Category Archives: Case Management

Guinea: The Challenge of Malaria Control in a Post-Ebola Context

The preliminary 2018 Demographic and Health Survey (DHS) data have been released for Guinea (Conakry). Since the last DHS in 2012, Guinea and its neighbors experienced the largest Ebola outbreak in history, an event that damaged already weak health systems.

The previous DHS showed very weak malaria indicators. Only 47% of households had at least one ITN, which averages to 0.8 ITNs per person (compared to the universal coverage of 2.0). Among vulnerable groups only 26% of children below the age of 5 years slept under an ITN, as did 28% of pregnant women. Very few, 18%, pregnant women got two doses of IPTp, and only 5% of febrile children received ACTs (testing was not reported then).

Not much has changed concerning ITN coverage as reported in 2018. Slight improvements are seen in IPTp (which now requires 3 or more doses) and malaria testing and treatment for children. Ironically none of the indicators has passed the original 2006 Roll Back Malaria target of 60%, let alone 80% for 2010 and not of course the drive for universal coverage.

DHS has released a preliminary report for 2018 and the malaria component is summarized in the charts posted here. The national coverage for ITNs is 44%, slightly lower than 2012, but the average per household member is slightly higher at 1.1. Again, these numbers do not mark significant progress. Looking at wealth and ITN ownership there is a slight benefit in terms of equity in net possession among those with lower income, but this must be seen in the overall context of very low basic coverage.

Having a net in the household and using it are different challenges as seen in the reports of sleeping under the net on the night prior to the survey among children under 5 years of age and pregnant women. The sad finding is that even in households that own a net, the coverage of these two groups remains very low. This is reflected in the low net per person ratio nationally (1.1).

One would almost wonder if malaria is a neglected disease in Guinea. The reality is that since 2003, Guinea has received around $172 million US dollars in malaria project funding from the Global Fund. Its most recent annual funding from the US President’s Malaria Initiative (PMI) is around $14 million.  Of that PMI funding 24% was designated for nets and related activities, while 52% was to be spent on medicines, diagnostics and pharmaceutical management. These investments include systems strengthening and capacity building in addition to commodities.

PMI provides the needed context: “Since the country was declared Ebola-free in in June of 2016, Guinea continues to make positive advances towards building a strong health system in line with the health recovery plan. The government continues to mobilize internal and external resources for rolling out the health system recovery plan, but much remains to be done if this plan is to yield the intended results.” Areas in particular need of strengthening within the National Malaria Control Program include coordination, health information systems, leadership, supervision and logistics.

Three years have passed since the last Ebola case in Guinea. Hopefully the country can stave off another outbreak and at the same time strengthen its health system. Guinea may not yet be targeted for malaria elimination, but until systems are strengthened, the resources going into malaria control will not be able to push malaria indicators toward saving more lives.

A child’s personal experiences with malaria lead to a life career fighting the disease

Gbenga Jokodola tells his story of growing up to fight malaria in Nigeria. Gbenga has a MPH in Field Epidemiology from the University of Ibadan, and a BPharm from Ahmadu Bello University. He is currently working with Malaria Consortium as a Zonal Project Manager on the Seasonal Malaria Chemoprevention (SMC) Project, delivering preventive care to over 400,000 children between the ages of 3 – 59 months in Jigawa and Katsina States of Nigeria. He has worked on several malaria projects over the years sponsored by Unicef, the Global Fund, Catholic Relief Services and the Bill & Melinda Gates Foundation. As he narrates below, his early experiences with malaria were formative of his present focus in life.

At 3 months of age Gbenga was probably still protected from malaria by maternal antibodies and did not realize what malaria held in store for his future

Growing up in Zaria, northern Nigeria in the 70s and 80s was one of the best experience any child could ask for. I lived with my parents in two rented rooms in a compound on one of the streets in Sabon Gari Zaria – a community that had virtually all the tribes in Nigeria and of course, with all the love and communal living you can ever get from a true Nigerian community.

In such loving setting we enjoyed as children, I imagined that mosquito communities also lived around our pit latrine and backyard. I imagined that parent-mosquitoes trained their off-springs very well on how to bite and fly away tactfully, how to dodge the usual clap-like manner we use in killing mosquitoes, which homes to avoid visiting, and so on.

I was reputed to be a strong boy then, one of the few kids who were “strong”; I was a “tough” boy who rarely fell ill to malaria. Then, it was common to hear, “Gbenga is a strong boy”. I ate and slept in any room in our compound – with or without covering from mosquito and was hailed for doing so by my friends who often fall ill to malaria.

Life lesson as a Primary School pupil: There is no immunity against malaria

One day, the “malaria forces” (mosquitoes) taught me a life lesson: Indeed, there is no immunity against malaria.

My local Government primary school rotated school attendance between morning and afternoon every week. As an 8-year-old, while preparing for my afternoon school I suddenly felt very cold and sleepy at the same time and decided to lie down briefly on my senior brother’s 6-spring bed in our sitting room. Shortly after, I was shivering and sweating profusely under 3 of my mother’s wrappers.

Help was not immediately near as most people were out. My head was pounding like I was a piece of yam being pounded with a pestle in my mother’s mortar. My stomach was churning. All the while, I kept saying “I am a strong boy, I will not be sick”! I was in that state for over an hour. I began to wonder if I was strong after all and will not end up dying. I could no longer talk but my teeth were chattering.

Gbenga second from left at about 7 years old in company of Sisters and friends in the compound

Sweating profusely, yet I was cold! I was helpless. It was in this state that one of our neighbor’s daughters walked into our sitting room, wondering if there was any food to eat. Immediately she saw the “strong man” shivering under 3 wrappers, she raised an alarm. Her shout saved me as neighbors immediately rushed into our sitting room. Among them was a relation of the landlord, a beautiful “Aunty” Esther, who was visiting from the Ahmadu Bello University school of Nursing. As soon as she came over, she said: “this is malaria!”.

Aunty Esther immediately organized and rescued me that day; she saved the life of the “strong man”! She quickly sought iced-cold water and toweled my body with my father’s “untouchable” towel hanging on the door of the inner room. Ah, what a good feel it was! She then gave me a sweet syrup which I later found out to be Paracetamol syrup. After about 30 minutes, she returned with a plate of hot rice and stew, encouraging me to eat before treatment with anti-malarial medication. I struggled to eat the rice, angry that I had lost my ever-available appetite! I only took few spoons, amidst the encouragement I received from all present.

I was then given an injection by Aunty Nurse Esther, tucked back into the bed and told to prepare to sleep. She then said, “Gbenga, no school for you today, okay? You even need to get well before you resume school”. Everyone knew I loved school. I had to lose a precious school day (and three more days) to malaria! So, I simply focused on staying alive, wondering which “wicked” mosquito bit me. That was the day I dramatically lost my title of “strong man” to malaria, painfully realizing that I was not immune to malaria at all!

My treatment against malaria was continued with further jabs of the needle (twice a day) over the course of the next 3 days at the Dispensary/Primary Health Unit “Aunty” Esther directed my parents to. I got well and resumed school after the third day. Later, I researched and found out I was treated with a sedative, Chloroquine and Paracetamol.

Gbenga with classmates at First Baptist Church, Benin Street, Sabon Gari Zaria

My parents later introduced “Sunday-Sunday Medicine” (one Sweetened pyrimethamine tablet weekly) against Malaria to our diet on Sundays. With this painful encounter with Malaria, I resolved to fight mosquitoes; I was determined to regain my “strong man” title. I made up my mind to be a community health worker, saving communities from diseases like malaria.

Fast-forward to Year 2007: My new twist in combating Malaria

By the year 2007, my personal malaria episodes had lessened with greater knowledge of the disease. In addition, the application of the preventive, diagnostic and treatment procedures reduced my malaria episodes to about 1 in 3 years. With each episode, I normally use laboratory test (microscopy) to confirm if severity is +, ++, or even +++. Thereafter, I get a prescription from a Physician on appropriate medication to use.

However, while practicing in Abuja, I encountered a tearful case of death from malaria, of an 8-year old beautiful daughter of a colleague. Three days prior to her death, a Community Pharmacist had dispensed anti-malarial medication to her, based on prescription tendered by the father from a Government hospital he had earlier taken her to. The news of her death brought back memories of how I would have died as

ACCESS-SMC Project: Scaling up access to seasonal malaria chemoprevention in the Sahel

an 8-year old from this same Malaria. Yes, this same Malaria! That death of the 8-year old triggered a fresh resolve in me to step up my fight with mosquitoes and combat malaria squarely at community, state, National and global levels.

Still at War with Malaria in 2018

Now armed with post-graduate training in Public Health/Epidemiology and field-based experience, my Malaria diagnosis strategy has now changed. I now use Rapid Diagnostic Test Kits (RDT). If confirmed positive, I receive prescription on the most applicable Artemisinin-based combination Therapy (ACT) to use.

My malaria story continues and will only end when mosquitoes are defeated – when children and adults no longer fall ill nor die from mosquito bites that cause malaria.

You can follow Gbenga on Twitter.

Asymptomatic Malaria – we need to eliminate what we can’t see

After the World’s first attempt at eradicating the complicated disease malaria mainly through a single tool, a period of control set in where the aim was to reduce mortality through prompt and presumptive treatment of fevers with anti-malarials, particularly in young children. During this period in the 1980s and 1990s it was recognized that parasite-based diagnostic capabilities in the form of microscopy were limited, so in malaria endemic areas, it was worth providing inexpensive medicines like chloroquine (CQ) and sulfadoxine-pyrimethamine (SP) to febrile children in order to save lives. When the fevers did not resolve, other illnesses explored.

The difficulty arose in identifying cases that did not offer clinical clues that they might be malaria. Today countries approaching malaria elimination face challenges, such as seen in Zanzibar where, “outdoor transmission, a large asymptomatic parasite reservoir and imported infections, require novel tools and reoriented strategies to prevent a rebound effect and achieve elimination.”[i] Here we examine the challenge of asymptomatic malaria infections.

Background

By 1998 when the Roll Back Malaria partnership formed, there had been enough research done so that the malaria community had a better arsenal of interventions including insecticide-treated bed nets, artemisinin-based combination therapy (ACT) and intermittent preventive treatment with SP during pregnancy. The Abuja Declaration of 2000 set a target of 80% coverage of these interventions by the year 2010.

While ACTs overcame the challenges of parasite resistance that had developed for the single drugs, CQ and SP, it cost several times more than those medicines. The need for easy-to-use, inexpensive, point-of-care diagnostics was recognized so that not only would ACTs be targeted only to parasitologically confirmed malaria cases, but also in the process, overuse and misuse would not contribute to parasite resistance of these new drugs.[ii] Unfortunately, the development and dissemination of antigen-based rapid diagnostic tests (RDTs), lagged behind the availability of ACTs meaning that health workers unfortunately continued their business as usual with presumptive treatment using ACTs. 

The benefits of RDTs were generally two-fold. First, they could be used by front-line, auxiliary and community-based health workers. Secondly, they tended to identify more cases than microscopy. The big challenge was convincing health workers to use them and trust the results, because the era of presumptive treatment had given these staff a false sense of confidence in their own clinical diagnostic abilities.

Although reaching the 2010 coverage targets has remained illusive for most endemic countries, there has been enough progress for major reductions in incidence (despite a recent upsurge).[iii] As the proportion of actual malaria cases among febrile illness patients declines, concern has risen that transmission might continue among people with subclinical or asymptomatic malaria. Here we explore the extent of this problem and new directions in parasitological testing needed to ensure continued progress toward elimination in each endemic country.

Understanding the Risk of Asymptomatic Malaria

Risk can relate to geographical, epidemiological, and socio-demographic factors as well as history of malaria interventions. Kenya has stratified the country by higher and lower malaria transmission areas. Even the higher areas are comparatively low compared to its higher transmission neighbors. Studying the prevalence of asymptomatic malaria in some of these higher transmission areas in the west of the country was seen as a way to better identify people at risk and learn about intervention effectiveness. An examination of apparently healthy children (no symptoms) revealed a Plasmodium falciparum malaria prevalence 36.0% (27.5%, 44.5%) by RDT and 22.3% (16.0%, 28.6%) by thick film microscopy.[iv] Living in a household with electricity was protective but the adjusted odds ratio of prevalence comparing households with and without indoor residual spray showed only borderline benefit. Unfortunately, in Zanzibar, asymptomatic malaria infection was not associated “with use of any vector control.”1

A major challenge in detecting cases through routine health care systems is care seeking patterns of care seeking for fever. The 2018 World Malaria Report acknowledges that there are major equity challenges in care seeking wherein families with higher incomes, better education and living in urban areas are more likely to seek help for their febrile children that rural, poor and less educated families who would be more at risk. Care seeking without the signs of fever is more challenging. A dual strategy of enabling better service utilization as well as outreach to detect cases will be necessary to detect asymptomatic cases.3

In Burkina Faso, the prevalence of asymptomatic malaria infection in children under 5 years of age was estimated at 38.2% in 24 of its 70 health districts. Those at most risk for asymptomatic malaria infection included the following:[v]

  • older children (48–59 vs < 6 months: OR: 6.79 [5.62, 8.22])
  • children from very poor households (Richest vs poorest: OR: 0.85 [0.74–0.96])
  • households located more than 5 km from a health facility (< 5 km vs ? 5 km: OR: 1.14 [1.04–1.25])
  • localities with inadequate number of nurses (< 3 vs ? 3: 0.72 [0.62, 0.82]
  • rural areas (OR: 1.67 [1.39–2.01])

Nine districts reported significantly higher risks (Batié, Boromo, Dano, Diébougou, Gaoua, Ouahigouya, Ouargaye, Sapouy and Toma. The researchers concluded that, “Such national spatial analysis should help to prioritize areas for increased malaria control activities.”

A study in Ghana found that, “children and pregnant women had higher prevalence of submicroscopic gametocytes (39.5% and 29.7%, respectively) compared to adults
(17.4%).”[vi]

An additional concern is emerging in terms of sharing of malaria parasite species between humans and primates, especially as urbanization and deforestation push these two populations into closer contact. For example Mapua and colleagues working in Central Africa Republic, “found the human malaria parasite P. ovale wallikeri in both asymptomatic humans and western lowland gorillas in Dzanga Sangha Protected Areas. Molecular analysis revealed that the genotype of the P. ovale wallikeri DNA found in a gorilla was genetically identical to that of a human isolate within the mt cytb and mt cox 1 genes, indicating potential human–ape transmission.”[vii] They noted similar sharing of parasites in the region between humans and chimpanzees.

Detecting and Responding to Asymptomatic Cases

WHO’s Framework for Malaria Elimination[viii] recognizes the important role of case detection and subsequent treatment as well as broader community level preventive responses around detected cases. In the context of elimination WHO notes that case detection “requires use of a diagnostic test to identify asymptomatic malaria infections.” WHO stresses that a case is a case, regardless of whether it is symptomatic or asymptomatic, as long as the diagnostic process confirms presence of malaria infection.

It is important to monitor Plasmodium parasitemia in areas where malaria transmission has declined and efforts to achieve malaria elimination are underway, such as Zambia, where 3,863 household members were tested.[ix] Only 2.6% were positive by either microscopy, RDT, or PCR. Of these, 48 (47%) had subpatent parasitemia, and 85% of those with subpatent parasitemia were asymptomatic. “Compared with individuals without parasitemia, individuals with subpatent parasitemia were significantly more likely to be aged 5–25 years.” The authors suggested that their findings pointed to the need for active or reactive case detection to identify asymptomatic individuals and thus better target individuals with subpatent parasitemia with appropriate malaria interventions.

WHO explains that active case detection (ACD) takes place in areas of limited or under-utilization of health care services.4 It may start with initial screening for symptoms, followed by appropriate parasitological laboratory confirmation. In low-transmission settings or as part of a focus investigation, “ACD may consist of testing of a defined population group without prior symptom screening (population-wide or mass testing) in order to identify asymptomatic infections.” Elimination cannot be achieved until even asymptomatic infections have stopped. The challenge is the expense of community-wide screening.

Reactive Case Detection (RCD), according to WHO, takes place in settings low transmission intensity where the few “occurring malaria cases are highly aggregated.”4 When a case is identified, usually through identification of an actual infected patient at a local clinic, the community where the patient comes from is visited and a “net is cast around the index case” where household members and neighbors within a selected radius are tested. In this process asymptomatic cases are also identified.

Our existing diagnostic tools may be inadequate. McCreesh and colleagues reported on subpatent malaria in Namibia that, “fever history and standard RDTs are not useful to address this burden. Achievement of malaria elimination may require active case detection using more sensitive point-of-care diagnostics or presumptive treatment and targeted to high-risk groups.” This includes loop-mediated isothermal amplification (LAMP) using dried blood spots, which they tested.[x] Likewise from experience in a Zambian study, Kobayashi and co-researchers suggest, “more sensitive diagnostic tests or focal drug administration may be necessary to target individuals with subpatent parasitemia to achieve malaria elimination.”[xi]

Responses to detecting asymptomatic cases start at the individual level with prompt treatment of those found through RCD to be infected. Then focused preventive interventions such as distribution of insecticide treated bednets can be provided to those in the cluster or village. Follow-up would be needed for such ‘hot spots.’ 

On a broader basis we have Seasonal Malaria Chemoprevention (SMC) as practiced in Sahelian countries where during the peak transmission (rainy) season intermittent preventive treatment is given to children monthly by community health workers and volunteers. Of course, many of these children would be asymptomatic carriers and SMC could benefit the reduction of parasites in circulation. At present SMC focuses on pre-school aged children, but Thera and co-researchers stress the importance of reaching school aged children who are also often asymptomatic carriers.[xii]

Another intervention being tested for mass drug administration (MDA) use providing the community with ivermectin, a drug that has been highly effective in controlling filarial diseases and also found to kill mosquitoes who take a blood meal from a person who has recently taken it.[xiii] This strategy is still being tested, but again MDA means all community members, especially those with asymptomatic infection, would be reached.

A major question requires further research. To what extent do asymptomatic, submicroscopic and subpatent parasitemia contribute to continued malaria transmission? Another question is how can we address malaria infection in other primates? We know that scientists recommend targeting of malaria elimination interventions based on mapping of these infections.5 We therefore need to study the actual transmission potential of this phenomenon.


[i] Björkman A, Shakely D, Ali AS, Morris U, Mkali H, Abbas AK, Al-Mafazy A-W, Haji KA, Mcha J, Omar R, Cook J, Elfving K, Petzold M, Sachs MC, Aydin-Schmidt B, Drakeley V, Msellem M and Mårtensson A. From high to low malaria transmission in Zanzibar—challenges and opportunities to achieve elimination. BMC Medicine (2019) 17:14, https://doi.org/10.1186/s12916-018-1243-z

[ii] Global Malaria Programme. Universal access to malaria diagnostic testing – An operational manual. World Health Organization. November 2011 (rev. February 2013). https://www.who.int/malaria/publications/atoz/9789241502092/en/

[iii] Global Malaria Programme. World malaria report 2018. World Health Organization. 19 November 2018. https://www.who.int/malaria/publications/world-malaria-report-2018/en/

[iv] Peprah S, Tenge C, Genga IO, Mumia M, Were PA, Kuremu RT, Wekes WN,  Sumba PO, Kinyera T, Otim T, Legason ID, Biddle J, Reynolds SJ, Talisuna AO, Biggar1 RJ, Bhatia K, Goedert JJ, Pfeiffer RM, Mbulaiteye SM. A Cross-Sectional Population Study of Geographic, Age-Specific, and Household Risk Factors for Asymptomatic Plasmodium falciparum Malaria Infection in Western Kenya. The American Journal of Tropical Medicine and Hygiene, Volume 100, Issue 1, Jan 2019, p.54-65. DOI: https://doi.org/10.4269/ajtmh.18-0481.

[v] Ouédraogo M, Samadoulougou S, Rouamba T, Hien H, Sawadogo JEM Tinto H, Alegana VA, Speybroeck N and Kirakoya?Samadoulougou F. Spatial distribution and determinants of asymptomatic malaria risk among children under 5 years in 24 districts in Burkina Faso. Malaria Journal 2018; 17:460 https://doi.org/10.1186/s12936-018-2606-9

[vi] Lamptey H, Ofori MF, Kusi KA, Adu B, Owusu-Yeboa E, Kyei-Baafour E, Arku AT, Bosomprah S, Alifrangis M, Quakyi IA. The prevalence of submicroscopic Plasmodium falciparum gametocyte carriage and multiplicity of infection in children, pregnant women and adults in a low malaria transmission area in Southern Ghana. Malar J. 2018 Sep 17;17(1):331. doi: 10.1186/s12936-018-2479-y.

[vii] Mapua MI, Hans-Peter Fuehrer HP, Petrželková KJ, Todd A, Noedl H, Qablan MA, and Modrý D. Plasmodium ovale wallikeri in Western Lowland Gorillas and Humans Central African Republic. Emerging Infectious Disease journal. Volume 24, Number 8—August 2018. https://wwwnc.cdc.gov/eid/article/24/8/18-0010_article

[viii] Global Malaria Programme. A framework for malaria elimination. ISBN 978-92-4-151198-8. World Health Organization 2017, http://www.who.int/malaria/publications/atoz/9789241511988/en/

[ix] Kobayashi T, Kanyangarara M, Laban NM, Phiri M, Hamapumbu H, Searle KM, Stevenson JC, Thuma PE, Moss WJ and the Southern Africa International Centers of Excellence for Malaria Research. Characteristics of Subpatent Malaria in a Pre-Elimination Setting in Southern Zambia. The American Journal of Tropical Medicine and Hygiene, 10 December 2018, DOI: https://doi.org/10.4269/ajtmh.18-0399

[x] McCreesh P, Mumbengegwi D, Roberts K, Tambo M, Smith J, Whittemore B, Kelly G, Moe C, Murphy M, Chisenga M, Greenhouse B, Ntuku H, Kleinschmidt I, Sturrock H, Uusiku P, Gosling R, Bennett A, Hsiang MS. Subpatent malaria in a low transmission African setting: a cross-sectional study using rapid diagnostic testing (RDT) and loop-mediated isothermal amplification (LAMP) from Zambezi region, Namibia. Malar J. 2018 Dec 19;17(1):480. doi: 10.1186/s12936-018-2626-5.

[xi] Kobayashi T, Kanyangarara M, Laban NM, Phiri M, Hamapumbu H, Searle KM, Stevenson JC, Thuma PE, Moss WJ, For The Southern Africa International Centers Of Excellence For Malaria Research.Characteristics of Subpatent Malaria in a Pre-Elimination Setting in Southern Zambia. Am J Trop Med Hyg. 2018 Dec 10. doi: 10.4269/ajtmh.18-0399. [Epub ahead of print]

[xii] Thera MA, Konea AK, Tangaraa B, Diarraa E, Niarea A, Dembeleb A, Sissokoa MS, Doumboa OK. School-aged children based seasonal malaria chemoprevention using artesunate-amodiaquine in Mali. Parasite Epidemiology and Control 3 (2018) 96–105. https://doi.org/10.1016/j.parepi.2018.02.001

[xiii] Smit MR, Ochomo EO, Aljayyoussi G, Kwambai TK, Abong’o BO, Chen T, Bousema T, Slater HC, Waterhouse D, Bayoh NM, Gimnig JE, Samuels AM, Desai MR, Phillips-Howard PA, Kariuki SK, Wang D, Ward SA, ter Kuile FO. Safety and mosquitocidal efficacy of high-dose ivermectin when co-administered with dihydroartemisinin-piperaquine. www.thelancet.com/infection Published online March 27, 2018 http://dx.doi.org/10.1016/S1473-3099(18)30163-4

The Essential Health Service Package in Nigeria

When examining the service delivery building block of a health system we much ask what, how and where?  “What” addresses the package of services, “How” describes the mechanisms and personnel who do the delivery, and “Where” considers making services accessible in or very near the community. These are the issues explored in this case study on Nigeria. As USAID notes, “An Essential Package of Health Services (EPHS) can be defined as the package of services that the government is providing or is aspiring to provide to its citizens in an equitable manner. Essential packages are often expected to achieve multiple goals: improved efficiency, equity, political empowerment, accountability, and altogether more effective care.”[i]

Although Nigeria has held Primary Health Care as the official foundation of its national health policy since 1986, it took nearly 30 years to give legal backing to a standard service package with the legislative passage and presidential signing of the National Health Bill in 2014. The law says that “all citizens shall be entitled to a basic minimum package of health services…” defined as “the set of health services as may be prescribed from time to time by the Minister after consultation with the National Council on Health” (National Health Bill, 2014 (SB. 215)).1

Up until that time one could infer the existence of an essential medicines list for primary care through the “Standing Orders” service provision algorithms.[ii] These algorithms guide front line health staff known as community health extension workers (CHEWs) in providing quality and accurate treatment and prevention for common illnesses. The Standing Orders also form the basis for training for CHEWs. For each area, “there is a set of actions including health education, further investigation, treatment, and follow-up necessary for good client’s care.”

As an example of essential medicines, the section of an algorithm for fever management below indicates that Artemisinin-Based Combination Treatment (ACT) malaria medicines and Long-Lasting Insecticide-Treated Nets (LLINS) for malaria prevention should be part of the basic package found at the front line.

USAID describes the official service delivery system in Nigeria as organized in three tiers. Tertiary facilities operated by the Federal Ministry of Health are the highest level of health care and serve as referral centers for patients. State Ministries of Health manage secondary facilities, which provide some specialized health services. Local Government Area (LGA) PHC Departments manage primary facilities, which provide the most basic entry point to the health care system-health centers, clinics, and dispensaries. It is at the LGA level in frontline PHC clinics where the CHEWs mentioned above function and deliver the basic package. Volunteer CHW programs exist and are often run by NGOs and are poorly coordinated, although efforts in recent years have aimed at standardizing their training and activities.

In reality, Nigerians at the community level face a mosaic of health service delivery mechanisms ranging from LGA clinics and dispensaries, patent medicine shops, private clinics often run by nurses and licensed to physicians living in the city, and a range of indigenous practitioners (herbalists, bone setters) and faith healers (based in all major religious groups).[iii]

CHEW providing Essential Services

The USAID report on Nigeria’s essential services shows major challenges in health equity.1

  • Coverage is low for reproductive health, maternal health, and immunization varies widely and is strongly associated with wealth, education level, and rural versus urban place of residence.
  • On some measures, health services coverage among populations with urban residence is more than double the coverage among populations with rural residence.
  • Only about 30% of women in the poorest households receive at least one antenatal care visit, compared to over 90 percent of woman in the wealthiest households, with service coverage steeply increasing along with wealth.
  • Coverage of most key preventive and curative health services is relatively low with large disparities in geopolitical zones, between rural and urban zones, and with regard to socioeconomic status; the poorest fifth of the population are much less likely to receive medical services than their counterparts in the wealthiest 20 percent of the population.

USAID’s Health Financing and Governance Project,1 helped group the Essential Package of Care into three “service delivery modes”:

  • family-oriented, community-based services that can be delivered on a daily basis by trained community health, nutrition or sanitation promoters with periodic supervision from skilled health staff;
  • population- oriented, schedulable services that require health workers with basic skills (e.g. auxiliary nurses/midwives and other paramedical staff) and that can be delivered either by outreach or in health facilities in a scheduled way; and
  • individually oriented clinical services that require health workers with advanced skills (such as registered nurses, midwives or physicians) available on a permanent basis.

These modes come along with recommended actions which could be interventions like safe water for the family or drugs like antibiotics for child pneumonia. Therefore, at present the package focuses more on essential interventions (than essential medicines) for groups such as adolescents, pregnant women, women in childbirth, and infants and children among other populations to be reached with of RMNCH services (reproductive, maternal, neonatal, and child health). In conclusion, Nigeria has articulated its PHC service delivery in terms of what, how and where, but has some ways to go in articulating a clear essential package across the life span and ensuring equitable access to and provision of these services across the country and among all income groups.


[i] Wright, Jenna (2016), ESSENTIAL PACKAGE OF HEALTH SERVICES COUNTRY SNAPSHOT: NIGERIA. United States Agency for International Development (USAID), Health Finance and Governance Project (Abt Associates). https://www.hfgproject.org/essential-package-of-health-services-country-snapshot-nigeria/

[ii] National Primary Health Care Development Agency (2015) NATIONAL STANDING ORDERS FOR COMMUNITY HEALTH OFFICERS/COMMUNITY HEALTH EXTENSION WORKERS, Revised By CHPRBN IN COLLABORATION WITH NPHCDA. Nigeria Federal Ministry of Health, Abuja.

[iii] Brieger WR. PHC: in search of a system that works. Africa Health 1987; 10: 30 31,26.

Burkina Faso Ensures Essential Medicines Reach the Front Line

Meike Schleiff of the Department of International Health, The JHU Bloomberg School of Public Health has explored how Burkina Faso manages to get essential medicines, including those for malaria, to the front line health services. She explains that the World Health Organization (WHO) has determined essential medicines to be, “those that satisfy the priority health care needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness.”(WHO, 2018) These medicines should be available as part of health systems functioning to all persons at appropriate amounts, affordable costs, quality standards and sufficient information assured to consumers. Every country develops an essential drug list,

In Burkina Faso, approval of modern medicines (specialty and generic), traditional pharmacopoeial drugs, medical consumables and medical biology reagents is assigned to the Drug Regulatory Directorate (DRP).

Essential Medicines in Burkina Faso are purchased and distributed primarily through the Centrale d’Achats des Médicaments Essentiels (CAMEG), or Central Purchasing of Essential Drugs system.(CAMEG, 2018) This CAMEG system operates with two agencies in Ouagadougou, and then has seven additional agencies in other zones of the country (see map). From the zonal agencies, the CAMEG supplies 67 District Dispatching Depots (DRDs), and also supplies University Hospital Centers, regional hospitals, and additional services provided by the Ministry of Health. For the private sector, the CAMEG manages supplies for NGOs, faith-based organizations, medical laboratories, pharmaceutical companies, and the Global Fund for HIV, tuberculosis, and malaria.(CAMEG, 2018)

Before the CAMEG was created, access to essential medicines and supplies was very difficult, particularly for rural and other hard to reach populations. This was due to geographical access as well as high prices for specialty drugs, limited availability of generic drugs, and prohibitive regulations against the introduction of generic medicines. In response to this situation, the CAMEG was created under a presidential decree in 1992 and commenced activities in 1994. In 1997, an evaluation was carried out to determine the impact of the CAMEG and decide whether to continue the activities through a long-term structure; the results of this evaluation proposed establishing a legally and financially autonomous non-profit entity to carry forward the work of the CAMEG.(CAMEG, 2018) Today, the CAMEG manages the selection of drug suppliers for the country, ensures compliance with WHO and national regulations on price and quality, and facilitates distribution and storage of drugs across the country. A full product list of the drugs managed by the CAMEG can be found on their website (www.cameg.com).

Medicines Reach Front-Line Health Facility

Community Level

The availability of essential generic medicines at health and social welfare centres in Burkina Faso is 74.5%, compared with an average of 40% across the African region and less than 60% globally.(World Health, 2016, Ministry of Health, 2010) For hospitals, rates are slightly lower with 61% of generics available and regional hospital centers and 39% at university hospital centers (Saouadogo and Compaore, 2010), but only 1.2% of branded medicines; this situation results in patients who are referred to hospitals from lower level facilities often being forced to purchase medicines from more expensive private pharmacies in order to receive the necessary care at higher levels of the health system.(Vervoort, 2012)

While immense progress has been made in ensuring affordability and accessibility of essential medicines in Burkina Faso, mark-ups at different points along the supply chain still result in prohibitively high prices at final points of sale; patients still pay for 37% of the cost of essential medicines and remain the single greatest healthcare cost for households in Burkina and a burden for the majority of the population who still live on less than $1.25 per day.(Vervoort, 2012)

References

CAMEG 2018. Centrale d’Achats des Médicaments Essentiels. Ouagadougou, Burkina Faso.

Ministry of Health 2010. Measuring the Price, Availability, Financial Accessibility, and Price Composition of Medicines in Burkina Faso. Ouagadougou, Burkina Faso: Ministry of Health of Burkina Faso.

Saouadogo, H. and Compaore, M. (2010) ‘Essential Medicines Access Survey in Public Hospitals in Burkina Faso’, 4(6), pp. 373-380.

Vervoort, K. 2012. Ensuring the Availability of Essential Medicines in Burkina Faso: A Shared Responsibility.

WHO 2018. Essential Medicines. Geneva, Switzerland.

World Health, O. (2016) Burkina Faso: Country Cooperation Strategy. Available at: http://apps.who.int/iris/bitstream/handle/10665/136973/ccsbrief_bfa_en.pdf (Accessed: May).

Community Based Health Insurance Can Fight Malaria

Community-Based Health Insurance (CBHI) is seen as a way to promote universal health coverage and protect vulnerable populations from catastrophic financial effects of illness. Malaria can be such an illness is not treated in a timely manner, and having insurance can help prevent delays.

In countries including Rwanda, Burkina Faso and Senegal a particular CBHI scheme known as mutuelles has taken root. For Rwanda USAID (2018) reports that …

The 2014–2015 DHS showed that insurance coverage has remained stable since the 2010DHS and that 79 percent of the households have at least one family member with health insurance and that among those insured 97 percent have community health insurance (mutuelles). Early ANC attendance is also encouraged by providing targeted SBCC, combined with innovative community- and facility-level performance-based financing and high enrollment in community health insurance schemes (mutuelles). The MoH, with the support of partners, has worked to improve the quality of services for case management at health facilities through training and capacity building efforts at national and district levels.

A study looked at health care seeking for children below 5years of age in Rwanda in 2005 to 2010 and found that, “In both years,under-five children with Mutuelles were more likely to use medical care than uninsured children. Children in 2010 had a higher probability of using medical care … regardless of the children’s poverty or Mutuelles status.” The study provides an example of how pre-payment CBHI can not only increase universal health coverage but also address challenges of equity (Mejía-Guevara et al., 2015).

Below is a chart showing the fee structure in Rwanda (Tashobya, 2017). [The trainer should ask participants about fees for CBHIs or other national health insurance schemes in their countries if such exist and how participation in CHBI helps achieve UHC.]

Fees in Rwanda’s community insurance scheme, Mutuelles                                  
Ubudehe/Social Category Annual Rwandan Francs per Household Member Approximate US Dollars
1 0 (Paid by government) 0
2 2,000 2.25
3 3,000 3.35
4 4,000 7.85

Now The East African reports that, “With more than 90 per cent of Rwandans covered under the community-based health insurance scheme locally known as Mutuelle de Santé, Rwanda is one of the few developing countries in the world that have successfully achieved universal healthcare” (Kagire, 2018) This was achieved by addressing enrollment, quality of cane and transferring management of the scheme to the Rwanda Social Security Board (RSSB). Now more than ever, no one needs to die from malaria in Rwanda.

  • Kagire, Edmund (2018). Rwanda Has Achieved Universal Healthcare. The East African. 15 December 2018. https://allafrica.com/stories/201812150128.html
  • Mejía-Guevara I, Hill K, Subramanian SV, Lu C. (2015). Service availability and association between Mutuelles and medical care usage for under-five children in rural Rwanda: a statistical analysis with repeated cross-sectional data. BMJ Open. 2015 Sep 8;5(9):e008814. doi: 10.1136/bmjopen-2015-008814.
  • Tashobya, Athan (2017). Mutuelle Month: Govt targets 100% subscription. The New Times. Published : April 03, 2017. https://www.newtimes.co.rw/section/read/210035
  • USAID/President’s Malaria Initiative (2018) Rwanda Malaria Operational Plan FY19. https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy19/fy-2019-rwanda-malaria-operational-plan.pdf?sfvrsn=3

Malaria Death Audits: A tool to help improve severe malaria case management and prevent malaria related deaths in Mashona East, Zimbabwe

Anthony Chisada, Paul Matsvimbo, Munekayi Padingani, Tsitsi Siwela of Jhpiego,the USAID ZAPIM Project, Harare, Zimbabwe,  and the Zimbabwe Ministry of Health and Child Welfare, Harare, Zimbabwe presented their experiences using death audits at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings follow.

Nearly 50% of the Zimbabwean population is at risk for malaria. Total numbers of malaria related deaths have remained almost constant over the past 5 years. The National Malaria Control Program’s National Malaria Strategic Plan aims to reduce malaria-related deaths by 90% from 2015 levels (462 deaths) by 2020.

To improve severe malaria care and reduce mortality, NMCP documents and investigates all malaria deaths to ascertain the cause of the death and understand if and how it was avoidable. Malaria death audit meetings are held quarterly with health facility staff using a standard death investigation form and case management notes and form a learning platform to look at qualitative and quantitative data related to the deaths.

The audits also examine the quality of care offered as per treatment guidelines and seek to identify ways to prevent future malaria deaths based on omissions and errors in presented cases.

This review examines the findings from death audit meetings facilitated by the PMI-funded Zimbabwe Assistance Program in Malaria project in the Zimbabwean provinces of Mashonaland Central, Mashonaland East and Matabeleland North. Six death audit meetings were conducted over an 18-month period, resulting in a total of 80 deaths audited. The audited deaths were purposely sampled for the potential learning value they offered and to diversify lessons learned.

According to audit reports, the main contributing factors to malaria deaths included: delayed presentation by patients, lack of comprehensive assessment and documentation of cases, inadequate care for patients with reduced level of consciousness and shock, inadequate follow-up of patient progress, lack of supportive investigations, and lack of access to renal replacement therapy/dialysis and blood transfusion.

Most deaths in age groups: under 5s(30%) and over 15(44%). Children are at risk of dying from malaria because of underdeveloped immunity, women taking children to gardens at night, delayed presentation  since mothers are busy. Problem most pronounced in UMP. People over 15 years also at risk of dying: Suggestive of exposure as they indulge in outdoor activities without any protection from mosquito bites.

Death audits reapportion delays (3rd delay increased from 8% to 28%). First delay remains the major contributory factor- need for strengthening SBCC efforts. Malaria death audit meetings enhances the usefulness of the malaria death surveillance system and provides an opportunity for identification and discussion of health system challenges. Some challenges identified are rectifiable thus mitigating deaths. These enable holistic patient care: Identification and management of co-morbidities is critical. Findings contributed to justification of introduction malaria clinical mentorship for improving QoC.

The introduction of malaria death audit meetings has added an active, learning platform to complement the use of the malaria death investigation form and also served as a useful learning tool within Zimbabwe’s clinical mentorship program. Regular malaria death audit meetings are potentially useful in improving malaria care and reducing malaria related deaths.

Improving Malaria through National Rollout of Malaria Service and Data Quality Improvement: A Case Study from Tanzania

Jasmine Chadewa, Chonge Kitojo, Goodluck Tesha, Naomi Kaspar, Lusekelo Njoge, Zahra Mkomwa, Dunstan Bishanga, George Greer, Abdallah Lusasi, and Sigsbert Mkude of the USAID Boresha Afya Project, the US President’s Malaria Initiative, the National Malaria Control Program, and the Community Development, Gender, Elderly and Children (Tanzanian Ministry of Health) shared how malaria data quality could be improved at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Below are their findings.

Tanzania has a high malaria burden (see Figure 1) and is facing an increased demand for health services. The Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) developed the Malaria Service and Data Quality Improvement (MSDQI) checklist to guide supportive supervision teams in evaluating the quality of malaria case management (MCM) services at facility level. MSDQI helps with the collection, monitoring, and evaluation of facility-based malaria performance indicators at all levels of service delivery that provide timely, accurate information and data for decision-making at district, regional, and national levels.

USAID Boresha Afya conducted MSDQI assessments in 1,222 health facilities in the Lake and Western zones in outpatient departments (OPDs) and during antenatal care (ANC). The program disseminates malaria and ANC guidelines, tablets, job aids, and standard operating procedures. It also continues to facilitate supportive supervision and mentorship through the MSDQI tool to build providers’ capacity in identified areas.

Among the challenges reported, Supervisors need to be trained in more than one module to reduce cost. There is turnover of MSDQI supervisors. Cases that come back positive for diseases other than malaria are not investigated further. The use of Android smartphones sometimes interfered with data collection and the reporting system. • Regions/districts depend on donor support to implement MSDQI activities.

In conclusion, effective implementation of the MSDQI tool requires regions, districts, and facilities to be well informed and given clear instruction so they can form supportive supervision teams. This should be done by:

  • Orienting teams on roles and responsibilities
  • Training teams on relevant competencies, resource allocation, and tablet

use for data collection

The team learned that MCM improved in OPDs and during ANC as a result of the MSDQI assessment. Improved access to quality MCM (diagnosis) nationwide. Frequency of malaria testing increased during the first ANC contact. Testing increased from 87% in April–June 2017 to 96% April–June 2018, a 9% change (see Figure 3). Second doses of intermittent preventive treatment of malaria in pregnancy (IPTp2) coverage increased by 15% on average in Boresha Afya-supported regions between October 2016 and June 2018 (see Figure 4).

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of USAID Boresha Afya and do not necessarily reflect the views of USAID or the United States government.

Experiences and Perceptions of Care Seeking for Febrile Illness among Caregivers and Health Providers in Eight Districts of Madagascar

Andrianandraina Ralaivaomisa, Eliane Razafimandimby, Jean Pierre Rakotovao, Lalanirina Ravony Harintsoa, Sedera Aurélien Mioramalala, Rachel Favero, Katherine Wolf, Patricia Gomez, Jocelyn Razafindrakoto, and Laurent Kapesa of MCSP/Jhpiego (Johns Hopkins University Affiliate), the Madagascar Ministry of Public Health and USAID presented their findings about febrile illness care seeking in Madagascar at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Details follow below.

Malaria Care and Treatment in Madagascar is hampered by low perception of malaria risk among caregivers. There is use of self-medication and a lack of health provider knowledge about malaria prevention and treatment in pregnant women. Low-quality care in primary health facilities is another concern (Source: WHO. 2015. Guidelines for the treatment of malaria, 3rd ed.).

As seen in the attached, Study Objectives focus on Caregivers and Pregnant Women as well as Health Providers to determine barriers to effective care seeking of febrile illnesses.

Both Qualitative and Quantitative Approaches were used. Among care seekers we conducted 16 focus group discussion sessions with 128 caregivers and pregnant women. There were also in-depth interviews with 32 pregnant women and 16 caregivers of children under 15. For Health Providers we conducted in-depth interview with 32 public and private health providers and administered 16 knowledge tests and case studies to health providers. We also reviewed logistic management information system records with 16 health

Barriers for Caregivers are seen in the attached table. Barriers were faced by both care seekers and those who did not seek care, but were more common among non-seekers.

Three tables follow that show perceptions of public sector providers, private providers and community health workers. There were positive and negative perceptions of each group of providers.

Health Provider Practices were also studied. They had low adherence to national guidelines for fever and malaria case management. Health workers reported high stock-outs rates of critical commodities (artemisinin-based combination therapy, artesunate). There was also lack of respectful care. Fortunately health provider diagnostic practices included 100% compliance with rapid diagnostic testing in cases of fever. They took temperatures and did physical exams appropriate to client’s symptoms and used microscopy at centers with local laboratory

General Bottlenecks to Timely Care Seeking still existed. There was insecurity due to political situation in some regions. Inability to pay for care or medications was common. Alternative health behaviors included seeking care with traditional healers, and self-medication. There was fear by clients of going to health facilities and inaccurate perceptions of care provided by formal health care system

Recommendations start with the need to train providers and CHWs on national treatment guidelines for managing fever in all age groups and in pregnant women. Efforts are needed to strengthen onsite provider mentoring and supportive supervision and improve respectful care of clients, especially in public sector. Since care seeking still based on cultural norms, there is need to strengthen community/family education about febrile illness dangers and advantages of timely care seeking. Communities can also consider forming “mutuelle” community insurance schemes to relieve cost of care burden.

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.

Multiple Approaches for Malaria Case Management in the Struggle to Reach Pre-Elimination of Malaria

Goodluck Tesha, Zahra Mkomwa, Jasmine Chadewa, Lusekelo Njoge, Abdallah Lusasi, Dunstan Bishanga, Chonge Kitojo, Erik Reaves, George Greer of the USAID Boresha Afya Project, the Tanzanian Ministry of Health, and the US President’s Malaria Initiative shared experiences on the role of malaria case management in pre-elimination efforts at the 2018 Annual Meeting of the American Society of Tropical medicine and Hygiene. Their results are seen below.

The 5-year USAID Boresha Afya project works in 1,817 facilities in the seven regions of the Lake/Western Zone, where malaria prevalence is high. Since 2016, Boresha Afya has collaborated with the National Malaria Control Program to support the goal of reducing the malaria case fatality rate to below 1% by 2020 by:

  • Promoting universal access to early diagnosis and prompt treatment
  • Providing preventive therapies to vulnerable groups

In the last 15 years, malaria transmission has been cut in half, dropping from about 33% to less than 7.5%. Over the last three malaria indicator surveys, the number of regions with extremely low malaria prevalence (<1%) increased from one (2008) to seven (2016). The percentage of the population living in low-transmission areas (<10% prevalence) increased from 31% in 2000 to 49% in 2015.

The intervention trained providers on quality testing using malaria rapid diagnostic tests (mRDTs). Training focused on conducting quality malaria microscopy examinations.

In addition, the team stratified malaria burden using GIS mapping and introduced malaria service and data quality improvement through a malaria dashboard. Community outreach programs were formed in remote areas.

Due to mRDT availability, more suspected malaria cases are tested before malaria treatment is administered. Per national guidelines, all pregnant women should be tested for malaria on their first visit to the clinic. All project regions have met or exceeded the national 80% testing rate target (see Figure 5).

In conclusion, to move toward malaria elimination, Boresha Afya will focus on ensuring more suspected cases are tested at facility level. Prompt treatment positive cases will then follow. Performing more community outreach should increase access to malaria case management in remote areas. Using GIS mapping will rapidly target services.

This poster is made possible by the support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of Jhpiego and do not necessarily reflect the views of USAID or the United States Government.