Category Archives: CHW

Rwanda Celebrates World Malaria Day 2017 – community is a major focus

Dr. Noella Umulisa, the Malaria Team Lead or the USAID Maternal and Child Survival Program in Kigali Rwanda shares with us experiences from Rwanda’s recent observance of World Malaria Day 2017.

The Malaria Day celebration took place in Huye districts in the southern Province. Why the southern province? – because among the 10 high endemic districts, 6 are the southern province. Why Huye district? – because IRS has been launched in Huye district yesterday and in another district Nyanza in Southern province.

The ceremony was attended by USAID and WHO representative, local leaders, MOH staff, partners, population of Simbi sector and the guest of honour was Dr Jeannine Condo the Director General of Rwanda Biomedical Center (which houses malaria activities).

A special recognition was given to community health workers (CHWs) who are playing a key role and are on the front line of fighting Malaria through sensitization of the population, testing and treating the population through community case management (iCMM and HBM) of Malaria, and now when a big number of CHWs will be involved in spraying households in their community.

The World Malaria Day celebration in Rwanda is marked by different activities for Malaria prevention conducted at community level from 24th to 29th April 2017.  Also, Malaria prevention and control messages are being disseminated using different communication tools and approaches such as radio and TV programs, community outreach activities, educating communities on proper use of bed nets.

Door to door mobilization is being conducted about the Indoor Residual Spraying (IRS) in high malaria burden districts of Huye and Nyanza. MCSP, with support from the US President’s Malaria Initiative, has participated actively in this event by supporting Community outreaches though theatre skits in the first 10 high endemic district.

The Director General made the following statement:

In January 2016, the Government of Rwanda and partners developed a Malaria Contingency Plan in response to the increase in malaria cases. The following interventions were implemented to address malaria rise in Rwanda: A Home Based Management of fever for adults at community level was set up countywide to reduce the malaria burden and prevent severe malaria and death. From Nov 2016 up to March 2017, the country distributed more than 6 million nets in 30 districts ensuring universal coverage of the entire population.

The country has increased access to health services for all through Community Based Health Insurance (CBHI). The Government of Rwanda provides free treatment of malaria to the most vulnerable population (Ubudehe 1&2 categories) to ensure that all financial barriers are no more to hinder the health service delivery for the community. Extension of Indoor residual spraying (IRS) in districts with high malaria burden where 5 out of 8 were sprayed (Nyagatare, Kirehe, Bugesera, Gisagara and Gatsibo).

We hope that this commitment will keep Rwanda on track to control and eventually eliminate malaria.

Success Stories in Community Health in Africa

The African Public Health Network of the Johns Hopkins Bloomberg School of Public Health held a panel discussion about community health successes in Africa on Monday 10th of April as the first in a series of events for the annual “Faces of Africa Week”.

Africa evokes different reactions to different people. For many, it’s the pictures of starving children, wars, poverty and disease that they find in various print and electronic media. But there has been a lot of achievement in Africa!

The Johns Hopkins Bloomberg School of Public Health – an institution that has invested a lot of time and resources in saving millions of lives at a time- has a huge footprint on the continent and other parts of the developing world through the work done and being done by experienced faculty members. Here is a summary of there thoughts as presented at Monday’s panel.

Dr. Henry Perry led the panel discussion on ‘The success stories in Public Health in Africa in the context of the role of Community Based Health Care’. He provided insights from the experiences of Rwanda and Ethiopia. He stressed the achievements of both countries in establishing and scaling up community health worker programs and in achieving Millennium Development Goals with reduced child mortality.

Dr. William Brieger shared his experience from having lived and worked in Nigeria for over 27 years. He shared the progress in working with volunteer health workers and helping to shape community directed interventions. This history ranged from volunteer CHW programs by local NGOs, FBOs and universities in the 1970s to the development of a standardized set of CHW guidance and training materials by the Federal Ministry of Health in 2012. In the 1990s Nigeria took part in WHO’s African Program for Onchocerciasis Control and established a system of community directed treatment with ivermectin (CDTI) and community directed distributors to enable communities to take charge of annual ivermectin delivery. Then in the 2000s efforts build on the CDTI model to create the community directed intervention approach that included delivery of malaria services (ITNs, Case management and intermittent preventive treatment), vitamin A and DOTS for TB through community effort.

Dr. Anbrasi Edward shared the Mozambique experience highlighting the Vurhonga projects and the impact of the care group model in improving maternal and child health. She described how the Care Group model was developed by an NGO that involved community volunteers providing education and services to small groups of community members. This model has spread throughout Africa.

Mr. Bonny Musefano from the Embassy of The Republic of Rwanda provide perspectives on how Rwanda rebuilt its health system after the 1994 genocide ultimately leading to good community health. He stress the importance of Rwanda’s innovative system of community health insurance called Mutuelles de Santé. Very high coverage means that almost all Rwandans have access to health care. He also stressed the country’s interest in innovative technology and how drones are being used to deliver medical supplies to remote areas.

The APHN is grateful to members of the panel and to Prof. David Peters who helped fund the event via the Department of International Health.

For APHN: Joseph Uwazota, Jean Olivier Twahirwa Rwema, Zyleen Kassamali, Eve-Marie Benson, and Massah Massaquoi

World Health Workers Week, a Time to Recognize Health Worker Contributions to Malaria Care

Since the beginning of the Roll Back malaria Partnership in 1998 there has been strong awareness that malaria control success is inextricably tied to the quality of health systems. Achieving coverage of malaria interventions involves all aspects of the health system but most particularly the human resources who plan, deliver and assess these services. World Health Worker Week is a good opportunity to recognize health worker contributions to ridding the world of malaria.

We can start with community health workers who may be informal but trained volunteers or front line formal health staff.  According to the Frontline Health Workers Coalition, “Frontline health workers provide immunizations and treat common infections. They are on the frontlines of battling deadly diseases like Ebola and HIV/AIDS, and many families rely on them as trusted sources of information for preventing, treating and managing a variety of leading killers including diarrhea, pneumonia, malaria and tuberculosis.”

The presence of CHWs exemplifies the ideal of a partnership between communities and the health system. With appropriate training and supervision CHWs ensure that malaria cases are diagnosed and treated promptly and appropriately, malaria prevention activities like long lasting insecticide-treated nets are implemented and pregnant women are protected from the dangers of the disease. CHWs save lives according to Nkonki and colleagues who “found evidence of cost-effectiveness of community health worker (CHW) interventions in reducing malaria and asthma, decreasing mortality of neonates and children, improving maternal health, increasing exclusive breastfeeding and improving malnutrition, and positively impacting physical health and psychomotor development amongst children.”

CHWs do not act in isolation but depend on health workers at the facility and district levels for training, supervision and maintenance of supplies and inventories. These health staff benefit from capacity building – when they are capable of performing malaria tasks, they can better help others learn and practice.

A good example of this capacity building is the Improving Malaria Care (IMC) project in Burkina Faso, implemented by Jhpiego and supported by USAID and the US President’s malaria Initiative. IMC builds capacity of health workers at facility and district level to improve malaria prevention service delivery and enhance accuracy in malaria diagnosis and treatment. Additionally capacity building is provided to health staff in the National Malaria Control Program to plan, design, manage and coordinate a comprehensive malaria control program. As a result of capacity building there has been a large increase in malaria cases diagnosed using parasitological techniques and in the number of women getting more doses of intermittent preventive treatment to prevent malaria during pregnancy.

Malaria care is much more than drugs, tests and nets. Health worker capacity is required to get the job done and move us forward on the pathway to eliminate malaria.

A Pilot to Use Malaria RDTs at the Community Level in Burkina Faso

A poster entitled “The Improving Malaria Care (IMC) Project’s Contribution to follow up a Pilot to Use Rapid Diagnostic Tests (RDTs) at the Community Level in Burkina Faso” was presented by members of Jhpiego’s Burkina Faso Team: Ousmane Badolo, Stanislas P. Nebie, Moumouni Bonkoungou, Mathurin Dodo, Rachel Waxman, Danielle Burke, William Brieger at the 65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

CHWs provide malaria testing, treatment and health education

CHWs provide malaria testing, treatment and health education

Early and correct case management of malaria in health facilities and at the community level is among the priorities of Burkina Faso’s National Malaria Control Program (NMCP). In line with this initiative, the NMCP piloted use of Rapid Diagnostic Tests (RDTs) by Community Health Workers (CHWs) to confirm malaria cases in the three health districts of Kaya, Saponé and Nouna between 2013 and 2015. With PMI support, follow-up visits were organized to document best practices, as well as challenges, on RDT use by CHWs that could serve as lessons learned for scale-up.

During follow-up visits, malaria commodities management (supply, storage and use) at the community level was examined, use of RDTs was assessed, and implementation at the community stockoutlevel was discussed with all actors at regional, district, health facilities, and community levels. The team examined the monitoring/supervision processes at all levels, used a check list on malaria commodities management, and employed a questionnaire for each type of actor. Both qualitative and quantitative data have been collected. A total of 108 persons were contacted including 32 CHWs, 42 community leaders and 34 health care providers and managers.

chw-drug-kitFindings revealed frequent stock-outs of RDTs and artemisinin-based combination therapies, non-payment of stipends to CHWs (a demotivator) and insufficient supervision of CHW by health teams. From the community perspective, 66% of community leaders were satisfied with their CHW’s work (diagnosis and treatment of uncomplicated malaria concernsand referral of severe cases to health facilities). However, 46% of community leaders complained of frequent stock-outs and unanimously agreed on the importance of regular payment of premiums to CHW.

Follow up of the pilot was valuable in obtaining community, CHW and health worker perspectives for improving the program. While the community finds the program acceptable, its sustainability will require that solutions be found for stock-outs, non-payment, and insufficient supervision before scale up takes place.

Community health workers provide integrated community case management using malaria rapid diagnostic test kits

Please find below the abstract of the above named article that is first appearing as an accepted paper in the journal Research in Social and Administrative Pharmacy. The authors – Bright C. Orji, Namratha Rao, Elizabeth Thompson, William R. Brieger, Emmanuel
‘Dipo Otolorin – conducted this work as part of Jhpiego’s commitment to fighting malaria in Nigeria.


Background: Throughout Nigeria malaria is an endemic disease. Efforts to treat malaria can also be combined with other illnesses including pneumonia and diarrhea, which are killing children under five years of age. The use of Rapid Diagnostic Test (RDT) aids early  diagnosis of malaria and informs when other illnesses should be considered. Those with positive RDT results should be treated with Artemisinin-based Combination Therapy (ACTs), while those with negative RDTs results are further investigated for pneumonia and diarrhea.

Community Directed Distributor performs malaria rapid diagnostic test of febrile child

Community Directed Distributor performs malaria rapid diagnostic test of febrile child

Critical health systems challenges such as human resource constraints mean that community case management (CCM) and community health workers such as volunteers called Community Directed Distributors (CDDs) can therefore play an important role in diagnosing and treating malaria. This report described an effort to monitor and document the performance of trained CDDs in providing quality management of febrile illnesses including the use of RDTs.

Method: The program trained one hundred and fifty-two (152) CDDs on the use of RDTs to test for malaria and give ACTs for positive RDTs results, cotrimoxazole for the treatment of pneumonia and Oral rehydration solution and zinc for diarrhea They were also taught to counsel on compliance medicine, identify adverse reactions, and keep accurate records. The CDDs worked for 12 Calendar months. Their registers were retrieved and audited using a checklist to document client complaints, tests done, test results and treatment provided. No client identifying information was collected.

Results: There were 32 (21%) male CDDs and 120 (79%) females. The overall mean age of the CDDs was 36.8 (±8.7) years old. 89% of the male CDDs provided correct treatment based on RDT results compared to 97.6% of the female CDDs, a statistically significant difference. Likewise CDDs younger than 36 years of age provided 92.7% correct case management compared to those 36 years and older (98.4%). The difference between the age groups was also significant. There was a strong association between CDDs dispensing ACTs with positive RDT results. In RDT negative cases, the most common course of action was dispensing antibiotics (43.2%), followed by referring the patients (30.34%) and the providing ORS (24.1%).

Conclusion: Volunteer CDDs who are community members can adhere to treatment protocols and guidelines and comply with performance standards. The next step is scaling this approach to a state-wide level.

Accepted Date: 26 September 2016. Please cite this article as: Orji BC, Rao N, Thompson E, Brieger WR, ‘Dipo Otolorin E, Community health workers provide integrated community case management using malaria rapid diagnostic test kits, Research in Social & Administrative Pharmacy (2016), doi: 10.1016/j.sapharm.2016.09.006.

Community Directed Interventions to Enhance PHC and MCH

William Brieger of the Department of International Health, JHU Bloomberg School of Public Health, delivered the keynote address to the Community Based Primary Health Care Working Group at the 2015 American Public Health Association in Chicago. The focus was on Community Directed Interventions (CDI) as a way to enhance implementation of primary health care and maternal and child health. Some excerpt from the talk follow.

Ivermectin coverageThe origins of the CDI Approach are based in Onchocerciasis Control and the implementation research done by the Tropical Disease Research (TDR) Program of WHO and collaborating agencies to help establish the foundational guidance of the African Program for Onchocerciasis Control in 1995. Since then we have seen an expansion of CDI into other health issues

We should start discussion with an understanding of ‘community’ which Rifkin et al. (1988) defined as a group of people living in the same defined area sharing basic values, organization, and interests. White (1982) proposed that community is an informally organized social entity which is characterized by a sense of identity. Manderson et al. (1992) in their work for TDR defined community as a population which is geographically focused but which also exists as a discrete social entity, with a local collective identity and corporate purpose.

Communities are people sharing values and institutions. Community is based on locality (geographic), interdependent social groups, interpersonal relationships expressed through social networks and built on s culture that includes values, norms, and attachments to the community as a whole as well as to its parts. Prior to developing any community intervention we must understand the boundaries, composition and structure of a community from the perspectives of its own members, as their local knowledge and participation are central to success.

community systemsCommunity Systems Strengthening has been taken up by the Global Fund in order to enhance coverage of various health interventions such as HIV drugs and bednets to prevent malaria. Community systems are community?led structures and mechanisms used by communities through which community members and community based organizations and groups interact, coordinate and deliver their responses to the challenges and needs affecting their communities. Many community systems are small?scale and/or informal. Others are more extensive – they may be networked between several organizations and involve various sub?systems. For example, a large care and support system may have distinct sub?systems for comprehensive home?based care, providing nutritional support, counselling, advocacy, legal support, and referrals for access to services and follow?up.

Efficacy, Social Control and Cohesion are important characteristics of communities that enable them to take on project and solve problems. Collective Efficacy is a perceived ability to work together. Social control provides evidence that communities are able to enforce their norms. Cohesion describes social interaction that brings people together. A strong sense of identity and a sense of belonging describe communities that can get things done. These characteristics lead to community competency to collaborate effectively in identifying the problems/needs of the community, achieve a working consensus on goals and priorities, agree on ways and means to implement the agreed-upon goals, and collaborate effectively in the required actions.

Communities chooseIt is important to distinguish between Community Based Intervention (CBI) and Community Directed Intervention. CBI takes place in the community but a Health/Development agency exercises authority over decisions on project design and implementation. Project activities (e.g., service delivery dates and procedures) are designed by the agency. Activities simply happen in the community.

With CDI the community exercises authority over decisions and decides on acceptable method to implement projects. This ensures sensitivity to local decision-making structures and social life. Activities happen both in and by the community; the community is in control.

CDI was pioneered for Onchocerciasis (River Blindness) Control as community directed treatment with ivermectin (CDTI). When communities are in charge, coverage is better than when ivermectin distribution is centrally organized by a health agency. The original 1995 CDI field testing showed better ivermectin coverage when the community was in charge of distribution. Since the beginning of CDTI, over 200,000 villages in 18 African countries have been distributing ivermectin annually through their own efforts. Lessons learned over the years are that CDI works best when 1) the smallest level of an organized community is the basis of action (e.g. a hamlet, a clan/kin group) and 2) communities are encouraged to choose as many CDDs as they think they need to get the job done. This means that the community is in charge, not individual volunteers who can be replaced anytime the community finds the need.

With CDI for onchocerciasis or any other health program, Communities plan and chose how to deliver services. This may be house-to-house, central place distribution or a combination. Health workers provide training and supervision to volunteer village health workers called community directed distributors (CDDs).

CDI study 2008TDR observed that CDI naturally expanded to include other services wanted by the community such as immunization, community development, water and sanitation, agriculture and forestry, HIV-AIDS, family planning, guinea worm, Vitamin A. TDR and APOC then decided that CDI with other service components should be systematically tested. The project sites added in a systematic manner other interventions to existing CDTI programs including home management of malaria, ITN distribution & promotion, TB DOTS, Vitamin A in addition to continued ivermectin distribution. These services varied in complexity and communities responded by dividing the work among several different volunteers.

Appropriate malaria treatment CDI studyCoverage of interventions like malaria case management, ITN promotion and Vitamin A distribution was higher in the intervention areas compared to the delivery of these services through the routine health system. TB DOTS presented the only challenge because of the social stigma associated with the disease. The study concluded that CDI can effectively incorporate high impact, evidence based interventions while at the same time maintaining and increasing ivermectin coverage. Since CDI does not rely on one volunteer but whole community effort, the problem of overburdening on community health worker did not arise. Other incterventions ould benefit from CDI such as Misoprostol, Intermittent Preventive Treatment, Deworming, Oral Rehydration solution, Zinc, Cotrimoxazole, Amoxicillin, Soap for handwashing and WaterGuard treatment kits.

MIPJhpiego an NGO affiliate of the Johns Hopkins University used CDI to deliver malaria in pregnancy (MIP) prevention services in Nigeria including Intermittent Preventive Treatment and Insecticide Treated Nets. Contrary to fears that CDI would detract from antenatal care attendance, the work of CDDs actually ensured that ANC attendance increased over time. Through CDI IPTp coverage increased compared to control communities and more pregnant women slept under ITNs regularly.

Community-Clinic modelJhpiego next expanded CDI for MIP into integrated Community Case Management (iCCM), thus taking community case management beyond community based care. Giving communities responsibility for organizing and managing their services using the CDI approach meant greater access to services whenever people need them. Using the CDI approach to iCCM CDDs reached 7,504 clients who presented signs and symptoms of malaria. CDDs successfully conducted malaria diagnosis using the rapid diagnostic test (RDT) kits. Overall, 47.8% tested positive while 52.2% tested negative. CDDs adhered to guidelines and all the 3,587 clients with positive RDT results received appropriate anti-malarial medicines. As appropriate 21.0% were treated for diarrhoea, 11.0% for pneumonia (of whom 68.0% were referred to the health facility)

CDDsA Supervisory Checklist and Performance Standards were developed and used for Assessing CDD performance. The results were discussed at monthly CDD meetings at their nearest health facilities. This led to further improvements in History taking, Examination, Conducting RDTs for Malaria and Illness Management.

TDR has done further scoping to learn if CDI would be acceptable by health workers and community members in Urban, Nomadic and Underserved Rural Communities. CDI was favorable received. In conclusion we have learned over the years that CDI can involve women, families and communities in meeting their own health needs.

Use of community health volunteers to increase coverage for integrated community case management in Bondo, Kenya

Colleagues[1] from John Snow, Inc. and Jhpiego are presenting presenting a poster at the American Society of Tropical Medicine 64th Annual Meeting Wednesday 28 October 2015. Visit Poster 1330. Below is a summary of their findings.

iccm kenyaBondo County is located in the Western region of Kenya. It has an IMR of 110 and an U5MR of 208 per 1,000 live births which is thrice the national U5MR of 74/1000. There continues to be limited access to and use of health services in some rural areas that are underserved by health facilities. This provided the impetus for advocating for the implementation of integrated Community Case Management (iCCM) as a way to address these health disparities.

An 18-month study is underway in Bondo to test whether community health volunteers (CHVs) can effectively deliver an iCCM package in the context of the existing community health strategy platform. The study is a quasi-experimental design with intervention and comparison groups of four community units each. Fifty-eight intervention group CHVs were trained on iCCM and health promotion, provided with iCCM commodities, and a monthly stipend of $23.

Kenya-CHW MCSP, USAIDIn the comparison group CHVs were only trained in health promotion and receive a similar stipend. Baseline survey was done in October 2013 and midline in July 2014; the latter was limited to the intervention group only.

An endline survey is planned for June 2015. Overall introduction of iCCM resulted in over 100% increase in iCCM cases managed from baseline compared to midline (2,367 vs. 4,868), with the CHVs’ share being 56%.

In terms of performance, the CHVs demonstrated good ability to follow the iCCM algorithm from the identification of signs to the classification of illness, and deciding whether to treat at home or refer to the health facility. The greatest improvement was in the ability to examine or “look” for signs of illness (average of 3% at baseline vs. 74% at midline), p <0.05.

Key stakeholders reported that there were various benefits of iCCM in Bondo such as improved access to health services, improved health behaviors at individual and community level, community empowerment, and increased trust of the CHVs by the community. Based on these results so far, CHVs can effectively provide iCCM services and thus contribute to reducing childhood morbidity deaths in Bondo, Kenya

[1] Savitha Subramanian, Mark Kabue, Dyness Kasungami, Makeba Shiroya-Wadambwa, Dan James Otieno, Charles Waka

Evaluation of Community Malaria Worker Performance in Western Cambodia: a Quantitative and Qualitative Assessment

Sara E. Canavati de la Torre and colleagues[1] conducted a study of Community health workers who focus on malaria. They are sharing their results with us below.

Village/ Mobile Malaria Workers (VMWs/MMWs) are a critical component in Cambodia’s national strategy to reduce malaria morbidity and mortality. Since Sara map image0162004, VMWs have been providing free malaria diagnosis and treatment using Rapid Diagnostic Tests and Artemisinin-based Combination Therapies in hard-to-reach villages (>5km from closest health facility).

VMWs play a key role in control and prevention, diagnosis and treatment of malaria as well as in delivering behavioral change communication (BCC) interventions to this target population. Out photos shows a village malaria worker at a health center registering number of patients diagnosed and treated during a month.

Sara CHW image013Overall the study aimed to evaluate the implementation of these activities performed by VMW/MMWs, a quantitative and qualitative assessment was conducted in 5 provinces of western Cambodia in order to:

  • understand job satisfaction of VMWs and MMWs vis-a-vis their roles and responsibilities;
  • assess their performance according to their job descriptions;
  • gain insights into the challenges faced in delivery of diagnosis, treatment and health education activities to their communities.

A total of 196 VMWs/MMWs were surveyed in October 2011 using a combination of quantitative and qualitative methods. Triangulation of quantitative and qualitative data helped to gain a deeper understanding of the success factors of this intervention and the challenges faced in implementation. The Map of Provinces shows ODs and HCs visited by the field team in zones 1 and 2 of the containment project.

Sara Results image018The Figure shows that overall, levels of VMW performance were in line with the expected performance (80%) and some were higher than expected. However, some performance gaps were identified in the areas of knowledge of malaria symptoms, treatment regimens, and key messages. In particular, there were low levels of practice of the recommended direct observed therapies (DOTs) approach for malaria treatment (especially for the second and third doses), reportedly caused by stock-outs, distance and transportation.

The national malaria program should aim to focus on improving knowledge of VMWs in order to address misconceptions and barriers to effective implementation of DOTs at community-levels. In addition to the findings, the tools developed, will potentially help the national program to come up with better indicators in the near future.

[1] Sara E. Canavati de la Torre1,2,8 Po Ly2, Chea Nguon3, Arantxa Roca-Feltrer4,9, David Sintasath5, Maxine Whittaker6, Pratap Singhasivanon7 – 1Faculty of Tropical Medicine, Mahidol University/ Malaria Consortium Cambodia, Phnom Penh, Cambodia; 2The National Centre of Parasitology and Malaria Control, Phnom Penh,, Cambodia; 3The National Centre of Parasitology and Malaria Control, Phnom Penh, Cambodia; 4Malaria Consortium Cambodia, Cambodia; 5Malaria Consortium Asia Regional Office, Bangkok, Thailand; 6 Australian Centre for International and Tropical Health, University of Queensland, Queensland, Australia; 7Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; 8Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; 9London School of Tropical Medicine and Hygiene, London, UK