Category Archives: CHW

On World Malaria Day the realities of resurgence should energize the call to ‘Beat Malaria’

Dr Pedro Alonso who directed the World Health Organization’s Global Malaria Program, has had several opportunities in the past two weeks to remind the global community that complacency on malaria control and elimination must not take hold as there are still over 400,000 deaths globally from malaria each year. At the Seventh Multilateral Initiative for Malaria Conference (MIM) in Dakar, Dr Alonso drew attention to the challenges revealed in the most recent World Malaria Report (WMR). While there have been decreases in deaths, there are places where the number of actual cases is increasing.

Around twenty years ago the course of malaria changed with the holding of the first MIM, also in Dakar and the establishment of the Roll Bank Malaria (RBM) Partnership. These were followed in short order by the Abuja Declaration that set targets for 2010 and embodied political in endemic countries, as well as major funding mechanisms such as the Global Fund to fight AIDS, TB and Malaria. This spurred what has been termed a ‘Golden Decade’ of increasing investment and intervention coverage, leading to decreasing malaria morbidity and mortality. The Millennium Development Goals provided additional impetus to reduce the toll of malaria by 2015.

On Facebook Live yesterday Dr Alonso talked about that ‘Golden Decade.’ There was a 60% decrease in mortality and a 40% decreases in malaria cases. But progress slowing down and we may be stalled at a crossroads. He noted that history show unless accelerate efforts, malaria will come back with a vengeance. Not only is renewed political leadership and funding, particularly from affected countries needed, but we also need new tools. Dr Alonso explained that the existing tools allowed 7m deaths be diverted in that golden decade, but these tools are not perfect. We are reaching limits on these tools such that we need R&D for tools to enable quantum leap forward. Even old tools like nets are threatened by insecticide resistance, and research on alternative safe insecticides is crucial.

Dr Alonso at MIM pointed to the worrying fact that investment in malaria overall peaked in 2013. Investment by endemic countries themselves has remained stable throughout and never gone reached $1 billion despite advocacy and leadership groups like the Africa Leaders Malaria Alliance. The 2017 WMR shows that while 16 countries achieved a greater that 20% reduction in malaria cases, 25 saw a greater that 20% increase in cases. The outnumbering of decreasing countries by increasing was 4 to 8 in Africa, the region with the highest burden of the disease. Overall 24 African countries saw increases in cases between 2015 and 2016 versus 5 that saw a decrease. A review of the Demographic and Health and the Malaria Information Surveys in recent years show that most countries continue to have difficulty coming close to the Abuja 2010 targets for Insecticide treated net (ITN) use, prompt and appropriate malaria case management and intermittent preventive treatment of malaria in pregnancy (IPTp).

The coverage gap is real. The WMR shows that while there have been small but steady increase in 3 doses of IPTp, coverage of the first dose has leveled off. Also while ownership of a net by households has increased, less than half of households have at least one net for every two residents.

In contrast a new form of IPT – seasonal malaria chemoprevention (SMC) for children in the Sahel countries has taken off with over 90% of children receiving at least one of the monthly doses during the high transmission season. Community case management is taking off as is increased use of rapid diagnostic testing. Increased access to care may explain how in spite of increased cases, deaths can be reduced. This situation could change rapidly if drug resistance spreads.

While some international partners are stepping up, we are far short of the investment needed. The Gates Foundation is pledging more for research and development to address the need for new tools as mentioned by Dr Alonso. A big challenge is adequate funding to sustain the implementation of both existing tools and the new ones when they come online. Even in the context of a malaria elimination framework, WHO stresses the need to maintain appropriate levels of intervention with case management, ITNs and other measures regardless of the stage of elimination at which a country or sub-strata of a country is focused.

Twenty years after the formation of RBM and 70 years after the foundation of WHO, the children, families and communities of endemic countries are certainly ready to beat malaria. The question is whether the national and global partners are equally ready.

Acceptance of the Contribution of Community-Based Health Workers (CBHWs) to Improving Prevention of Malaria in Pregnancy in Burkina Faso by Health Center Staff

Efforts are underway to test the a community-based system for providing IPTp to pregnant women in Burkina Faso as a means of increasing coverage. Justin Tiendrebeogo, Ousmane Badolo, Mathurin Dodo, Yacouba Savadogo, Danielle Burke, Susan Youll, and William Brieger share a formative study among health staff concerning their perceptions of the ability of Community Based Health Workers to provide increased doses. This was presented at the 7th Multilateral Initiative for Malaria Conference in Dakar. Below are the findings.

The Burkina Faso Ministry of Health, with support from its partners, initiated a study on the feasibility of increasing provision of intermittent preventive malaria treatment in pregnant women (IPTp) with sulfadoxine-pyrimethamine (SP). Existing community-based health workers (CBHWs) were enlisted to deliver the third and fourth doses recommended by the World Health Organization. Currently, only facility-based health care providers give SP, and women in rural areas have trouble accessing health facilities for the medicine.

Using CBHWs has the potential to reach more women with a greater number of doses of IPTp-SP. Direct training and supervision of CBHWs is the responsibility of frontline health care staff, including antenatal care (ANC) providers. Therefore, to ensure a successful rollout of community delivery of IPTp, it is crucial that these staff accept the new roles of CBHWs. This baseline study was conducted to learn the frontline staff’s views about existing and proposed CBHW activities.

Study’s Geographic Areas. Three districts (Batié, Pô, and Ouargaye) in the southern part of Burkina Faso. Twelve centre de santé et de promotion sociale (health and social promotion centers [CSPS]) were selected in Ouargaye, Pô, and Batié Health Districts. In each district, two CSPS were randomly assigned as intervention catchment areas, for a total of six centers. Then using matching criteria, the remaining six CSPS were designated as control sites.

Health Worker Interviews were conducted among a total of 35 CSPS staff: 23 were men, and 12 were women. Semi-structured interview guides were used in this formative study. Open-ended questions sought the views of ANC providers and CBHW supervisors about the current work of CBHWs and the feasibility of using this health cadre to administer IPTp to pregnant women. The Study sought to understand provider opinions to design an IPTp-SP intervention involving CBHWs.

Qualitative analysis identified common themes in the open-ended responses. Providers like the CBHW program, noting that “CBHWs come from the community” and help with language barriers. However, CBHWs are not always available or move frequently from one community to another. A few male providers noted issues with timely payment of stipends to CBHWs.

Most providers were open to CBHWs providing IPTp-SP to pregnant women: “It will reduce [our] workload.” Unlike female providers, some male providers stressed the need for CBHWs to be “well trained.”

Providers commented that CBHWs were needed and could contribute. For example CBHWs could increase the uptake of IPTp-SP, prevent deaths and malaria, educate women and the community, and prevent stock-outs of SP. While CBHWs do not currently provide IPTp-SP, several providers noted that CBHWs already conduct community education sessions with pregnant women on taking IPTp-SP.

A few noted that CBHWs already monitor adherence to IPTp-SP doses and send women to the health facility when doses are needed. Providers expressed the importance of including information on malaria prevention and treatment, IPTp-SP administration, stock management, and data collection in the CBHW training.

The findings guided discussions and planning with both district and CSPS staff in the design of the CBHW training and IPTp-SP intervention. The results led to development of the training-of-trainers process that started with the district health team, who then trained CSPS staff—the CSPS staff then trained CBHWs.

Gaining the frontline staff’s acceptance of and perceptions about CBHWs—and building on them—will hopefully lead to greater ownership and better management of project implementation at the community level.

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, PMI, or the United States Government.

Community-Based Health Workers in Burkina Faso: Are they ready to take on a larger role to prevent malaria in pregnancy?

Community Based Health Worker (CBHW) opinions were sought prior to establishing community delivery of intermittent preventive treatment of malaria in pr4egnancy in Burkina Faso. Bill Brieger, Danielle Burke, Justin Tiendrebeogo, Ousmane Badolo, Mathurin Dodo, Yacouba Savadogo, and Susan Youll report on the findings from the CBHWs at the 7th Multilateral Initiative for Malaria Meeting in Dakar.

In 2012 and 2013, World Health Organization recommended that a minimum of three doses—rather than two doses—of intermittent preventive treatment of malaria in pregnancy (IPTp). This three-dose recommendation has made it more challenging to achieve the 85% national coverage target in Burkina Faso. Existing health services in other endemic countries have also had difficulty achieving the two-dose target. Using a formative approach, this study tested if the 85% target could be achieved by having IPTp delivered to the community through trained community-based health workers (CBHWs) who are supervised by the health system.

Existing training materials for these CBHWs outline a basic role in promoting antenatal care (ANC) and guiding communities to use curative and preventive malaria services. The question was to what extent are the CBHWs practicing what they were taught, and could training in community delivery of IPTp build on their existing roles.

Because of continuous malaria transmission, these three districts in the southern part of Burkina Faso were chosen for the intervention study: Batie, Po, and Ouargaye. Also in these three districts, community health workers have been involved in the implementation of other programs, such as immunization, malaria, nutrition, and family planning.

As part of this formative study to design the community-based IPTp intervention, semi-structured interviews were conducted with CBHWs in three health districts (Batie, Po, and Ouargaye) with a high malaria burden. In general, the Directorate of Health Promotion in the Ministry of Health encourages communities to select one male and one female CBHW, although the actual CBHWs chosen would depend on availability and literacy of the CBHW.

In each district, four centre de santé et de promotion sociale (health and social promotion centers [CSPS] were selected, and their catchment areas were divided among intervention and control groups. Effort was made to reach all CBHWs currently practicing in these 12 catchment areas. Numerical and narrative data were entered in a database and analyzed by gender based on major themes relating to ANC, pregnancy, and malaria services. Interview transcripts were manually reviewed for themes.

Of the CBHWs interviewed, a total of 62 were male and 42 were female.  Both female and male CBHWs provide advice and education to women in their villages, which may include advising women to go to the CSPS for pregnancy or ANC, family planning, immunization, or illness. Some CBHWs stated that they remind women about follow-up ANC appointments. As one female CBHW explained, “on their return [from CSPS for care], I ask [the pregnant woman] what has been said and I shall ensure they practice this.”

A male CBHW noted that he “direct[s] women, in case of amenorrhea, [to] go to CSPS to check for pregnancy, to [receive] follow[-up] care, and be in good health.” Many male CBHWs were likely to mention malaria-related activities, including education about causes and prevention of malaria. A few male CBHWs talked about helping people recognize malaria, seek treatment, and comply with recommended medicine regimens.

A few male and female CBHWs specifically mentioned encouraging women to take sulfadoxine-pyrimethamine for IPTp. Some reported involvement in distributing bed nets. In contrast to the male CBHWs, some female CBHWs may even accompany women to ANC to ensure that the women receive services.

Some challenges were faced by CBHWs. At least a third of the CBHWs noted difficulties in carrying out their work, but they also had encouragements: “Acceptance by the community of my activities facilitates the task.” “Nothing is easy, but with the understanding of people, there are no problems.” While officially, CBHWs were to receive a stipend, one CBHW explained that “nothing is easy, especially that I am not paid for all these activities.” Others also noted that “for the moment, there is nothing that is easy as we lack the tools [for the job].”

CBHWs report being active in promoting the health of pregnant women and encouraging women and the community to prevent and treat malaria. Although their training stresses postnatal care, this area was not mentioned during interviews. Likewise, CBHWs did not address the danger signs of malaria in pregnancy during the interviews, which is in their training. Female CBHWs were more likely to encourage pregnant women to attend ANC at CSPS and follow up with them after the visit, while the male CBHWs were more focused on providing health information. Logistical challenges and payment of stipends need to be addressed before adding more duties for the CBHW to complete. Overall, CBHWs are positioned to deliver IPTp under the supervision of CSPS staff.

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, PMI, or the United States Government.

Community Health Volunteers Contribute to Improved Malaria Prevention and Management in Kribi, Cameroon

Kodjo Morgah, Eric Tchinda, and Naibei Mbaïbardoum of Jhpiego (a Johns Hopkins University Affiliate) in Cameroon are presenting a poster at the Multilateral Initiative for Malaria Conference in Dakar this week. Their findings, seen below, show how community health volunteers can contribute to improving the quality of malaria control services in Chad and Cameroon.

CHV Lilian Kubeh preparing to administer a rapid diagnostic test. Photo by Karen Kasmauski.

Project objectives focused overall on contributing to the reduction of malaria-related morbidity and mortality in Cameroon and Chad. It also aimed to strengthen community-based interventions through the use of community health volunteers (CHVs) to manage simple cases of malaria and conduct awareness-raising activities. The geographic scope of the project was Kribi District in the south of Cameroon. Thirty-two health facilities are supported by Jhpiego. Kribi District has an estimated population of 134,876.

Reports from the National Malaria Control Program show that malaria is the leading cause of morbidity in Cameroon—an estimated 1,500,000 cases occur each year. In 2016, it was the leading reason for medical consultations (23.6% of all medical consultations) and hospitalizations (46% of all hospitalizations). Among children under 5 years of age, malaria accounted for 41% of all medical consultations and 55% of all hospitalizations. Malaria is also a leading cause of mortality. In 2016, Cameroon had 2,639 deaths caused by malaria—12% of all deaths across all age groups and 28% of all deaths among children under 5 years of age were attributed to malaria.

Project intervention strategies target the four levels of the health system. The CHV intervention was mobilized to support the strategy at the community level as seen in the attached diagram. In 2012 and 2014, 38 CHVs were selected by the community and received training to support areas in the district more than 10 km from a health center. (Note: 10 km was the measurement tool used to determine the geographic scope of each CHV for this project.) An initial donation of medications, data collection tools, and small equipment was made available to CHVs using funding from ExxonMobil Foundation.  An evaluation of the training intervention was conducted by an external consultant in April 2016.

CHV Daniel Ze conducting an individual educational session on IPTp. Photo by Karen Kasmauski.

CHVs conduct outreach activities in their communities—via home visits and community education sessions—to provide health education on malaria transmission and prevention, use of long-lasting insecticidal nets, the importance of intermittent preventive treatment in pregnancy (IPTp), and the importance of promptly seeking medical care for suspected cases of malaria. CHVs also support national health campaigns and health promotion events, including World Malaria Day. In Cameroon, where CHVs are also able to test and treat patients, they administer rapid diagnostic tests (RDTs) and treat cases of uncomplicated malaria.

Motivation of CHVs included ongoing training and technical updates, regular replenishment of materials, CHVs are recognized and respected community leaders, provision of per diem and transport costs, and continued advocacy targeting district officials to provide CHV stipends to ensure sustainability. Attached are details of the supervisory activities that provided continual technical support to the CHVs to ensure that they retain knowledge and skills to carry out their activities and track their data.

Between 2013 and 2016 CHVs in these communities were able to reach nearly 20,000 people with a variety of malaria services as seen in the attached table. The project paid close attention to data quality, which was reviewed with the CHVs on a regular basis, resulting in improved data quality.  CHVs improved the accessibility of malaria prevention and care services for communities living in remote areas. Results from April 2016 external evaluation show these results. Knowledge of malaria prevention is significantly higher in households that did not receive CHV support (p = 0.001). Use of long-lasting insecticide-treated nets is higher in households that benefitted from CHV support (88%) than in households that did not benefit from CHV support (73%) (p = 0.023). There was an increase in the delivery of IPTp2, from 60% in 2012 to 70% in 2016.

In conclusion CHVs have increased their communities’ access to health centers through referrals, health education on malaria prevention, IPTp, and treatment for simple and severe cases of malaria. Regular supervision of CHVs by their supervisors (the health zone managers) is essential to maintaining and strengthening CHV performance and motivation. Continuing advocacy efforts with local authorities is necessary to ensure that CHV activities are sustainable. The project team aims to establish a mechanism to improve documentation of its activities to better measure the impact on indicators at the community, facility, and district levels, and provide evidence for advocacy to sustain these efforts.

Multilateral Initiative for Malaria (MIM) – Jhpiego Presents in Dakar

The 7th Pan African Malaria Conference holds from 15-20 April 2017, Dakar, Senegal. The conference celebrates 20 years since the initial establishment of the Multilateral Initiative on Malaria (MIM) by the Tropical Disease Research Program and partners.

During the conference next week, staff from Jhpiego malaria projects in Burkina Faso, Liberia, Nepal, Madagascar and Cameroon will share oral and poster presentations to highlight their work. Below is a list along with the location numbers.

  • Application d’un Audit de la Qualité des données (DQA) du paludisme dans le District Sanitaire de Kribi, Cameroun, SS-13 Oral
  • Contribution des Agent de Santé Communautaire (ASC) à l’amélioration de la prévention et la prise en charge du paludisme dans le district de Kribi, Cameroun, B-40 Poster
  • MOH’s effort in developing and implementing Quality Assurance plan (QAP) for Global Fund-supported antimalarial drugs: A case study of Nepal in the context of malaria elimination, C-107 Poster
  • Community-Based Health Workers in Burkina Faso: Are they ready to take on a larger role to prevent malaria in pregnancy? D-115 Poster
  • Contribution of Community-Based Health Workers (CBHWs) to Improving Prevention of Malaria in Pregnancy in Burkina Faso: Review of health worker perceptions from the baseline study D-118 Poster
  • Malaria in Pregnancy: The Experience of MCSP in Liberia, D-140 Poster
  • Improved Malaria Case Management of Under-Five Children: The Experience of MCSP-Restoration of Health Liberia project D-141 Poster
  • Experiences and perceptions of care seeking for febrile illness among caregivers, pregnant women and health providers in eight districts of Madagascar D-142 Poster

Abstracts will be shared here on the day of each presentation for those unable to attend MIM. Also check Jhpiego at Exhibit Booth 148.

Improving the efficacy of reactive screen-and-treat for malaria elimination in southern Zambia

Global Health Day 2018 sponsored by the Johns Hopkins University Center for Global Health featured a poster presentation by several colleagues on Improving the efficacy of reactive screen-and-treat for malaria elimination in southern Zambia. Fiona Bhondoekhan, William Moss, Timothy Shields, Douglas Norris, Kelly Searle, Jennifer Stevenson, Harry Hamapumba, Mukuma Lubinda and Japhet Matoba (Southern Africa International Centers of Excellence in Malaria Research, the JHU Bloomberg School of Public Health, and the Macha Research Trust, Zambia) share their findings below.

Background: Malaria screen-and-treat (called Step D in Zambia) is a reactive case detection strategy in which cases detected at a health center trigger community health workers (CHWs) to screen for secondary malaria cases within a 140-meter radius of the index case household using PfHRP2 rapid diagnostic tests (RDTs). Few studies evaluated whether an evidence-based strategy using environmental features that characterize the immediate surroundings of a household, can improve the efficiency of secondary case identification.

Objective: This study utilized the Step D and extended the screening radius to 250-meters (termed Enhanced Step D or ESD) to assess which local environmental variables can guide CHWs to identify secondary cases more efficiently. As Zambia works toward eliminating malaria, more refined and targeted case detection strategies are required to find the untreated malaria cases that could serve as potentially asymptomatic sources of infection. This study can help guide and plan reactive case detection strategies in Zambia that allow community health workers/field teams to employ an evidence-based strategy to find malaria-positive secondary households situated near index case houses more efficiently.

Methods: Demographic information, malaria diagnosis, bed-net use and ownership, cooking energy source, and household floor material were obtained from surveys. Households were stratified into malaria positive and negative secondary households using RDT and qPCR results. ArcGIS was used to generate the following local environmental variables: screening radius (140 vs. 250-meters), number of animal pens within 100-meters, distance to nearest animal pen, distance and elevation difference between index and secondary houses, as well as the following large scale environmental variables: distance to main road and nearest stream category. Generalized estimating equations (GEE) estimated the cross-sectional effect for the difference in odds of a positive vs. negative secondary household for each predictor. For the secondary analysis GEE with the same model specifications was used to estimate the cross-sectional difference in odds of a positive vs. negative household for each environmental predictor. Model fit was evaluated with the Hosmer-Lemeshow goodness of fit test and significance was evaluated as a p-value of 0.05. Statistical analyses were carried out using STATA 14.2.

Results: Screening within the index households yielded an overall parasite prevalence of 8.6%, which was higher by qPCR (8.1%) than RDT (2.7%) as seen in Table 1. Secondary households had an overall parasite prevalence of 1.9% with similar differences by test used. Key results from regression analysis seen in Table 2 include a difference in prevalence according to screening radius as well as by proximity to the nearest stream. Secondary analysis produced similar results but showed statistically significant higher odds for households where animal pens were present.

Conclusion: Screening for secondary households within low-transmission setting in Zambia could be optimized by using both local-scale indicators such as the presence of animal pens and large-scale indicators such as streams as environmental guiding tools.

Acknowledgements: This research was supported in part the Bloomberg Philanthropies and the Johns Hopkins Malaria Research Institute, and the NIH-sponsored Southern and Central Africa ICEMR 2U19AI089680.

Malaria by the numbers: are the statistics real or are they a barrier to community involvement?

George Mwinnyaa grew up in a small village in Ghana, West Africa. “I witnessed the death of several people including my siblings and my father. I became a health volunteer and later a community health worker.” George presented at the Johns Hopkins University TEDx event on 10 March 2018. Below are excerpts from that talk focused on his experiences in malaria interventions in Ghana and reflects on numbers found in public health interventions and questions what these numbers really mean to community members on the ground. George is currently an MHS student studying infectious disease epidemiology at the JHU Bloomberg School of Public Health.

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I have always been very skeptical with numbers, particularly numbers that indicate program accomplishments from the developing world. Whenever I see numbers reporting a problem such as the mortality relating to malaria, Pneumonia, or diarrheal diseases- it puzzles me because these are all diseases that have received great attention, and there have been many interventions implemented. Yet these problems still exist, and the question is why?

Today malaria is still among the top causes of infant mortality in many African countries, including Ghana, yet we have mosquito nets, coils, sprays, long sleeved shirts that have been circulating in the country for years……and sometimes I wonder: why?

Total funding for malaria prevention and control was 2.7 billion dollars in 2016. Between 2014-2016, 582 million nets were distributed, of which 505 million were distributed in Africa, yet the number of malaria cases increased from 211 million in 2015 to 216 million in 2016 (WHO-malaria fact sheet, 2017).

I was once a supervisor for the distribution of long-lasting insecticide treated nets in rural communities. The numbers driven world saw big numbers that showed that many pregnant women were not sleeping under mosquito nets and so the solution to solve the malaria problem was to give them mosquito nets.

First, they started out by selling the nets and people would not buy them, then they offered them free to pregnant women and that did not change anything, next they distributed to families in a household and that did not change anything, and finally they implemented what is known as the hanging of long lasting insecticide treated bed nets.

This time we went into a house with a hammer, nails and ropes, and families showed us their bedroom and we hung the net for them. And yet malaria still rules. What happened with the free bed nets is now widely reported across different countries in Africa.
What do the numbers we measure mean to the people they represent?

As an example, there was a man in a small fishing village with seven children. His biggest worry was how to get food for his family. So the world of numbers develops numbers-based interventions, numbers-driven solutions. Reporters found months after the family received the mosquito nets that no one in the family slept under the mosquito nets; instead the man had sown the nets together and used them for fishing to feed his family.

Frustrations abound on both ends of the system, for public health agents and community members. Numbers act as the barrier between the two ends of the “system”, and our goal must be to break the barrier. The numbers that drive interventions can be meaningless to the community people they represent unless we engage the community and learn how our interventions can really help them.

Potential Contribution of Community-Based Health Workers to Improving Prevention of Malaria in Pregnancy

Justin Tiendrebeogo, Ousmane Badolo, Mathurin Dodo, Danielle Burke, and Bill Brieger of Jhpiego have designed and are implementing a study to determine the effect of delivering Intermittent Preventive Treatment for Malaria in Pregnancy through community health workers in Burkina Faso with the support of the US President’s Malaria Initiative and the USAID Maternal and Child Survival Project. They have shared the design and start-up activities for the study at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene. A summary follows:

CHW Flipchart Page

The Ministry of Health of Burkina Faso with the support of its partners initiated a study on the feasibility of increasing provision of Intermittent Preventive Malaria Treatment in pregnant women (IPTp) with sulfadoxine-pyrimethamine (SP) by involving existing community-based health workers (CBHWs). As Burkina Faso adopted the WHO recommendations for more doses of IPTp during pregnancy, it was proposed that the challenge of achieving coverage of third, fourth and additional doses could be met using CBHWs.

The approved protocol calls for CBHWs to refer pregnant women to antenatal care (ANC) to receive their first IPTp dose. Subsequent doses at one-month intervals would be provided by trained CBHWs, who would report back to supervising midwives at the ANC clinics. Several steps were taken to gain approval and set up the intervention.

CHW Using Flipchart

First, IPTp data from the health information system was gathered. IPTp coverage based on ANC registration in the 6 intervention clinics was 69% IPTp1, 68% IPTp2, 56% IPTP3, and 1% IPTp4. Similar information was obtained from the 6 control clinic catchment areas. Situation analysis found that while CBHW curriculum stresses the importance of ANC, it does not address IPTp at community level.

In response updated training materials have been developed. The study team also collected information on village size and availability of CBHWs, especially females. Among the villages in the catchment of the 6 intervention ANC clinics, 33 were found to lack female CBHWs.

Supervisory Meeting

As a result, the team needed to recruit additional female CBHWs, as revised national recruitment guidance stressed attainment of primary school certificate over gender, meaning mainly men had been hired previously. Two institutional review boards were involved and suggested the need to address the potential rare side effects of SP and concerns that community IPTp would not detract from ANC clinic attendance.

Since district and clinic level health staff will be involved in implementing the program using the national CBHW program, lessons learned from this effort to expand the work of CBHWs in preventing malaria in pregnancy should be applicable and adaptable to the whole country.

Improving Early ANC Attendance and IPT Uptake through Community Health Volunteers

Community health workers are playing an increasing role in maternal health programming.  Augustine Ngindu, Susan Ontiri, Gathari Ndirangu, Beth Barasa, Evans Nyapada, David Omoit, Johnstone Akatu, and Mildred Mudany of The Matewrnal and Child Survival Program, The Kenya Ministry of Health and Jhpiego share their experiences in Kenya at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene in Baltimore on 2017-11-06.  If you are in Baltimore, hear more at Scientific Session 13. Below is an abstract of their presentation

Kenya adopted the use of intermittent preventive treatment with sulfadoxine pyrimethamine in 1998 but the proportion of pregnant women receiving at least two doses (22% (2010) and 56% (2015) has remained below the national target of 80%. In 2015, the country adopted an IPTp3 indicator for monitoring IPTp uptake; that year, the proportion of women taking at least 3 doses was 38% (2015).

Some of the factors leading to low IPTp coverage include poor knowledge on the need for early antenatal care (ANC), distances to health facilities, sociocultural practices and a lack of financial resources. In 2012, community health volunteers (CHVs) were enlisted through a pilot program in one county to deliver messages aimed at increasing the proportion of women starting ANC ? 20 weeks of gestation and thus expand the proportion of women receiving IPTp early in the second trimester.

A community survey in 2013 showed an increase in IPTp2 from 22% in 2010 to 63%. The practice was considered a success story, and was subsequently replicated in 30 sub-counties, in 4 out of 14 malaria endemic counties. The rollout involved training of 9,042 CHVs, in 761 community units. Between 2015 and 2016, the CHVs reached 86,433 women with MiP messages. During this time, there was an average increase in IPTp1 from 51% to 68%, and IPTp2 increased from 42% to 55% (p? 0.001). This could be attributed to early ANC attendance, which increased from 32% to 48% in the same period.

The use of CHVs to sensitize pregnant women to start IPTp early in the second trimester and continue with scheduled ANC visits increases the probability that women will receive the recommended IPTp-SP doses. The rollout of the practice to other malaria endemic counties is likely to have contributed to increase in IPTp uptake in the four target counties.

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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