to a “birthday present” for the king this year of a multimillion-dollar private jet.”

IRIN notes that “About two-thirds of Swaziland’s 1.1 million population live in chronic poverty in a food insecure country that also has the world’s highest HIV/AIDS prevalence, with one in four people aged 15-49 infected.” This is not an environment where malaria can be eliminated, as is the goal of the South African Development Community.

Controlling and eliminating malaria in the context of a strong health system requires political will.  Some countries are making great strides. Maybe the African Leaders Malaria Alliance can be a forum for applying peer pressure for ‘good political behavior’.

The Global Fund Observer has poignantly highlighted the risks of losing a voice for civil society at the Global Fund.  The Fund to date had been one of the few donor groups to actively encourage civil society organization (CSO) participation on grant writing and management and has developed the innovative community systems strengthening approach to show that the people who live with the conditions supported by grants are as important as the systems that deliver formal health services.

While civil society is not perfect, it has served important functions within the Global Fund strategy.  To date the Global Fund Board has asserted the need for civil society representation on Country Coordinating Mechanisms (CCMS) as well as ensuring that CSOs are also considered equally as principal recipients (PRs) of funding.  This was based in part on findings some years ago that CSOs achieved better grant performance scores on average than did government or UN agency PRs.

CSOs come in many colors, but an important function of CSOs in any setting, even beyond the funding and management of Global Fund projects, is to serve as advocate and watchdog.   This is a crucial role as the GFATM’s Office of the Inspector General continues to uncover problems in grant management.  Here we don’t want to confuse NGO with CSO because some politically well connected NGOs have been caught with their hands in the till just as have government ministries. (One even wonders if recently disclosed Global Fund improprieties in Mali’s Ministry of Health were not a symptom of government weakness and corruption that led to its downfall?)

There is even worry expressed by the Civil Society Action Team that these moves might threaten the role of civil society in CCMs.
After dissolving the Civil Society Team at the GFATM, the new management wants civil society to feel happy that they now have several paths through which to pursue their interests – thus is laughable – the more paths, the more confusion and the less clear the status of civil society.

As mentioned from the start, the GFATM pioneered civil society involvement in major international grants processes because the ultimate recipients of such grants are often ignored with the consequence that targets are not achieved.  Most of the money that the GFATM receives comes from individual taxpayers in G8 countries. We taxpayers as members of our own communities want equal recognition of the members of endemic country communities in providing oversight to grants and becoming active participants in program implementation and evaluation.

It is not too much to ask that the people who should benefit most from the Global Fund have a distinct, definable role in the Fund’s processes.

Nancy Fullman shares highlights of Asia Pacific Malaria Elimination Network (APMEN) fourth annual meeting.

The twelve-country Asia Pacific Malaria Elimination Network (APMEN) is generating knowledge on what works to sustain the gains in malaria control and elimination during a time of malaria funding uncertainty. With the Republic of Korea as its host, the 2012 APMEN annual meeting takes place May 7 –11th 2012 in Seoul with the theme of “Efficiency in Elimination.” Focused on pressing malaria issues in the Asia Pacific region, APMEN countries and partners will discuss antimalarial drug resistance, cross-border importation of malaria cases, and maximizing program efficiency by identifying malaria “hot spots” and focusing interventions in these areas.

As the fourth of its kind, this APMEN meeting’s theme of “efficiency” reflects the urgent global need to maintain and expand malaria programs, in spite of substantial funding shortages related to the global financial crisis (e.g., postponed grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria)

With this meeting APMEN country representatives and partners aim to learn from country success stories – such as Cambodia’s impressive 35% reduction of malaria from 2010 to 2011 – and discuss strategic approaches for addressing the looming challenges of spreading artemisinin resistance and reducing the prevalence of Plasmodium vivax in the Asia Pacific. Although P. vivax is thought to account for fewer malaria deaths worldwide than P. falciparum (i.e., most prevalent strain of malaria in Sub-Saharan Africa), P. vivax is a main source of severe illness throughout the Asia Pacific region. Further, P. vivax currently has fewer effective treatment options than P. falciparum, which is a key research and investment issue identified by APMEN partners.

Since 2009, APMEN has brought together countries in the Asia Pacific that have adopted a national or subnational goal for elimination, as well as a broad range of key academic, development, non-governmental, and private sector partners. Through its regional network collaborations and annual gatherings, APMEN promotes the exchange of best practices, early introduction of innovative strategies, and support needed for country malaria control programs to push toward their goals for malaria elimination.

In 2012, work from several APMEN countries, including documentation of Bhutan’s malaria elimination efforts and subnational surveillance programs in the Solomon Islands, has received international attention. With Cambodia’s recent welcome to APMEN as the network’s twelfth country partner, this year’s APMEN meeting in Seoul aims to further broaden the dialogue among country partners and harness the region’s collective expertise to improve malaria elimination efforts in the Asia Pacific region.

Further information regarding APMEN can be found at www.apmen.org.

by Emmanuel Fiagbey, VOICES Project – Akosombo, Ghana: April 24, 2012

Volta River Authority (VRA) Heads of Departments and Safety Coordinators become Malaria-Safe Agents

The Volta River Authority, one of the largest body corporates in Ghana with a total workforce of over 3,000 personnel has made yet another move to live up to its motto of “Setting standards for public sector excellence in Africa.” The Authority with its many operational sites of workers and their families located in Akosombo and Akuse in the Eastern Region, Aboadze in the Western Region, Accra and Tema in the Greater Accra Region, Sunyani and Techiman in the Brong Ahafo Region, Tamale, Wa and Bolgatanga in the three northern regions of the country has embarked on efforts to make the authority a Malaria-Safe institution.

As part of activities marking the 2012 World Malaria Day, the Health Dept., Human Resource Dept., and the Project and Systems Monitoring Dept. of the VRA in partnership with the Johns Hopkins University Bloomberg School of Public Health Center for Communication Programs, (JHU-CCP) Voices for a Malaria-free Future project and the National Malaria Control Program, organized a one day training of 15 heads of departments and 30 Safety Coordinators of the Authority at Akosombo with the goal of equipping the officials with the knowledge and skill of operating as Malaria Safe Agents within the authority. Other departments represented at the training included the Environment and Sustainable Development Dept., Engineering Services Dept., Hydro Generation Dept., Thermal Generation Dept., General Services Dept., Real Estates and Utility Services Dept., Northern Electricity Dept., VRA Schools Dept., Corporate Communication Dept. and the Senior Staff Association.

In an opening speech read on his behalf by Mr. William Amuna, Director Project and Systems Monitoring Dept., the Chief Executive Officer of the VRA, Mr. Kweku Andoh Awotwi stated that the position of Safety Coordinators in organizing safety meetings places them in the best position and provides them the best platform to help promote malaria prevention and adoption of effective treatment behaviors among the VRA workforce, staff families and communities around them. “I would like to believe that today marks a humble beginning of the collaboration between the Volta River Authority and the JHU-CCP-Voices project for a more effective and efficient implementation of the authority’s malaria control program.”

In presenting the statistics on malaria cases within the authority, Dr. Rebecca Acquaah-Arhin, Director Health Services Dept. regretted the increase in malaria cases recorded at the authority’s health facilities in the past three years, (2009-2011) which rose from 10,803 cases in 2009 to 16,241 cases in 2011. Dr. Aquaah-Arhin explained that, in spite of the excellent health services the VRA provides to its workers and their families, and also reaching over 2 million inhabitants along the Volta lake, malaria remains a threat to performance and wellbeing. Stating the impact of the disease on the workforce, she noted that in 2009, 2,324 malaria cases were recorded among employees and their dependants. This rose to 2,523 in 2010 and dropped a little to 2,392 in 2011. Malaria, she stressed cost the VRA 82,943.84 Cedis (approximately $52,000) in 2011 alone, “and this is the challenge our partnership with the JHU-CCP Voices project and our Malaria –Safe program must lead us in planning and working to resolve,” she emphasized.

A National Voice against malaria, Dr. Atsu Seake-Kwawu who led the technical session of the training programme stressed that Safety Coordinators could only operate effectively as Malaria-Safe Agents by remaining continually in touch with current relevant information on the causes, prevention and treatment of malaria and most especially the recommended interventions by the NMCP in managing the disease. He called on all Safety Coordinators at the workplace and also in their communities to ensure the recent mass distribution of LLINs produces positive results by ensuring all who have the nets sleep under them every night. “Your role as Malaria-Safe Agents and Safety Coordinators will not be complete if you fail to challenge any health worker, drug distributors etc who will continue to distribute monotherapies such as Chloroquine in your community. ACTs, in particular the AMFm brand must remain your drug of choice for the treatment of all cases of uncomplicated malaria,” he stressed.

The VRA Malaria-Safe Strategy which was presented for discussion by the Country Director of the JHU-CCP-Voices for a Malaria Free Future project Mr. Emmanuel Fiagbey outlined the objectives, barriers, opportunities for applying the strategy and actions the Volta River Authority must sponsor in order to make the organization malaria-safe. Among the key functions of the authority’s Safety Coordinators as Malaria Safe Agents identified during the training workshop were:

• Incorporation of malaria information dissemination and education into the agenda of safety meetings at the workplace and in the community;
• Promotion and dissemination of malaria prevention and treatment messages among the workforce, staff families and communities;
• Facilitation and organization of special workdays to get rid of mosquito breeding sites in workers’ communities;
• Serving as models in the use of ITNs and adoption of other prevention and treatment behaviours among their community members; and
• Ensuring involvement of all departments of the authority in the implementation of the VRA Malaria-Safe Strategy in the three strategic objective areas of;
1. Strengthening the workforce against malaria to reduce the effect of malaria and enhance productivity of every worker.
2. Empowering mothers/caregivers and children and other dependants of VRA workers to be appropriately engaged in malaria prevention and treatment.
3. Engaging surrounding communities as partners and beneficiaries in malaria prevention and treatment.

The VRA Malaria-Safe Strategy which was developed with technical assistance from the Johns Hopkins University Center for Communication Programs Voices Project and the Asuogyaman DMAT will be finalized and officially launched in November as a major component of the VRA’s annual safety week celebrations.

Community Directed Distributors serving to save lives in Akwa Ibom State, Nigeria

by Bright C. Orji, Jhpiego, Nigeria

In 2011 when Jhpiego expanded its malaria program in Nigeria to include integrated community case management (iCCM) of malaria, diarrhea and pneumonia using community directed intervention (CDI) approach, the aim of the program was to encourage community participation through community selected volunteers in mobilizing community for better access to life-saving interventions. This iCCM intervention successfully built on existing CDI activities including distribution of insecticide treated nets and intermittent preventive treatment (IPTp) using sulphadoxine-pyrimethamine (SP) as well as an increased ante natal care attendance through community referral.

The communities in the CDI program were required to select as volunteers members of the community whom they trust and who were able to read and write, reside in the community and more importantly be willing to volunteer their time. The volunteers at the end of their training and under the supervision of the health facility lifesaving interventions such as conducting parasitological diagnosis of malaria using Rapid Diagnosis test (RDTs) and provision of anti-malarial drugs (ACTs) to the door steps of those at risk. They treated the three conditions according to the national guidelines.

Not only did communities select their own volunteers, but over time engaged in self-monitoring of the program and oversight of the volunteers, ensuring that community members volunteered actually carried out the tasks they agreed to take on. Communities also designed their own reward systems for the volunteers.

Ekpuk Essien and Ekpuk Itiat are kindreds (clans) in rural Ndon Eyo and Ikot Annang communities in the Niger Delta region of Southern Nigeria. Ekpuk Essien has a total of 29 households with 294 population compared to Ekpuk Itiat with 33 households and total population of 381. Both communities base their livelihoods on farming.

Ekpuk Essien selected Mrs. Comfort John while Ekpuk Itiat selected Mrs. Aniefiok Udofat and Uduakobong Aniedi Ikpe as volunteers. All the volunteers were trained at the same time on iCCM. On returning from the training Comfort went from one house to another treating children with fever and encouraging mothers and care-givers to ensure their wards slept under insecticide treated nets.

Last December, Ekpuk Essien recognized and rewarded Comfort with cash and promised to give her some seedlings for the forth-coming farming season. These are efforts to encourage Comfort to continue with her resourcefulness to the community.

However, this cannot be said of the Ekpuk Itiat. When Uduakobong and Aniefiok returned from the training. Uduakobong travelled to Uyo the capital city, her colleague Aniefiok was waiting for her return before providing services. Uduakobong failed to return at the agreed time. Itiat community has waited for almost a month without the volunteers providing services and meanwhile the volunteers had collected monthly stipend, a monthly token the community agreed to contribute to support the volunteers.

Therefore, the community summoned them and imposed a fine of one goat for failing to provide services. With current challenges in the management and control of malaria funding, the emergence of community self-monitoring gives the hope of Sustaining Gains, Saving Lives that would lead to more Investment in Malaria.

Both of these villages demonstrated the importance of community self-monitoring of health programs. Health workers can provide technical supervision for CDI and iCCM efforts, but only the community can hold its members accountable for delivering the life saving services.

Rwanda on track to zero deaths from malaria by 2015

By Dr. Corine Karema

Today, April 25th, the world will be commemorating Malaria Day as stipulated in the Abuja Declaration of 2000. Just like the previous years, Rwanda will join the rest of the world in commemorating this day by highlighting achievements in controlling Malaria while also renewing commitment of achieving zero targets of malaria related deaths by 2015.

The theme for this year’s World Malaria Day is “Sustain Gains, Save Lives: Invest in Malaria”, a theme that is testimony to the renewed global commitment of finding lasting solutions for eliminating Malaria from our midst.  For Rwanda, a country that has registered significant progress in combating Malaria, this commitment is a shared vision for which we attach greater value.

Coming up with sustainable and investment solutions for Malaria control is a new discourse which underlines the importance of continued investment in combating this disease with the view of propelling malaria-endemic countries along the path of achieving the health and poverty related Millennium Development Goals by 2015. Here in Rwanda, the battle against Malaria has not been an easy one. It has called for strategic interventions, committed leadership of our government and support from development partners to register progress that we see today across the country.

I will share with you some of the outstanding achievements we have registered over the past years, many of which are captured in the recently released 2010 Demographic Health Survey (DHS). The recent scaling up of interventions has made significant progress:

• reductions in morbidity by 87% from 1,669,614 malaria cases in 2005 to 212,200 cases in 2011 and
• reduced mortality by 76% from 1,582 deaths in 2005 to 380 deaths in 2011.

This reduction is as a result of scaling up of preventive measures especially coverage and use of long lasting insecticidal nets (LLINs) which according to the 2010 DHS results…

• 82% of households have at least one LLIN
• 72% of pregnant women slept under their nets and
• 70% of children under-five years were using bed nets

Previously and as the case is in most developing countries, Malaria is treated based on signs and symptoms. However, Rwanda is one of the few countries in the world today where up to 94 percent of Malaria cases are laboratory through microscopy or rapid diagnostic tests at all levels of health care structure including the community level.

The involvement of Community Health Workers (CHWs) in early diagnosis and treatment of children Under-five years has also had an impact on malaria incidence throughout the country as currently 95% of children are tested and treated for malaria within 24 hours of symptoms onset.

In addition, Malaria control activities have been integrated and decentralized at all levels including –

• a strong CHWs network which facilitates community involvement and participation,
• the community health insurance scheme also known as Mutuelles de Sante and
• a strong Health Management Information Systems (HMIS) including the web based community health information system (SIS.com)

The above interventions are strengthened by use of mobilisation and sensitisation campaigns using different channels of communication. The advocacy and social mobilisation is oriented towards intensifying different efforts to sustain the gains made as the country moves towards pre-elimination phase of malaria as outlined in the new Malaria Strategic Plan (2012-2017).

To emphasize on the importance of the World Malaria Day, this year’s event will be held during the scheduled Rwanda Malaria Forum that will be held in Kigali in mid June 2012. The Forum will bring together malaria experts from international community who will deliberate on the challenges African countries and in particular, Rwanda, face in malaria control and how to overcome them.

The recommendations of the forum will guide our sector in finalizing the new Malaria Strategic Plan that outlines Rwanda’s strategies from malaria control to pre-elimination phase by 2017. A series of activities to run for a week have also been planned to reach community levels where different interventions of promoting awareness on preventive measures will be discussed with input from community leaders.

Therefore, as we mark this day in Rwanda, we take pride of our achievements but also remain mindful and conscious of the challenges ahead a in realising the ambitious target of having a Rwanda that is free from Malaria.

The Author is Head of Malaria and Other Parasitic Diseases Division Rwanda Biomedical Center/IHPDPC, Follow: Twitter @ckarema

Intermittent Preventive Treatment of Malaria in Pregnancy (IPTp) as part of antenatal care (ANC) is a key malaria control strategy in areas of stable falciparum transmission.  Growing resistance of parasites to the drug used for IPTp, sulfadoxine-pyrimethamine (SP) have led malaria program managers to wonder whether they should stop IPTp.  Information presented at the Roll Back Malaria (RBM) Partnership’s Malaria in Pregnancy Working Group meeting this week in Kigali, Rwanda, cautions about not throwing the baby out with the bathwater.

Peter Ouma of the Kenya Medical Research Institute/US Centers for Disease Control & Prevention and a member of the Malaria in Pregnancy Research Consortium shared research that showed continued value of SP for IPTp. Peter shared data on the importance of three doses of IPTp on reducing placental parasitemia, the condition that causes inter-uterine growth retardation and is especially helpful for primi- and secundi-gravidae.

Three IPTp doses is within the context of the recommended “at least two” doses recommended for pregnant women after quickening in stable transmission areas. In fact some countries like Ghana already recommend three.

Peter also advocated for more attention to SP drug quality. Most of the donors focus attention on quality approval processes for the treatment drugs – artemisinin-based combination therapy (ACT) – but many countries buy their own SP from various sources. Thus continued use of IPTp with SP should be linked with drug quality control to achieve maximum effectiveness.

Of course people recognize that SP will eventually need to be replaced.  Various individual and combination drugs are being tested. Richa Chandra of Pfizer presented information on one such preventive treatment – Azithromycin and Chloroquine FDC (AZCQ).  Most interestingly, AZCQ was found to be synergistically effective even with parasite strains that were resistant to chloroquine.

Should research favor roll out of AZCQ, practical planning and costing issues would need to be addressed. Like other drugs being tested, this combination would need to be given for three days unlike the one-time-only treatment dose of SP. Richa stressed the importance of community engagement if adherence to this 3-day regiment is to be achieved.

There was fear from the programmatic side that early cessation of IPTp within ANC would create a programming gap, such that when a replacement drug or combination comes along, it would be difficult to reintroduce IPTp into the ANC routine.  But continued IPTp with SP is more than a placeholder; scale up and maintain IPTp programs in our high transmission countries will still save lives.

Currently the Roll Back Malaria (RBM) Partnership’s Malaria in Pregnancy Working Group is meeting in Kigali, Rwanda. Seven country teams present have presented their progress and challenges, including most recent information on coverage/use of long-lasting insecticide treated nets (LLINs) and intermittent preventive treatment for pregnant women (IPTp).  Other working group members have also presented coverage data from other countries.

Two main challenges emerged. First, for the most part stable endemic countries that are using IPTp and reporting recent levels of coverage for this and for LLINs are hardly reaching the 2010 RBM targets of 80%.  The second challenge is that some countries have actually recorded recent drops in IPTp coverage.

Group members presented experience and research that help explain these challenges.  Coverage with the minimum two doses of IPTp has been hampered by the following:

• periodic stock-outs of sulfadoxine-pyrimethamine (SP) supplies
• complexity of the steps involved in providing IPTp properly as directly observed treatment at antenatal clinic
• poor dissemination of national malaria in pregnancy (MIP) policies and guidelines
• inconsistencies in IPTp guidelines between malaria control and reproductive/maternal health service units
• lack of coordinated planning between those two units

The second problem, as seen in the chart to the left may be due to the above mentioned factors, but also imply more serious health systems problems. SP has become a forgotten step-child in the essential medicines portfolio.  Once reduced treatment efficacy was observed with SP, countries began switching to artemisinin-based combination therapy (ACT) for case management. SP was, according to meeting participants, still efficacious for prevention, but the formal health sector has not always responded by keeping it in stock.

In fact the private sector still stocks SP because customers demand this cheaper alternative to ACT, even though such unregulated use may add to the problem of parasite resistance.  Also donor programs, recognizing that SP is relatively cheap, often rely on endemic countries to purchase their own SP stocks, which some are reluctant to do.

IPTp saves lives in countries with stable malaria. The pregnant woman herself may not ‘feel’ the results of malaria that is concentrated in her placenta, but the fetus is deprived of nourishment and may be spontaneously aborted, stillborn, or born with low birth weight that increases the likelihood of neonatal mortality.

The 2012 World Malaria Day Theme of Sustain Gains, Save Lives: Invest in Malaria, could not be more timely in light of the charts seen here.  First we still have to make the gains in many countries, especially in respect to protecting pregnant women.  We need to sustain gains, not backslide.  This can only be done if donors and health ministries continue to fund MIP control activities and health program managers in both malaria control and reproductive health sincerely collaborate.

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.

Identified 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.

Opportunities 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.