Category Archives: Case Management

Community Based Intervention in Malaria Training in Myanmar

Nu Nu Khin of Jhpiego who is working on the US PMI “Defeat Malaria Project” led by URC shares observations on the workshop being held in Yangon with national and regional/state malaria program staff to plan how to strengthen malaria interventions at the community level. The workshop has adapted Jhpiego’s Community Directed Intervention training package to the local setting.

Yesterday’s opening speech was being hailed as a significant milestone to give Community-Based Intervention (CBI) training teams the knowledge, skills, and attitudes they need to effectively provide quality malaria services and quality malaria information.

This core team is going to train the critical groups of community-level implementers including CBI focal persons and malaria volunteers at the community level.

We embarked this important step yesterday with the collaboration of Johns Hopkins University, Myanmar Ministry of Health and Sports, and World Health Organization Myanmar.

Participants will be developing action plans to apply the community approach to malaria efforts in townships and villages in three high transmission Rakhine State, Kayin State and Tanintharyi Region.

Contribution of the Improving Malaria Care (IMC) Project to Improving Malaria Case Management in Burkina Faso

Malaria case management including diagnosis and treatment is an essential component of malaria control and elimination. Ousmane Badolo, Mathurin Dodo, and Bonkoungou Moumouni of Jhpiego working on the USAID Improving Malaria Care Project in Burkina Faso explained at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene how they worked to improve case management by Strengthening the capacity of health care providers. There findings follow:

Malaria kills mostly children under five and pregnant women in Burkina Faso, and is the leading reason for medical consultation and hospitalization. Improving case management is a real challenge in reducing morbidity and mortality. The goal of the National Malaria Control Program (NMCP) was to reduce the morbidity by 75% by end of 2000 and malaria mortality to close to zero by the end of 2015.

The United States Agency for International Development-supported Improving Malaria Care (IMC) project aims to reduce malaria morbidity and mortality. This includes strengthening the capacity of health providers to deliver high quality management- diagnosis and treatment, of malaria cases.

Between 2014 and 2016 IMC and the NMCP revised malaria guidelines, oriented 163 national trainers, trained 1,819 providers at all levels and organized supportive supervision of these staff. As a result correct diagnostic testing of malaria cases increased from 62% to 82%.

The proportion of people with uncomplicated malaria who received artemisinin combination therapy (ACT) increased from 85% to 94%. Strengthening of the data management system facilitated this information to be collected.

Training these providers based on national guidelines and reinforcing their learning through supervision has enabled the NMCP to have a pool of health providers capable of treating the most vulnerable population and helping to reduce malaria mortality level in Burkina Faso.

This training is accompanied by the implementation of formative supervision. Continued supervision and quality data management positions the NMCP to reach and document its goals.

Funding for this effort was provided by the United States President’s Malaria Initiative. This poster 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 the Improving Malaria Care Project and do not necessarily reflect the views of USAID or the United States Government.

Contribution of the Standards-Based Management and Recognition (SBM-R) approach to fighting malaria in Burkina Faso

Quality improvement tools play an important role in ensuring better malaria services.  Moumouni Bonkoungou, Ousmane Badolo, and Thierry Ouedraogo describe how

Standards Based Management and Recognition Approach to Quality Improvement

Jhpiego’s quality approach, Standards-Based Management and Recognition, was applied to enhancing the provision of malaria services in Burkina Faso at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their work was supported through the President’s Malaria Initiative and the USAID Improving Malaria Care Project.

In 2015, Burkina Faso recorded 8,286,463 malaria cases, including 450,024 severe cases with 5379 deaths. The main reasons for these death are:  Inadequate application of national malaria diagnosis and treatment guidelines, delays in seeking health care and poor quality of case management.

The Standards-Based Management and Recognition (SBM-R) approach is used to improve quality of care using performance standards based on national guidelines. SBM-R includes the following steps:

  • set performance standards
  • implement the standards
  • monitor progress and
  • recognize as well as celebrate achievements

Areas or domains assessed by the approach are: services organization, case management at both health center and community, Intermittent Preventive Treatment in Pregnancy (IPTp), promotion of Long Lasting Insecticide treated Nets (LLIN) use and infection prevention and control.

Since June 2016, 26 health facilities in three regions have been implementing SBMR. Therefore, 105 health workers have been trained. Performance progress was measured through 5 evaluations including baseline. Baseline has shown the highest score was 47% (Kounda) while the lowest was 9% (Niangoloko).

The main issues observed were: lack of program activities, management tools, handwashing facilities, LLINs and misuse of Rapid Diagnosis Tests. Their cause was determined and an improvement plan was developed by each site. The second, third and final evaluations revealed a change in performance scores for all sites.

The external evaluation showed 17 out of 26 health facilities with a score higher than 60%; among them 10 with a score above 80% (Bougoula, 94%). At the same time, IPTp 3 increased from 34.48% in 2014 to 78.38% in 2016 and no malaria death has been registered since October 2015.

For the site under 80% the key reasons were: staff turnover, commodities stock-out and lack of infrastructure. The process continues with recognition of health facilities and supporting others (those at less than 80%) to reach the desired performance level. The SBM-R approach appears to be a great tool for improving quality and performance of health facilities.

Health provider orientation to national malaria case management guidelines in regional hospitals in Burkina Faso

Good clinical practice in managing malaria requires awareness and understanding of national case management guidelines. Moumouni Bonkoungou, Ousmane Badolo, and Thierry Ouedraogo of Jhpiego in Collaboration with the National Malaria Control Program and sponsorship from the “Improving Malaria Care” project of USAID/PMI explain how health workers in Burkina Faso were oriented to the national guidelines at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene. They have found that short orientations are less expensive and reach more health workers that traditional training sessions.

Malaria remains the leading cause of consultations, hospitalization and death in health facilities in Burkina Faso. In 2015, 23,634 cases of severe malaria were recorded in hospitals with 1,634 deaths, a mortality rate of 7% at this level compared to 1% nationally. Since April 2014, 1,819 providers from 49 districts have been trained in malaria case management, specifically at the first level (health center – CSPS). Conversely, at referral centers – medical centers with surgical units (CMA), regional hospitals (CHR) and university hospitals (CHU) – providers are not well educated on the new WHO guidelines for malaria prevention and case management.

Health worker orientation session

This situation led the United States Agency for International Development-supported Improving Malaria Care (IMC) project and the National Malaria Control Program (NMCP) to organize orientation sessions for providers in 8 CHR in September 2016. The sessions were conducted by trainers at the national level, supported by clinicians from hospitals including pediatricians and gynecologists.

A total of 298 health workers were oriented, including 24 physicians, 157 nurses, 56 midwives, as well as pharmacists and laboratory technicians. 39% of participants were female and 43% have less than 5 years of service in these hospitals. The sessions have provided participants with an opportunity to familiarize themselves with the new guidelines for malaria prevention and case management.

The orientations have also made it possible to identify the difficulties encountered by referral structures in malaria case management, which include: insufficient staff, inadequate capacity building, no blood bank in some hospitals, reagent stock-outs, inadequacies in the referral system, and insufficient equipment.

To address these difficulties, staff redeployment, internal supervision, development of tools to monitor reagents stocks have been proposed. To move forward, response plans for the period of high malaria transmission is expected to be developed for these referral facilities.

Implementation of a Quality Improvement Approach for Malaria Service Delivery in Zambezia Province, Mozambique

Baltazar Candrinho, Armindo Tiago, Custodio Cruz, Mercino Ombe, Katherine Wolf, Maria da Luz Vaz, Connie Lee and Rosalia Mutemba are sharing their work during a scientific session on enhancing quality of care for malaria services in Mozambique at the 66th Annual Meeting of the American Society of Tropical Medicine 66th Annual Meeting on 6 November 2017. A summary of their talk follows:

In Mozambique, malaria in pregnancy (MIP) is one of the leading causes of maternal and newborn morbidity and mortality. Malaria also accounts for over 40% of deaths in children less than five years old. With provincial and facility-level commitment, a simple and comprehensive quality improvement (QI) system has been established in 10 of 16 districts in Zambezia Province.

Since 2016, the Mozambique Ministry of Health (MOH) and Zambezia Provincial Health Directorate, in collaboration with partners, have implemented a malaria QI effort based on the Standards-Based Management and Recognition (SBM-R) approach. A standards-based approach to improving quality of malaria care engages both management and service providers to work together to assess the current performance, address gaps to ensure that all patients receive a minimum (standardized / evidence-based) package of care, and ultimately improve patient outcomes and facility performance.

Thirty-one performance standards in five content areas (MIP, Case Management, Laboratory, Pharmacy, and Management of Human Resources and Malaria Commodities) were developed and adopted by the MOH in 2016. With support from partners, 40 health workers, including managers, clinicians and lab technicians, received training on SBM-R, and facility QI teams were established.

These teams use checklists based on standards to conduct quarterly assessments that identify performance gaps, and then develop action plans to address areas of improvement. The MOH antenatal care and child health registers also contain information on coverage of key malaria interventions, including IPTp, and malaria diagnosis and treatment during pregnancy and for children under five with fever.

Average attainment of standards at baseline in 20 health facilities was 30%, and is expected to improve as implementation progresses with quarterly application of the checklist (data will be available before November). Improvements in key malaria indicators for pregnant women and children under five years old are expected as the percentage of standards attained increases.

The Need to Prevent the Spread of Malaria Drug Resistance to Africa

Chike Nwangwu is a Monitoring and Evaluation Specialist who is currently working on his Doctor of Public Health (DrPH) degree at the Johns Hopkins Bloomberg School of Public Health. Here he presents an overview of the threat of parasite resistance to first-line antimalarial drugs and the need to prevent the spread of this problem in Africa which beard the greatest burden of the global malaria problem.

Malaria, remains one of the most pervasive and most malicious parasitic infections worldwide.  Malaria is caused by Plasmodium parasites when they enter the human body. There are currently five known plasmodium species that cause malaria in humans- P. falciparum and P. vivax are the most prevalent globallyThese parasites are transmitted through the bites of infected female anopheles mosquitoes “malaria-vectors” which perpetuate the spread of the parasite from human-human or from host- human.

Globally, according to the WHO, an estimated 212 million cases of malaria and 429 000 malaria related deaths occurred in 2015.[1]  The global share of malaria is spread disproportionately across regions; Over 90% of global malaria cases and deaths occurred in the African region, with over 70% of the global burden in one sub region-Sub Saharan Africa. In areas with high transmission of malaria, children under 5 are at the highest risk to infection and death; more than two thirds of all malaria deaths occur in this age group.[2]

Although malaria remains a global concern, malaria is preventable and curable.  Increased efforts in malaria prevention and treatment within the past two decades has led to revolutionary success- 6.8 million lives have been saved globally and malaria mortality cut by 45% since 2001.[3] Globally, within a five-year interval (2010-2015) new malaria transmission and mortality in children under 5 years of age fell by 21% and 29% respectively. This has been the one the greatest public health successes in recent years [4]

The improvement of malaria indices aligns with intensification of efforts, through funding, research, innovation pushing the scale up of key malaria interventions in the malaria prevention- diagnostic- treatment cascade. For example, in Sub-Saharan Africa where malaria is most prevalent, there has been a recorded 48% increment in Insecticide Treated Net (ITN) usage since 2005, 15% rise in chemoprevention in pregnant women and within the same time frame diagnostic testing increased from 40% of suspected malaria cases to 76%.[5]

Treatment/ Emergence of insecticide and drug resistance

Malaria treatment plays a key role in controlling its transmission. First, prompt and effective treatment of malaria prevents progression to severe disease and limits the development of gametocytes, thus blocking transmission of parasites from humans to mosquitoes.[6] Drugs can also be used to prevent malaria in endemic populations, including various strategies of chemoprophylaxis, intermittent preventive therapy, and mass drug administration can be effective.[7] Like other interventions, availability and use of antimalarial has been a success. However, this has also come with some challenges. The emergence of resistance, particularly in P. falciparum and P. vivax to antimalarial-quinine and sulfadoxine-pyrimethamine, has been a major contributor to reported resurgences of malaria in the last three decades.[8]

Distribution of reported resistance to antimalarials. As at 2005, antimalarial resistance was is established in 81 of the 92 countries where the disease was endemic (WHO, 2004)

Falciparum resistance first developed in some areas in Southeast Asia, Oceania, and South America before the 70’s eventually the parasite became resistant to other drugs (sulfadoxine/ pyrimethamine, mefloquine, halofantrine, and quinine. Drug-resistant P. vivax was first identified in 1989 in one region and later spread to other regions of the world.[9] As at 2005, antimalaria resistance to chloroquine and sulfadoxine-pyrimethamine was established in 81 of the 92 countries where the disease was endemic. (Figure 1) In 2005, alongside acetaminophen, antimalarial were among the most commonly abused medications in the African region, with the majority of the population having detectable amounts of chloroquine in the blood.[10]

Antimalarial drug resistance is the decrease in viability of an antimalarial to cure an infection.  Parasite resistance results in a delayed or partial clearance of parasites from the blood when a person is being treated with an antimalarial.[11] Antimalaria resistance occurs as the byproduct of at least one mutation in the genome of the parasite, giving an advantageous capacity to evade the impacts of the drug. Within the human host, drug resistance develops gradually. First, a modest number of drug-resistant parasites survive exposure to the drug whilst the drug-sensitive parasites are eliminated. In the absence of additional drugs and competition from drug-sensitive pathogens, the drug-resistant parasites proliferate and their populace develops. This new population is therefore resistant to additional malaria medications of the same type.

Following the discovery of resistance to quinine and sulfadoxine-pyrimethamine, the development of resistance was initially forestalled by the utilization of a new class of malaria drugs – Artemisinin-derivative combinations. These ACTs (Artemisinin Combination Therapy) work by combining artemisinin and an active partner drug with different mechanisms of action. The WHO, with guidance from extensive drug efficacy tests and research, recommends the use of 5 types of ACTs for treatment of uncomplicated malaria caused by the P. falciparum parasite. By 2014, ACTs have been adopted as first-line treatment policy in 81 countries.[12]

Although ACT use has been a breakthrough in malaria treatment, development of resistance to de novo ACTs poses one of the greatest threats to malaria control efforts. P. falciparum resistance to artemisinin has been detected in five countries of the Greater Mekong sub-region (Lao, Myanmar, Thailand, Cambodia, and Vietnam). To date P. vivax resistance to an ACT has not been detected.

Artemisinin resistance is currently defined within the confines of delayed parasite clearance; it represents partial/relative resistance-i.e. most patients who have delayed parasite clearance do not necessarily have treatment failure. Following treatment with an ACT, infections are still cleared, as long as the partner drug remains effective.  Various factors are believed to contribute to the development and spread of resistance to artemisinin; use of oral artesunate monotherapies (oAMT) inclusive.

A global response has been mounted to curtail the spread of ACT resistance to other regions, especially to regions like Sub-Saharan Africa. Research on the mechanisms of drug resistance has steered efforts in the direction, recently the identification of the PfKelch13 (K13) mutations has allowed for a more refined definition of artemisinin resistance that includes information on the genotype. [13]  In addition, stricter policies have been developed for malaria control; Therapeutic efficacy studies (TES) are conducted and used as the main reference from which national malaria control programmes determine their national treatment policy.[14]  These studies help to ensure the efficacy of treatments with recommendations to ensure that these medicines are monitored through surveillance at least once every 24 months at established sentinel sites and in regions with emerging resistance, the creation of additional sentinel surveillance sites. [15]

Preventing and containing antimalarial drug resistance- Recommendations to countries

As research is being done to fully understand the mechanisms of antimalarial resistance; basic recommendations to limit its spread have been disseminated.[16] First, the production and use of oral artemisinin-based monotherapy should be halted and access to the use of quality-assured ACTs for the treatment of falciparum malaria should be ensured. In countries where antimalarial treatments remain fully efficacious; correct medicine use must be promoted, with weight placed on encouraging diagnostic testing, quality-assured treatment, and good patient adherence to the treatment.  Lastly, to reduce the burden of the disease, and prevent the spread of resistance, in regions where there is still high transmission, intensification of malaria control efforts is key, rapid elimination of falciparum malaria would accelerate efforts.

  • [1] World Malaria Report 2016, World Health Organization, Geneva, 2016
  • [2] ibid
  • [3] CDC, Malaria Fast Facts 2017
  • [4] ibid
  • [5] World Malaria Report, 2016
  • [6] Gosling RD, Okell L, Mosha J, Chandramohan D. The role of antimalarial treatment in the elimination of malaria. Clin Microbiol Infect. 2011;17:1617–1623.
  • [7] Greenwood B. Anti-malarial drugs and the prevention of malaria in the population of malaria endemic areas. Malar J. 2010;9
  • [8] White NJ. Antimalarial drug resistance. J Clin Invest. 2004;113:1084–1092
  • [9] CDC, Malaria Fast Facts, 2017
  • [10] White NJ. Antimalarial drug resistance. J Clin Invest. 2004;113:1084–1092.
  • [11] Peter B. Bloland, Drug resistance in malaria, World Health Organization, 2001
  • [12] World Malaria Report, 2016, World Health Organization, Geneva,2016
  • [13] Artemisinin and artemisinin-based combination therapy resistance April 2017,World Health Organization, 2017
  • [14] Responding to antimalarial drug resistance, World Health Organization, 2017: http://www.who.int/malaria/areas/drug_resistance/overview/en/
  • [15] ibid
  • [16] Ibid

Nepal on the Path to Malaria Elimination

Jhpiego’s Emmanuel Le Perru has been placed with Nepal’s malaria control program by the Maternal and Child Survival Program (USAID) to strengthen the agency’s overall response to malaria as well as ensure top performance of Nepal’s Global Fund Malaria grant. Emmanuel shares his experiences with us here.

From 3,000 cases in 2010, Nepal reported around 1,000 cases in 2016, including 85% Plasmodium vivax cases. However private sector reporting is almost null so number of total cases may be the double. Nepal’s National Malaria Strategic Plan (NMSP) targets Elimination by 2022 (0 indigenous cases) with WHO certification by 2026.

Ward Level Micro-stratification is an important step for targeting appropriate interventions. Key interventions in the NMSP include case notification system by SMS (from health post workers or district vector control inspectors) to a Malaria Disease Information System, later to be merged with DHIS2. Case investigation teams conduct case and foci profiling as well as “passive cases” active detection and treatment (including staff from district such as surveillance coordinator, vector control inspector, and entomologist).

Malaria Mobile Clinics actively search/treat new cases in high risk areas (slums, brick factories, river villages or flooded areas, migrant workers villages, etc.). PCR diagnosis with Dry Blood Spot or Whole Blood is used to identify low density parasite cases, relapses or re-introduction. Coming up in April-June 2018 will be a Pilot of MDA (primaquine) for Plasmodium vivax in isolated settings (80% of cases in the country are P vivax).

Recent successes in the national malaria effort include the number of cases notified by SMS went from 0% to 45%. Also the number of cases fully investigated went from 22% to 52%, though this needs to go up to 95% for elimination. 73% of districts are now submitting timely malaria data reports per national guidelines, an increase from 52% in November 2015.

The border runs right through this town making importation of malaria cases easy

The Global Fund (GFATM) malaria grant rating went from B2 to A2. Nepal Epidemiology Disease Control Division (EDCD), WHO and GFATM are keen to pilot MDA for P vivax in isolated setting which MCSP/Jhpiego Advisor taking the lead.

Moving forward the malaria elimination effort needs to address Indo-Nepal Cross boarder collaboration since 45% cases are imported. Hopefully WHO will help EDCD Nepal to propose a plan of action to India. The program still needs to convince partners of relevance of malaria mobile clinics vs community testing and of the relevance of MDA for P vivax. More entomological and PCR/laboratory expertise is needed. With these measures malaria elimination should be in sight.

Pneumonia and Malaria – similar challenges and pathways to success

ConcentrationOfPneumoniaDeathsWorld Pneumonia Day (WPD) helps us focus on the major killers of children globally. While Pneumonia is responsible for more child mortality across the world, in tropical malaria endemic areas both create nearly equal damage (see WPD graphic showing Nigeria and DRC which are both have the highest burden for pneumonia, but also malaria). Of particular concern is case management at the clinic and community level where there is great need to differentiate between these two forms of febrile illness so that the right care is given and lives are saved.

WPD_2014_logo_portraitDiagnostics are a particular challenge. While we now have malaria rapid diagnostic test kits that can be used at the community level, we must rely on breath counting for malaria. The Pneumonia Diagnostics Project (see video) “is working to identify the most accurate and acceptable devices for use by frontline health workers in remote settings in Cambodia, Ethiopia, South Sudan and Uganda.”

Ease of use at low cost must be achieved. One approach to solve the pneumonia diagnostics challenge at community and front line clinic level is to find “mobile phone applications or alternative energy for pulse oximetry,” to test low oxygen levels.

PneumoniaCareVaccine development for both diseases is underway. The challenge for malaria results from the different stages of the parasites life-cycle. Lack of affordable vaccines for pneumonia limits at present widespread preventive action, though public-private partnerships offer hope.

Dispersable and correct dose for age prepackaged malaria drugs are already available. Now more child-friendly medicines for pneumonia are being developed. In low resource settings, “amoxicillin dispersible tablets are a better option, particularly for children who can’t swallow pills. They have a longer shelf-life, are cost-effective, don’t need refrigeration, and are easy to administer.”

Similarities in the problems and solutions to control these two diseases require that interventions must continue to be developed and implemented jointly in order to benefit children the most. As can be seen again from the WPD graphics (right), many children do not get needed treatment. Integrated case management at all levels is the answer.

Case Management of Malaria: A Review and Qualitative Assessment of Social and Behavior Change Communication Strategies in Four Countries

Kamden Hoffmann1 and Michael Toso2 presented a poster today at the 143rd annual meeting of the American Public Health Association in Chicago. Their findings are posted below.

report coverIntroduction. With the introduction and growing availability of combination therapy and rapid diagnostic tests, case management of malaria has evolved and expanded in scope. Social and behavior change communication (SBCC) activities have been developed to influence prompt care seeking behavior, adherence to test results, and completion of full treatment regimens. This review describes SBCC programming, and the extent to which it has been evaluated for impact, in Zambia, Ethiopia, Rwanda, and Senegal.

Objectives. The purpose of this review is to identify promising SBCC practices related to case management at both community and service provider levels in the four focus countries: Zambia, Ethiopia, Rwanda and Senegal. Essential for any large-scale communication strategy is a form of impact assessment. Impact assessments aim to answer the question, “Did the communication strategy achieve the specified objectives?” Impact assessments look at the difference that the strategy made in the overall program environment. The indicators can vary depending on the approach and channels used in the strategy.

An example of an impact indicator for malaria case management could be: the proportion of children under five years old with fever in the last two weeks for whom treatment was sought. Typical data sources include:

  • Population-based household surveys, such as the Demographic and Health Survey, the Malaria Indicator Survey, or the Multiple Indicator Cluster Survey.
  • Sub-national household surveys, particularly in areas where malaria communication activities were targeted.

Countries Picture1

Methods. An initial review was undertaken, consisting of a thorough PubMed search for articles related to malaria case management that mentioned SBCC, in the four countries. Malaria case management country-level documents, project reports and related SBCC materials were also collected. Implementing partner reports were gathered from each country related to SBCC and/or malaria case management. A comprehensive list of search terms were used for all four countries.

Qualitative analysis consisted of Key Informant Interviews (KIIs) with members of NMCP SBCC/BCC units within the Ministry of Health, USAID implementing partners, and President’s Malaria Initiative staff. A semi-structured questionnaire was used to gather information related to perceptions and first-hand experiences. A total of nine interviews and four written responses were collected. All interviews were recorded and transcribed. The transcribed interviews and written responses were entered into NVivo 10. An initial codebook was developed based on the semi-structured interview guide. Open and axial coding enhanced the initial codebook as themes were generated in the software.

Countries Picture2

Conclusions. The review was not able to find a substantial amount of material to show gains in the ability to measure impact of SBCC interventions in malaria case management outcomes. Several programs were able to measure changes in care-seeking behavior and uptake of ACTs; however, these types of programs need to be refined in order to measure the specific contribution of malaria SBCC interventions. Each country reviewed presented a program related to either the care group model or a model with a strong community component, and holds promise for further exploration in terms of launch points to expand the measurement of SBCC impact.

MToso IMG_0503Author Affiliations.

1 Insight Health, 710 Sutter Gate Lane, Morrisville, North Carolina 27560

2 Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs, 111 Market Place Suite 310, Baltimore, MD 21202, USA

Funding for this study was provided by the US President’s Malaria Initiative.

References.

1 Kidane G, Morrow R. Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomized trial. The Lancet 2000.

2 Innovation for Scale: Enhancing Ethiopia’s Health Extension Package in the Southern Nations and Nationalities People’s Region (SNNPR) Shebedino and Lanfero Woredas, October 1 2007-September 30 2012. Report of the Final Evaluation. December 2012.

3 Linn AM, Ndiaye Y, Hennessee I, et al. Reduction in symptomatic malaria prevalence through proactive community treatment in rural Senegal. Trop Med Int Health. 2015;20(11):1438-1446.

4 Landegger, J., et al. CHW Peer Support Groups for Integration of Health Service Delivery and Improved Performance: Learning from a Peer Group Model in Rwanda

5 Limange, J., et al., Evaluation: Mid-Term Evaluation of the USAID/Zambia Communications Support for Health Program, January 2013, USAID.

6 Salvation Army/Zambia (TSA), Salvation Army World Service Organization (SAWSO), and TSA Chikankata Health Services Chikankata Child Survival Project (CCSP), 2005?2010, Final Evaluation Report. December 2010.