Category Archives: Community

Malaria Mass Drug Administration: Ensuring Safe Care of Reproductive Age Women

The potential impact of mass malaria drug administration (MDA) on pregnant women was the focus of Symposium 146 at the recent 65th Annual Meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The symposium was co-chaired by Clara Menéndez and Larry Slutsker who opened the session with an overview.

mda-recommendations-whoAs malaria control interventions are scaled up and sustained and malaria transmission levels decline and prevalence falls, an increasing number of countries are starting to see elimination on the horizon. For pregnant women, the antimalarial antibodies that have provided some level of protection in moderate to high malaria transmission settings are reduced as malaria transmission declines.

Current evidence shows that as transmission levels decline, the consequences from P. falciparum malaria are even greater for pregnant women. As countries enter pre-elimination stage and move towards eventual elimination, it will be important to address the needs of pregnant women given their increased vulnerability.

To help achieve elimination, countries are exploring strategies involving widespread distribution of anti-malarials, primarily artemisinin-combination therapies (ACTs), to asymptomatic individuals, including both mass drug administration (MDA) and mass screen and treat (MSaT).

Animal studies have suggested potential embryo toxicity and teratogenic effects of artemisinin drugs in the first trimester of pregnancy.

Given the limited human data, ACTs are currently contraindicated in first trimester, except in documented cases of clinical malaria illness where quinine is unavailable. This poses a challenge in mass campaigns, as it requires the identification of women in early pregnancy who are not yet obviously pregnant. Screening including offering pregnancy tests and/or interview to ask a woman her pregnancy status directly may not work as many may not wish to reveal their pregnancy status.

Final Algorithm for Screening Prior to MDA in Mozambique

Final Algorithm for Screening Prior to MDA in Mozambique

While only about 5% of the population is pregnant at any given time, and only 1/3 of those are in the first trimester, approximately 20% of the population is comprised of women of reproductive age who may be pregnant. Thus, the number of women who need to be screened for pregnancy is substantial across countries. In addition to privacy issues, costs of screening processes are another barrier.

During the symposium Francisco Saúte from Mozambique and Samuel J. Smith from Sierra Leone shared experiences. Clara Menéndez addressed ethical issues involved in the potential risk of MDA with the ACT Dihydroartemisinin-Piperaquine (DHA-P). These two countries have addressed pregnant women in MDAs in two widely different contexts.

Mozambique is learning whether MDA is a valuable component to malaria elimination in the low transmission areas in the southern part of the country. In Sierra Leone MDA was seen as a lifesaving tool to prevent malaria deaths during the Ebola epidemic when taking blood samples for diagnosis was a major risk.

Over several rounds of MDA, Mozambique refined its pregnancy screening procedures over several rounds of MDA as seen in the attached slide.  Costs, confidentiality, convenience and efficiency entered into the equation that saw a greater focus on communicating with women rather that testing. Lessons learned from MDA in Mozambique included –

  • Screening for early pregnancy in the context of MDA is challenging, particularly among teenage girls where disclosing pregnancy can be problematic
  • Need to train field workers (preferably women) about the need to ensure confidentiality of pregnancy testing/results
  • Confidentiality is also crucial to ensure adherence to t
    MDA Rationale in Sierra Leone during Ebola Outbreak

    MDA Rationale in Sierra Leone during Ebola Outbreak

    he pregnancy testing

  • Women not accepting pregnancy test must be warned on risks/ benefits of ACTs in 1st trimester
  • Health authorities must understand that IPTp and MDA are not mutually exclusive

The Ebola epidemic in Sierra Leone and its neighbors, Liberia and Guinea, devastated the health workforce, and the availability of any sort of testing supplies was low.  The country experienced a major drop in utilization of clinic based MCH services including those for malaria during the period.

MDA Goals in Sierra Leons

MDA Goals in Sierra Leone

Because of initial similarities in presenting symptoms between Ebola and malaria, people were often fearful of going to the health center in case they were detained for Ebola care or were exposed to other patients who had Ebola. Community MDA seemed to be one way to protect the population from malaria in this emergency situation. The attached slide offers a rational for the MDA. A second slide explains Sierra Leone’s goal for MDA with Artesunate-Amodiaquine in the context of Ebola. Though not completely, the Sierra Leone MDAs were able to exclude pregnancy women in their first trimester.

Pregnant women excluded from MDA in Sierra Leone

Pregnant women excluded from MDA in Sierra Leone

In conclusion MDA is a tool conceived primarily for countries and areas of countries as part of the pre-elimination strategy. It presents a variety of logistical challenges, but a major concern should also be the ethical issues of giving a potentially toxic drug to women in their first trimester of pregnancy. Alternative strategies to protect these women, including insecticide treated nets, must be explored.

Gaining an early start to IPTp through promotion of MIP at the community level in Kenya

posterA poster entitled “Community health: Improving start of IPTp early in second trimester through promotion of MIP at the community level in Kenya” was presented by Augustine Ngindu, Gathari Ndirangu, E Nyapada, David Omoit, and Mildred Mudany from Jhpiego’s Kenya Team at the 65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

WHO policy recommends that pregnant women living in moderate to high malaria transmission areas start receiving intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine pyrimethamine (SP) early in second trimester to prevent malaria in pregnancy (MIP).

Training Community Health Volunteers in Bungoma

Training Community Health Volunteers in Bungoma

In Bungoma County, Kenya, 52% of pregnant women start IPTp in their third trimester. Between June and September 2015, 197 Community Health Assistants (CHAs) were trained, who in-turn trained 2,344 Community Health Volunteers (CHVs) in Bungoma County.

Following the training, CHVs  registered new pregnant women at their homes and encouraged them to seek antenatal care (ANC)  and start taking IPTp early in the second trimester. The CHVs also helped to identify previously registered women who were not attending ANC and refer them to ANC for MIP services.

The CHVs, with CHA supervision, reached 44,133 pregnant women with MIP messages on starting IPTp early in the second trimester and use of a net. Data from 70 health facility registers was collected biannually and showed a 12% increase (24%-36%) in the proportion of pregnant women starting ANC attendance ? 20 weeks of pregnancy between October 2014 and March 2016.

Community Health Volunteers Encourage ANC Attendance

Community Health Volunteers Encourage ANC Attendance

Although there was a decline in the proportion of women receiving IPTp-SP between October 2014 and January 2015 and between October 2015 and February 2016 due to SP stock-outs, this did not significantly affect ANC attendance. The 12% increase in early ANC attendance is likely associated with CHV efforts in sensitizing women to start IPTp early in the second trimester and indicates a positive change in health seeking behaviour that can be sustained over time provided the commodities are available.

The success with CHVs promoting MIP at the community level has led to it being replicated in three additional counties and it will be extended in phases in other malaria endemic counties.

Accelerating IPTp uptake through updated WHO IPTp guidance in Malawi

A poster entitled “Building Capacity to accelerate IPTp uptake through the adoption of 2012 WHO IPTp guidance in Malawi” was presented by John Munthali, Lolade Oseni, Dan Wendo, Kabango Malewezi, and Tambudzai Rashidi from Jhpiego’s Malawi Team at the

Community activities encourage IPTp uptake in Malawi

Community activities encourage IPTp uptake in Malawi

65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

Malawi adopted the World Health Organization’s updated guidance on intermittent preventive treatment in pregnancy (IPTp) in 2013. Support from the US President’s Malaria Initiative through USAID funded health projects, enabled collaboration between the National Malaria Control Program (NMCP) and the Reproductive Health Directorate (RHD) of the Ministry of Health, to build capacity from national to district to frontline health facility levels to implement the updated IPTp policy.

iptpaccessThese partners updated IPTp policy in the National Malaria Treatment Guidelines, and developed appropriate training manuals. All 5708 health workers from the 304 facilities in the 15 project districts were trained on the IPTp policy and guidelines. Post-training test scores of health staff increased over pre-test by an average of 40 percentage points.

The community action cycle approach engages community volunteers and local community based organizations to identify and solve local problems and was used to encourage pregnant women to attend antenatal care (ANC) and receive IPTp and long lasting insecticide-treated nets.

Sample page from ANC register showing delivery of IPTp3 and 4, but these data are not yet recorded on summary HMIS forms

Sample page from ANC register showing delivery of IPTp3 and 4, but these data are not yet recorded on summary HMIS forms

Health information system data from the 15 Districts were used to compare ANC and IPTp coverage for 2012 and 2015 fiscal years (Oct.-Sept.). ANC registration in the project area rose from 113,683 to 394,116. IPTp1 as a proportion of ANC registration rose from 52% to 87%, and IPTp2 increased from 17% to 62%. While IPTp3 doses were recorded in the ANC registers, reporting forms in 2015 still did not include space to enter this IPTp3.

Observations at clinics showed IPTp3 and 4 were provided. Malawi’s experience shows that collaboration between NMCP and RHD as well as between clinics and communities not only disseminated knowledge of the new policy, but resulted in increased uptake of services and protection of pregnant women from malaria.

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.

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.

“Nobel” drug discoveries rewarded, but delivery of malaria and filarial medicines to the community also matters

Herbs, soil and hard scientific work have yielded Nobel Prizes in Medicine/Physiology for three scientists whose results now save millions of lives from death and disability due to malaria, onchocerciasis (river blindness) and filariasis (elephantiasis), according to the New York Times. Two of the winners, “Dr. Campbell and Dr. Omura, developed Avermectin, the parent of Ivermectin, a medicine that has nearly eradicated river blindness and radically reduced the incidence of filariasis.” Dr Tu Youyou, “inspired by Chinese traditional medicine in discovering Artemisinin, a drug that is now part of standard anti-malarial regimens and that has reduced death rates from the disease.”

Community Case Management of Malaria in Rwanda using Rapid Diagnostic Tests and ACTs

Community Case Management of Malaria in Rwanda using Rapid Diagnostic Tests and ACTs

The development of these chemicals into human medicines was a long time coming, and in the case of artemisinin, over 2000 years. The Guardian quotes the Deputy Director of the Liverpool School of Tropical Medicine as saying that, “Artemisinin was discovered when fatalities from malaria were rocketing and the world was terrified we’d be looking at a post-chloroquine era. It has been a real game-changer.”

In fact artemisinin in combination with other medicines or artemisinin-based combination therapy (ACT) rescued many lives in the face of parasite resistance to earlier first line drugs like chloroquine and sulfadoxine-pyrimentamine (though artemisinin resistance is now growing). ACTs are also made freely available to populations in malaria endemic countries through such programs as the Global Fund to fight against AIDS, TB and Malaria (GFATM), the US President’s Malaria Initiative, the World Bank and others.

Avermectin began its medical role as a veterinary drug that killed parasites in livestock. Eventually research by Merck based on the similarities between animal and human filarial worms led to the testing and development of ivermectin to control onchocerciasis through annual doses that killed microfilariae.

Not only are both ACTs and ivermectin on WHO’s essential medicines list, but they form the basis of global efforts to eliminate disease. Once Merck determined that ivermectin was safe and effective in humans, it began donations of the drug to what has become the African Program for Onchocerciasis Control (APOC) and its counterpart that is working to eliminate the disease in the Americas. APOC and its national counterparts now reache people in over 200,000 endemic villages in 18 African countries with annual doses.

Community Directed Distribution of Ivermectin in Cameroon

Community Directed Distribution of Ivermectin in Cameroon

While we celebrate the recognition that the drugs and their discoverers are receiving, we should not lose sight of the fact that without good delivery mechanisms these life saving medicines would not reach the poor, neglected, often remote populations who need them.

Beginning in 1995, APOC and the Tropical Disease Research Program of WHO and partners pioneered what has now become known as Community Directed Interventions (CDI) where the thousands of communities “beyond the end of the road” and their selected volunteers organize the annual ivermectin distributions. This community directed approach works for community case management of malaria, too.

Hopefully in the future, groups like APOC will receive Nobel Prize recognition for ensuring that those in need actually receive the medicines they require. In the meantime we encourage more countries to adopt the CDI approach to reduce malaria deaths and work toward the elimination of malaria, onchocerciasis and filariasis.

RSAP Themed Issue on Pharmaceutical Logistics for integrated Community Case Management (iCCM) – Call for Papers

RSAP_v11_i4_COVER.inddA themed issue for Research in Social and Administrative Pharmacy (RSAP at http://www.journals.elsevier.com/research-in-social-and-administrative-pharmacy/) will feature the challenges of guaranteeing regular and adequate pharmaceutical supplies and commodities for integrated Community Case Management (iCCM). iCCM can be described as a comprehensive approach to providing essential health services in and by the community. iCCM relies on having basic commodities like Rapid Diagnostic Tests (RDTs) and artemisinin-based combination therapy (ACT) medicines for malaria, oral rehydration solution (ORS) packets and zinc for diarrhea, in addition to appropriate antibiotics like amoxicillin and cotrimoxazole for pneumonia available in the community.

Early successes describing the documentation of need and initial procurement of these essential therapies in developing nations have been published; however, this themed issue will share original research, models, and expert commentaries on ensuing stages in procurement and supply chain management (PSM) that will sustain iCCM.

PSM/logistical success for iCCM can occur in countries that have a department or unit that focuses on community health promotion and supports standardized training and equipping of Community Health Workers (CHWs) even in small villages. Unfortunately, most programs lack adequate procurement and supply management systems, especially planning and forecasting. Front-line health center staff who train and supervise village-based iCCM volunteers express concern about the difficulty in acquiring enough medicines for their own clinical needs, let alone supplies for volunteer community health workers.

DSCN5479Other programs reserve iCCM only for selected communities in a catchment area based on distance or availability of community health extension/auxiliary workers. There are also examples of iCCM that are narrowly focused on one or two health problems, while others take a more comprehensive approach. Clearly each has different logistical concerns such as the generic issues of forecasting, procurement, shipping and storage, while others experience the difficulty obtaining funding support when many disease control programs have vertical financial streams.

There are various models for providing medicines at the community level. One is the pioneering work of the World Health Organization’s (WHO’s) Tropical Disease Research (TDR) program in promoting Community-Directed Treatment with Ivermectin (CDTI) for River Blindness Control, which evolved into the Community Directed Intervention (CDI) approach for delivering basic health commodities by the community, itself.[1]

Policymakers, health organizations, and front-line clinicians often say, “no product, no program.” This themed issue will share the experiences and lessons of iCCM, both successes and challenges, to help the global health community see the need for more systematic planning of PSM for iCCM. International agencies and donors clearly recognize that alternative forms of essential health service delivery are needed to achieve coverage targets and save lives. The community as a source of care has a solid foundation as established at the International Conference on Primary Health Care, which produced global guidance through the Alma Ata Primary Health Care Declaration of 1978,[2] but in all those years, actualization of this ideal has been difficult for logistical reasons. This RSAP themed issue should not only help us understand the present challenges, but map a way forward to better access to essential health commodities in communities throughout the developing world.

The themed issue will include various contributions such as:

  • Commentary/Overview from the World Health Organization staff who have spearheaded the iCCM movement
  • Implementation/intervention research on:
    • The link between front-line clinics and community health workers/distributors in guaranteeing iCCM commodities
    • The challenge of providing iCCM commodities for use by nomadic populations
    • Provision of iCCM commodities by different types community workers
    • Successes and challenges in maintaining supplies and commodities for large-scale and national community primary health care programs
    • Comparative lessons from other community based programs such as family planning commodity distribution and home-based care for people living with HIV
  • Documented program experiences including:
    • The challenges of maintaining iCCM supplies and logistics in emergency situations, as with disaster refugee and outbreak situations
    • The role of donors and non-governmental organizations (NGOs) in providing commodities.

We are still seeking additional contributions. If you have a paper or idea for one or more, please contact the guest editors. Papers must be submitted on the Elsevier RSAP platform at http://ees.elsevier.com/rsap/ by February 1, 2016 for publication in fall of 2016.

Guest Editors:

  • William R Brieger, MPH, DrPH, Professor, Department of International Health, Bloomberg School of Public health, The Johns Hopkins University; Senior Malaria Specialist, Jhpiego; RSAP Editorial Board Member. <bbbrieger@yahoo.com>
  • Maria KL Eng, MPH, PhD, Departmental Associate, Department of International Health, Bloomberg School of Public health, The Johns Hopkins University; Instructor for “Pharmaceuticals Management for Under-Served Populations” <meng@jhu.edu>

[1] http://www.who.int/bulletin/volumes/88/7/09-069203/en/

[2] http://www.who.int/dg/20080915/en/

Data for Decision Making Series: The Importance of CHW Data Collection

This posting appeared originally on website of 1 Million Community Health Workers.

This week marks our final installment in the Data for Decision Making series! For our final interview weDSCN1535 talked with Dr. William (Bill) Brieger, Senior Malaria Specialist at Jhpiego and a Professor in the Health Systems Program of the International Health Department at John Hopkins Bloomberg School of Public Health. For over two decades Dr. Brieger taught at the African Regional Health Education Center at the University of Ibadan, Nigeria. He also previously served as a public health and health education consultant to various international organizations including the World Bank, the African Program for Onchocerciasis Control, UNICEF, the World Health Organization, US Peace Corps, and various USAID implementing partners. Dr. Brieger is internationally known for his expertise in social and behavioral aspects of disease control and prevention.

What are the most pressing challenges in the development of scaled-up CHW programs today?

 I think part of the challenge is that it is difficult to obtain a clear commitment and approach regarding the implementation of CHW programs. A good contrast is seen in the difference between integrated community case management (iCCM) and community directed intervention (CDI). With iCCM, organizations focus on getting treatments to people, whereas with CDI, organizations are interested in building up capacity within communities to support distribution of key health services. Philosophically, iCCM and CDI programs are two different approaches, with CDI aiming to help communities make a conscious decision about participating in the process and making a comDSCN5479mitment to support any volunteers within the community.

The other challenge is that NGOs provide different programs and interventions, which is difficult for countries – mainly Ministries of Health – to manage. I think Rwanda has been the most successful with harmonization and represents a good example of overcoming NGO program fragmentation. Rwanda has systematized the implementation of NGO programs, by requiring NGOs to go through the Ministry of Health to ensure that their programs adhere to the national standards. Burkina Faso has also tried to tackle this problem, and the Ministry of Health has created a “Community Health Promotion Directorate” to assist in harmonizing service provision amongst NGOs. There are certain structural approaches to management that can help scale-up programs while maintaining community commitment; but CHW scale-up will not work unless the community is strongly involved in the selection of health volunteers and is holding those volunteers accountable to community norms and expectations.

Why is data on frontline health workers, particularly CHWs, important?

Data on CHWs and data from CHWs are equally important. Organizations need to know who is providing services in the community so they can plan for training and continuing education. Having a good record of community volunteers and keeping that record updated is important, especially at the health center level. Data collection starts with the health center keeping data on the villages where they operate – the geographical coverage, counts on the volunteers within that village, demographic information about the volunteers, and where they work. Monthly records should be submitted by CHWs to ensure proper service delivery and patient tracking. If all of this is being done, then the data needed for making programmatic decisions can be sent forward to the district, state, or regional province.

In your opinion, what are the largest gaps in data on frontline health workers, particularly CHWs, right now?

 One of the largest gaps in CHW datDSCN1485aa is data showing whether CHW deployment mirrors community needs. For example, based on experiences in Rwanda and Nigeria, we know it is very important to have older female CHWs provide maternal health services, particularly woman who have been pregnant before. It is critical for an older woman to provide these services because she will be able to gain the trust of her community, which will allow pregnant women in the community to see the volunteer to discuss their pregnancy and receive treatment without any stigma. Situations like this demonstrate how important it is to keep track of the demographics of CHWs, along with the service needs of communities, especially services involving confidentiality like home-based care for HIV. With this information in hand, it can be quickly determined if an organization has CHWs with the appropriate characteristics to serve a community.

How can we begin to close these gaps?

DSCN1595 volunteer brings his village register to clinic for checking Currently, most health centers do not keep a good record of community volunteers. This is where we can start to close the gaps in CHW data. If organizations and governments start streamlining data at the health center level, this data can then be reported to other levels of the health system. It is important to at least have an annual or semiannual assessment to determine changes, such as exits and promotions, within the CHW population. I have always envisioned it as a partnership between the health center and the community, so that the health center really knows the catchment area. For example, in most of the health centers and small clinics in Nigeria, the staff draws a hand-drawn map of their catchment area so that they know where their clients will come from. While imperfect, this allows the health center staff to have a good understanding of the community demographics. However, before this can happen it is critical that we start to actually keep track of community volunteers and health workers.

The neighborhood godmothers – “Badjenu Gox” – pledge to have Zero Malaria in Senegal

Yacine Djibo, Founder & President of Speak Up Africa is helping focus International Women’s Day (March 8th) on efforts to protect women from malaria in Senegal. She is highlighting the commitments of 8 strong and beautiful women, in Senegal, that are dedicated to eliminating malaria in their country. These commitments are part of an inclusive mass communication campaign that aims to launch a national movement in favor of malaria elimination in Senegal: the “Zero Malaria! Count Me In” campaign

ZeroPaluInternational Women’s Day, represents an opportunity to celebrate the achievements of women all around the world. This year’s theme is “Empowering Women – Empowering Humanity: Picture it” envisions a world where each woman and girl can exercise her choices, such as participating in politics, getting an education or fighting malaria. Below is the sixth feature on women fighting malaria……

Ndèye Fatou Diallo is the National President of the Badjenu Gox (neighborhood godmothers in Wolof, one of the languages spoken in Senegal). She lives in Grand Dakar and is responsible for the Badjenu Gox in 557 towns across Senegal.

5. Ndeye Fatou Diallo ENG

Ndèye Fatou Diallo, National President, Badjenou Gox, Senegal.

Ndèye Fatou Diallo and her fellow Badjenu Gox are committed to making a difference in the lives of their neighbors.

The Badjenu Gox program was launched in January 2009 in every village of Senegal to leverage the presence and the leadership of women in the communities.

The “Badjenu Gox” program aims to reduce maternal and child morbidity and mortality to achieve MDGs 4, 5 and 6. Chosen by the community, the Badjenu Gox are volunteers that live in the communities and work to ensure systematic use of health services by the communities. This community led approach program allows community ownership of the health issues that affect them.

The Badjenu Gox are trained and provided with the appropriate tools they need to raise awareness about maternal and child health, including around malaria prevention and iwd_squarecontrol. They do so through home visits and by holding sensitization meetings in their neighborhoods.

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Headquartered in Dakar, Senegal, Speak Up Africa is a creative health communications and advocacy organization dedicated to catalyzing African leadership, enabling policy change, securing resources and inspiring individual action for the most pressing issue affecting Africa’s future: child health.

 

 

Counting on Sadane Ndiaye and other community supervisors like her to eliminate malaria in Senegal

Yacine Djibo, Founder & President of Speak Up Africa is helping focus International Women’s Day (March 8th) on efforts to protect women from malaria in Senegal. She is highlighting the commitments of 8 strong and beautiful women, in Senegal, that are dedicated to eliminating malaria in their country. These commitments are part of an inclusive mass communication campaign that aims to launch a national movement in favor of malaria elimination in Senegal: the “Zero Malaria! Count Me In” campaign

ZeroPaluInternational Women’s Day, represents an opportunity to celebrate the achievements of women all around the world. This year’s theme is “Empowering Women – Empowering Humanity: Picture it” envisions a world where each woman and girl can exercise her choices, such as participating in politics, getting an education or fighting malaria. Below is the fourth feature on women fighting malaria.

Along with 369 community supervisors throughout Senegal, Sadane Ndiaye of the Keur Momar Sarr district completed a one-week comprehensive training to learn all aspects of malaria treatment, prevention and care as a part of the Football Combatting Malaria Program (FCM). FCM, implemented through a partnership with local health districts, the National Malaria Control Program, Speak Up Africa, Aspire Academy, and the Leo Messi Foundation, catalyzes grassroots advocacy and behavior change communication to further reduce the burden of malaria in the community.

Sadane Ndiaye, Supervisor, Football Combating Malaria, Senegal

Sadane Ndiaye, Supervisor, Football Combating Malaria, Senegal

At the end of the week-long course, which included key information on how to install and properly maintain insecticide treated mosquito nets, Sadane became a Community Supervisor, charged with returning to her community and training four additional change agents. Daily, Sadane leads this team in malaria awareness activities including household visits, lectures, and social mobilization activities, reaching hundreds of community members and making a sustainable impact.

Football Combating Malaria aims to emphasize communication and community leadership to beat this disease. As a community supervisor, Sadane sets the example of exactly that which is needed to reach a malaria free Senegal.

iwd_squareThank you Sadane for joining the national malaria elimination effort and educating your fellow community members around malaria prevention and treatment.

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Headquartered in Dakar, Senegal, Speak Up Africa is a creative health communications and advocacy organization dedicated to catalyzing African leadership, enabling policy change, securing resources and inspiring individual action for the most pressing issue affecting Africa’s future: child health.