Category Archives: Children

Health for All at the International Institute for Primary Health Care, Ethiopia

The time is ripe for a revitalization of the primary health care (PHC) movement. “Health for All through Primary Health Care” (HFA) was first envisioned at the 1978 International Conference on Primary Health Care (World Health Organization and UNICEF), and was enshrined in the Declaration of Alma-Ata. The HFA goal of bringing essential, affordable, scientifically sound, socially acceptable  health care provided by health workers who are trained to work as a health team and who are responsive to the health needs of the community, guided by strong community engagement by the year 2000 but has not been fully met. Fortunately the vision of Alma-Ata has taken root, sprouted and flourished in a number of locations.

Thanks to the vision and intellectual and political leadership of Dr. Tedros Adhanom Ghebreyesus, the then Minister of Health of Ethiopia and recently elected Director General of the World Health Organization, Ethiopia is an outstanding example of the Alma-Ata legacy. Access to PHC services was greatly expanded through the training of 40,000 Health Extension Workers (women from the local area with one year of training, each of whom serve 2,500 people and receive a government salary), recruitment of 3 million community female health volunteers (called the Health Development Army), and engagement with communities to enable them to take responsibility for improving their health.

This expansion of PHC enabled Ethiopia to achieve its health-related MDGs. Child mortality (those younger than 5 years of age) declined from 166 deaths per 1,000 live births in 1990 to 67 in 2016 (MDG 4). Significant progress was achieved in reducing levels of childhood malnutrition (MDG 1). MDG 5 was almost reached, with a decline in maternal morality of 72%, versus the goal of 75%, and the percentage of mothers obtaining a delivery by a skilled provider increased 6-fold between 1995 and 2016. The prevalence rate of modern contraceptive use increased from 6% in 2000 to 35% in 2016. MDG 6 (for HIV, malaria and tuberculosis) was also reached. The number of new HIV infections declined by 90%, and the number of AIDS-related deaths by 53%. Between 1990 and 2015, the tuberculosis incidence and mortality rate declined by 48% and 72%, respectively. The malaria incidence rate declined by 50% and malaria mortality by 60%. Ethiopia’s PHC system is acknowledged as the major factor leading to these impressive health gains.

Representatives from more than half of sub-Saharan Africa countries have come to Ethiopia to see its PHC system in action. Because of this interest, in 2016 the Federal Ministry of Health of Ethiopia established the International Institute for Primary Health Care – Ethiopia, with seed funding from the Bill & Melinda Gates Foundation and technical support from the Johns Hopkins Bloomberg School of Public Health. Our goal is for the Institute to become a global center of excellence for training, knowledge dissemination and research in primary health care, supported by multiple donors.

The Institute has begun to provide formalized short-term training to high-level policy makers and officials, program planners and managers, as well as to those engaged in service delivery, to see first-hand how an effective national PHC system functions. Trainees come from within Ethiopia and around the world. Trainees also visit communities, meet their leaders, and observe primary health care providers at work. Trainees will return to their home country with renewed energy and new vision and skills to revitalize their own primary health care system.

The Institute will also conduct and support research that yields evidence to guide ongoing strengthening of the Health Extension Program, and will rapidly disseminate open access information about recent advances in PHC. The Institute marks a significant step forward on the road to achieving the Alma-Ata vision of Health for All.

A website for IIfPHC-E is being built to provide further information about these programs and will be available at: www.iifphc.org.

This posting was prepared by: Kesetebirhan Admasu1, Michael J. Klag2, Yifru Berhan Mitke3, Amir Aman4, Mengesha Admassu5, Solomon Zewdu6, Jose Rimon7, Henry B. Perry8

1Chief Executive Officer, Rollback Malaria Partnership, Geneva, Switzerland and Chair, Advisory Board, International Institute for Primary Health Care — Ethiopia

2Dean, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

3Minister, Federal Ministry of Health, Government of Ethiopia, Addis Ababa, Ethiopia

4State Minister, Federal Ministry of Health, Government of Ethiopia, Addis Ababa, Ethiopia and Co-Chair, Advisory Board, International Institute for Primary Health Care – Ethiopia

5Executive Director, International Institute for Primary Health Care – Ethiopia, Addis Ababa, Ethiopia

6Health and Nutrition Development Lead – Ethiopia, Integrated Programs, Global Policy & Advocacy – Global Development, Bill& Melinda Gates Foundation, Addis Ababa, Ethiopia

7Director, Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

8Coordinator for Johns Hopkins University Support of the International Institute for Primary  Health Care – Ethiopia, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

Seasonal Malaria Chemoprevention Implementation in Senegalese Children

20151028_123042-1Dr Mamadou L Diouf and colleagues[1] from the National Malaria Control Program, Dakar Senegal and the President’s Malaria Initiative/USAID, Dakar, Senegal presented their experiences with Seasonal Malaria Chemoprevention among children aged 3-120 months in four southern regions of Senegal at the 64th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings are outlined below.

Malaria is major cause of disease and death in infants and children, with seasonal transmission, highest in the southern and eastern regions which are the wettest areas. SMC is administration of a complete treatment course of AQ+SP at monthly intervals to a maximum of 4 doses during the malaria transmission season to children aged between 3 and 59 months in areas of highly seasonal malaria transmission (where both drugs retain sufficient antimalarial efficacy).

Health post nurse training volunteersTarget areas for implementation are areas where more than 60% of clinical malaria cases occur within a maximum of 4 months, the clinical attack rate of malaria is greater than 0.1 attack per transmission season in the target age group, and AQ+SP remains efficacious (>90% efficacy).

Adoption of SMC in 2013 as a new intervention in malaria control policy. Four south-eastern regions eligible according to WHO criteria for SMC (Tambacounda, Kédougou, Sédhiou and Kolda) chosen

The poster presented Senegal’s experience implementing SMC and focuses particularly on process, challenges and lessons learned. Available information generated from the national SMC implementation guidelines, technical documents, field activity reports, and SMC impact evaluation survey were reviewed.

The medication distribution strategy relied on a door to door campaign strategy with community volunteers. On the first day, the volunteers, trained by health workers, administer drugs to the children under surveillance of their mothers or guardians. For the 2 remaining days, mothers administer the medication.

campaign resultsIn 2014, the SMC Campaign was conducted in the four regions for three months covering the high transmission season (August, September, October, and November). Kedougou, was the only region that conducted 2 SMC rounds as it started implementing in 2013.

The target was extended to children from 3 to 120 months (624,139 estimated in target age group). This age group extension, compared with WHO recommendations (3 to 60 months,) was based on shift of vulnerability towards the ages from 60 to 120 months shown by the epidemiologic data on malaria morbidity in Senegal.

Administrative coverage rates for the 3 passages respectively was 98.6%, 97.9% and 98.0%. Information was obtained from the SMC impact evaluation survey in the south of Senegal, 2015 July by Dr JL Ndiaye.

SMC districtsKey interventions and process began with the National and regional Steering Committees involving NMCP, health staff, donors/partners and researchers. There was development and update of tools and materials (guidelines, planning forms, data collection and analysis support. Training of staff took place at all levels and operational actors

Early field planning was held with staff at regional and district level: identification of activities, dates, estimation of household/child targets, estimation of resources needed (budgets, HR, logistics, etc.). Early delivery of drugs, tools, supports was ensured to be available at health post level at least 1 week before the 1st campaign day.

Rigorous selection of volunteers and supervisors was based on specific criteria. Develop communications activities took place at least 2 weeks before and during the campaign period focusing on SMC gains, HH census, administration by mothers for the 2 remaining days, and possible side effects.

New casesCampaign roll out included supervision of the process at the districts and health posts (organization model, administration). There was mobilization of logistics for transportation of volunteers, drugs, and materials. Day to day monitoring took place with regional debriefing to analyze data from districts, geographical progression, target coverage progression and identify issues and challenges. Daily electronic distribution of “SMC bulletin” to health staff and partners helped to disseminate information on districts performances.

Post campaign evaluation took place at all levels: workshops for sharing and validating data and information, identification of key issues, lessons learned, and formulation of recommendations to improve future campaigns. Local health agents, NMCP staffs, partners and authorities were involved.

Spontaneous pharmacovigilance system tracked and treated side effects. This consisted of distribution of yellow cards to health facilities, case notification by health agents, availability of a side effects line listing, and immediate and free-of-charge case management.

The following key challenges were faced:

  • Correct availability of drugs and tools at health posts
  • Complete coverage of all households and children
  • Completion of 2nd and 3rd doses by guardians of children
  • Availability of children and guardians during harvest period and class time
  • Comprehensive communication for population particularly in possible occurrence of side effects
  • Case management of side effects free of charge
  • Availability and promptness of data
  • Long term logistic availability

Rainy SeasonFinally there were some outstanding questions. Can we switch SMC from campaign to routine system at health post level? Can we expand SMC to other regions and with what targets? Also, can we improve formulation and taste of drugs for enhancing children’s compliance?

Financial support: This work was made possible through support provided by the United States President’s Malaria Initiative, and the U.S. Agency for International Development, under the terms of an Interagency Agreement with the Centers for Disease Control and Prevention (CDC). The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development or the Centers for Disease Control and Prevention.

[1] Dr Mamadou L Diouf, Mr Medoune Ndiop, Dr Mady Ba, Dr Ibrahima Diallo, Dr Moustapha Cisse, Dr Seynabou Gaye, Dr Alioune Badara Gueye, Dr Mame Birame Diouf

Correlates of prompt and appropriate treatment of malaria in children in Madagascar

Colleagues[i] from the Johns Hopkins Center for Communications Programs (CCP), the US President’sToso 1 image Malaria Initiative and the Ministry of Public Health in Madagascar, presented a poster today at the American Society of Tropical Medicine 64th Annual Conference in Philadelphia. Their findings on malaria treatment in Madagascar follow.

According to Madagascar’s 2013 Malaria Indicator Survey, malaria prevalence among children aged 6-59 months was 9.1% (microscopy). Prompt diagnosis and treatment of malaria is critical for minimizing complications and ensuring complete recovery.

In Madagascar, Artemisinin-based Combination Therapy (ACT) is the recommended treatment for uncomplicated malaria. Using survey data collected in 2014 from eight districts. We assessed the socio-demographic, ideational and community factors associated with prompt treatment of fever with ACT among children aged less than five years.

The data showed that about one quarter (24.4%) of households had a child with fever during the two weeks prior to the survey. About three quarters of female caregivers reported that they sought treatment for their child with fever.

Toso 2 imageNonetheless, only about one fifth of the children were reportedly tested for malaria during their sickness: from 4.7% in the Highlands transmission zone to 30% in the Equatorial zone. Overall, less than one tenth (8.9%) of caregivers reported that their child sick with fever in the last two weeks received prompt ACT, varying from 5.4% in the Highland transmission zone to 16.2% in the Equatorial zone.

The factors associated with prompt ACT treatment include district of residence, perceived susceptibility, and malaria treatment ideation (derived from treatment-related perceived self-efficacy, attitudes, and interpersonal communication; perceived response efficacy of malaria diagnostic test, and knowledge of ACT).

The data also showed that female caregivers resident in higher transmission disctricts (Manakara – Equatorial zone; Morombe – Tropical zone) were more likely to obtain prompt ACT treatment for their children compared to their peers resident in lower transmission district of Miarinarivo (Highlands). A high sense of perceived susceptibility to malaria was associated with decreased odds of prompt treatment while high scores for treatment ideation increased the odds.

Programs should continue promoting prompt treatment for malaria targeting both demand and supply sides. The delay in appropriate treatment associated with perceived susceptibility to malaria indicates the need to intensify efforts to strengthen self-efficacy for prompt malaria treatment in areas where malaria is common. A comprehensive program to promote prompt treatment should address the treatment ideation elements assessed in this study.

[i] Stella O. Babalola, Grace Awantang, Nan Lewicky, Michael Toso, Sixte Zigirumugabe, Arsene Ratsimbasoa, Monique Vololona