Tropical Health Matters

As part of the work for the Johns Hopkins University course on Social and Behavioral Foundations of Primary Health Care, Simon Riek posted in the class blog about a community-based health initiative in South Sudan as seen below.

South Sudan continues to experience high maternal and child mortality rates, limited healthcare access, and a shortage of trained professionals. The Boma Health Initiative (BHI) is a community-based healthcare program that trains and deploys Community Health Workers (CHWs) to deliver maternal care, immunizations, and disease management in underserved areas. While promising, BHI faces funding instability, supply shortages, and a lack of standardized training and supervision. To ensure sustainable impact, I strongly advocate for increased financial investment in CHW’s training as a priority policy goal.

For this policy to succeed, we must engage key stakeholders strategically. World Health Organization (WHO) – Department of Health Systems Governance & Financing. WHO supports community-based health models and can provide technical and financial resources. Advocacy Approach: Partner with WHO to champion CHW training through reports, policy dialogues, and media engagement.

South Sudan’s Ministry of Health (MoH) – Directorate of Community Health Services. As the lead health agency, MoH oversees BHI implementation and CHW workforce management. The advocacy approach should push for MoH to allocate domestic funding for CHW training, ensuring sustainability beyond donor reliance.

The World Bank’s Human Development Practice Group funds health initiatives but has not directly committed to BHI. Advocacy approaches include presenting cost-effectiveness evidence to secure investment in CHW training programs.

Some physicians from the South Sudan Doctor’s Association (SSDA) fear CHWs will replace trained professionals, while others support task-sharing. Advocacy approaches include collaborating with SSDA to define CHW roles, ensuring they complement rather than replace professional healthcare providers.

In order to expand BHI and improve CHW training, I urge the South Sudanese government to commit long-term funding. Partners, including WHO and World Bank need to invest in capacity-building initiatives. Finally the SSDA must support CHWs as a critical part of the healthcare system.

This study was presented by Stalin Edegba Ewoigbokhan of Emerald Public Health Consulting Services Ltd., Abuja, Nigeria, at the second annual conference and scientific meeting of the Health Promotion and Education Alumni Association, College of Medicine, University of Ibadan on 27 September 2024.

This study investigates the perspectives of community members and key informants on the roles of informal community-based health workers (CBHWs) in achieving the global 95-95-95 HIV/AIDS targets across four Local Government Areas (LGAs): Akpabuyo and Calabar Municipal in Cross River and Essien Udin and Ikot Ekpene in Akwa Ibom State, Nigeria. The research focuses on understanding the contributions, challenges, and community perceptions of CBHWs in HIV prevention, treatment, and care, which are crucial for meeting the World Health Organization’s 2030 goals for halting HIV Transmission.

The study involved eight focus group discussions (FGDs) with a mix of male and female participants across the four LGAs, 27 in-depth interviews with key informants, including community leaders, health officials, program managers, and CBHWs. The data was analyzed to identify recurring themes related to the roles and effectiveness of CBHWs in HIV prevention and treatment within the communities.

Community members identified major health issues, such as tuberculosis, HIV, and hypertension. Key drivers of the HIV/AIDS epidemic cited by participants included unprotected sex, sex work, sharing of infected sharp objects, men having sex with men, blood transfusions, and breastfeeding by HIV-positive mothers. CBHWs were acknowledged for their roles in HIV counseling, condom distribution, first aid, and drug administration. However, they face significant challenges, including insufficient supplies, poor funding, and inadequate training. Despite these challenges, both community members and key informants view CBHWs as essential in reducing HIV-related stigma, promoting treatment adherence, and contributing to HIV prevention.

While CBHWs play a critical role in HIV prevention and care, their effectiveness is often limited by systemic issues such as inadequate resources and poor infrastructure. The study recommends enhancing CBHWs’ impact through increased government support, adequate incentives, continuous training, and better integration into the formal health system. These measures are essential for optimizing the contributions of CBHWs toward achieving global HIV/AIDS targets.

Keywords: Community-Based Health Workers (CBHWs),HIV Prevention, 95-95-95 Targets, Challenges in HIV Care

Tom Kehinde has posted an important perspective on local and community action in HIV control on the blog for the course Social and Behavioral Foundations of Primary Health Care. See the key issues from that posting below.

Nigeria grapples with one of the highest burdens of HIV/AIDS globally, with an estimated 1.9 million people living with the virus. Despite significant international assistance, the country heavily relies on external financing to combat the epidemic. This dependency on foreign aid is unsustainable in the long term and undermines Nigeria’s ability to address the epidemic effectively, perpetuating health disparities and social inequalities. Marginalized populations, such as women, youth, face heightened vulnerability to HIV infection due to limited access to prevention, treatment, and care services. To confront this pressing issue, empowering local HIV control organizations through increased domestic funding not only enhances their capacity to deliver targeted interventions but also fosters community ownership and sustainability.

(Photo source: The guardian)

Highlighting the position of stakeholders on this issue, firstly, WHO plays a pivotal role in providing technical guidance and support to countries like Nigeria in combating HIV/AIDS. Collaborating with WHO to develop evidence-based guidelines and technical assistance programs could bolster Nigeria’s efforts towards mobilizing domestic resources for HIV financing. National Agency for the Control of AIDS (NACA): the leading agency responsible for HIV/AIDS control in Nigeria, NACA advocates for increased domestic financing and empowerment of local HIV control organizations. Partnering with NACA to strengthen advocacy efforts and capacity-building initiatives could drive policy change. Despite the importance of mobilizing domestic resources for HIV financing, several challenges persist. These include inadequate funding allocations in national budgets, limited institutional capacity for effective resource mobilization and management. Developing a strategic plan such prioritizing advocacy for increased domestic funding for HIV/AIDS programs, enhance coordination among stakeholders, strengthen institutional capacity for resource mobilization and management, and promote community engagement and ownership of HIV/AIDS interventions. To conclude, mobilizing domestic resources for HIV financing is vital for Nigeria’s epidemic control. WHO must provide tailored guidelines, technical support, and advocate for local engagement. NACA should prioritize policy advocacy such as lobbying for increased budget allocations, strengthen collaboration as establishing joint task forces with other government agencies and NGOs, facilitating resource-sharing and coordinated efforts, and enhance community involvement. These concerted efforts will empower local organizations, bolster health systems, and mitigate the HIV burden, fostering sustainable development.

Sudan’s Mental Health Crisis: Community-Led Peer Mental Health Counseling

Omnia Hassan has posted about a unique program of peer-led mental health counseling. Read her thoughts below and check them in the class blog of Social and Behavioral Foundations of Primary Health Care. As Sudan faces persistent war and conflict, the focus must turn to Sudanese internally displaced persons (IDPs) who are unable to escape the country, facing increasing incidence rates of several serious mental health burdens. Graphs Source: Mental health consequences among Sudanese due to the armed conflicts and civil unrest of 2023: a cross-sectional study In Sudan, there are only two psychiatric hospitals and seventeen outpatient mental health facilities for a population of over 40 million. To support the IDPs with improved access to mental health care, the development of a community-led mental health counseling program may be beneficial where community members are educated on how to counsel their peers through mental health burdens. This initiative aims to reduce the effects of mental health illnesses, create a space to speak about difficult experiences, provide accessible mental health resources, and empower Sudanese individuals, restoring their autonomy. A successful example of this program in Uganda with Rwandan and Somali refugees with PTSD where the evidence demonstrated that 65% of participants no longer fulfilled the criteria for PTSD. Universities in Sudan, such as Ahfad University of Women, have committed themselves to the education and training of community members to equip them with the knowledge and skills to provide mental health counseling for their peers. The Sudan Ministry of Health (MoH) has lent staff and workers to increase the numbers of those being trained to become lay counselors. Funding is a particular point of discussion, and the United States has frequently sent funds to Sudan for humanitarian assistance. The U.S. Department of State funded a grant for the Ahfad University of Women before as part of the University’s Trauma Training Treatment Center. Photo Source: Reuters The UN Refugee Agency acknowledges the displacement issues brought upon the Sudanese population during the war. They have explicitly commented on the displacement of Darfuris in the western region of Sudan, sharing the interventions they have implemented to mitigate mental health issues, such as promoting social cohesion. With over 10 million people uprooted and 9 million people internally displaced, Sudan’s war fuels the largest displacement crisis in the world. The mental health of these individuals needs to be addressed as they endure the most grueling event of their lives.

 

Essential Medicines, Commodities and Supplies Needed for Community Level Primary Health Care Interventions is our 2-credit online course offered from 5-9 June 2023 as part of the Global Health Systems Summer Institute. Please check the syllabus and share with colleagues.

Course Description” Essential commodities are among the 8 basic primary health care services and the 6 health systems building blocks as defined by the World Health Organization

Primary health care programs in low and middle-income countries require essential health commodities be made available at the community level. Logistic systems need to be developed to ensure that commodities are adequately estimated and delivered. In addition, systems for safely maintaining and monitoring stocks are needed at the community level.

The Summer Institute offers a variety of short-term courses in a variety of global health areas between 5-30 June 2023. The Global Health Systems Summer Institute provides early- and mid-career public health professionals with cutting-edge skills in a variety of global health topics. The Institute is also a great opportunity for part-time MPH and other Hopkins students and fellows to learn a valuable set of skills in an in-demand and rapidly growing field of public health. Below are issues covered in the Essential Medicines course.

• Overview of Essential Medicines for Primary Health Care
• Essential Medicines for Primary Health Care
• Basic Primary Health Care Procurement and Logistics
• Financing for Essential Medicines
• Implementation of Essential Medicines Programs in Primary Health Care
• Preventative Chemotherapy for Neglected Tropical Diseases
• Ensuring Essential Pharmaceuticals Go “Beyond the End of the Road”
• Supply Chains
• The Role of Indigenous Medicine
• Supply Chain Management for CDI: The Malaria Example
• Logistics Management Information System in Community Based PHC
• Community Mass Drug Distribution
• The CDI Process: Expanding Beyond Ivermectin
• Supply Chain Management in Ethiopia
• Community Supply Chain Challenges in Nigeria

Lisa Marie Clark has contributed this posting to the Blog site for the JHU site for the course Social and Behavioral Foundations of Primary Health Care.

Cervical cancer is among the leading causes of death for Kenyan women. Every day, 9 women die from cervical cancer alone in Kenya. HPV vaccination reduces the risk dramatically, particularly for HPV types 16 and 18, which may be responsible for up to 70% of cervical cancers.

Optimal vaccination is in early adolescence starting at age 10, before sexual activity begins. In 2020, uptake of the HPV vaccine in Kenya was low, with only 33% of the target population receiving the first dose and only 16% percent receiving a second dose.  Low uptake may be due to a variety of factors including misinformation, lack of access, and low supply of vaccines.

In 2019, the Kenyan Ministry of Health began including the HPV vaccine in the routine vaccination schedule. The vaccine, with support from GAVI, the vaccine alliance, is offered free of charge. However, the Catholic Church and medical professional groups influenced by religious ideology have been a major opponent to vaccine uptake. The Kenya Catholic Doctors’ Association has been vocal about urging parents to promote abstinence over vaccination, equating HPV vaccination with permission to engage in sexual activities. See vaccination from Republic of Kenya’s Ministry of Health in photo.

In the face of such obstacles to vaccine uptake, more funding is needed to strengthen Kenya’s vaccination campaign, with a focus on building trust and strengthening partnerships with faith leaders to improve vaccine uptake. With more funding from GAVI and improved community engagement vaccination rates would improve, HPV infection rates would decrease, and lives would be saved as a result.

In their 2021 presentation at the American Society of Tropical Medicine and Hygiene, “Hands-only CPR Training Program of Secondary School Students in Ibadan, Nigeria”, Olufunso Odunukan and colleagues of the Revolving Heart Foundation mentioned that plans were underway to expand the training. Below, they share their recent public training in Lagos, Nigeria.

Freedom Park Lagos played host to the Revolving Hearts Foundation (RHF) – a non-governmental organisation which advocates Cardiopulmonary Resuscitation (CPR) trainings and more of the presence/ use of Automated External Defibrillator (AED) in public places in Nigeria (and by extension Africa). The foundation represented by its visionary Dr. Olufunso Odunukan, an interventional cardiologist based in the United States, took a wide cadre of staff – from management to the most junior level, and vendor representatives through a detailed and practical session of administering CPR in a bid to save more lives and reduce loss due to not-quick-enough basic interventions in the face of a cardiac arrest or someone passing out due to a heart attack.

The NGO also presented an AED to the management of Freedom Park and in the same training showed how to set up the device following previously programmed instructions on the gadget. After that, with the use of mannequins and simulated AED materials, the RHF representative Dr. Odunukan took the participants through a very hands-on and practical experience of deploying CPR in a model situation. There was a video presentation that detailed what to do in the event a person suffers a cardiac arrest in a public place, at home, on the sidewalk, on stage or similar places.

The participants who included a wide array – cleaners, vendor workers, senior staff and middle management all gave good feedback as to the extent and impact that the training would have, even beyond the four walls of the Park. They also participated in a skit of a proper situation where they might need to take charge or be part of helping in an emergency situation, especially with the benefit of the lessons they had picked up in the training.

Dr. Odunukan equally advocated that this shouldn’t be a one-off session as the training could be replicated from time to time, so that everyone is prepared and savvy in the proper manner to be able to intervene and save lives, at least as a first aid in such situations, until professional medical assistance arrives. After the latter, on behalf of RHF, he presented the AED to the management of Freedom Park represented by the C.O.O.  Ms. Iyabo Aboaba who gladly accepted the device and reiterated the necessity of such gesture with the pledge to put it to good use, in line with the vision of the NGO to save more lives.

The training which lasted about 1hour 30 minutes ended with FAQs and an interactive and enlightening session based on the model skit and how to replicate an efficient process in the event of a real-life situation.

The TiPToP malaria in pregnancy project of Jhpiego and Unitaid has been adjusting to the COVID-19 pandemic. Their abstract below is being presented at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting and explains the use of bulk SMS to support health worker knowledge retention on antenatal care and the use of intermittent preventive treatment of malaria in pregnancy during COVID-19 in Bosso local government area of Niger State, Nigeria. See Author List below.

In light of COVID-19 travel restrictions, bulk SMS were used to support knowledge retention of health workers following an in-person training held before the pandemic. In December 2019, 72 facility health workers and 260 community health workers (CHWs) in Bosso local government area of Niger State, Nigeria participated in a 12-day training about benefits of early antenatal care (ANC) attendance, CHW referrals to ANC, and use of intermittent preventive treatment in pregnancy (IPTp) with sulphadoxine-pyrimethamine to prevent malaria.

In-person supervision visits were conducted 3 months following training, although three months later in-person supervision was no longer possible due to COVID-19 related travel restrictions. Post-training support transitioned to use of bulk SMS which were sent twice a week to each cadre for two 3-month rounds of messaging.

Knowledge tests comprised of 10 multiple choice questions linked to key ANC and IPTp guidelines were administered at 5 time points: 1) baseline; 2) post-training; 3) at in-person supervision visit 3 months after training; 4) after first round of bulk SMS (6 months post-training); and 5) after second round of bulk SMS (9 months post-training).

Average test scores for each cadre were calculated at each time point and T-tests were used to assess differences in scores. The results show that facility health workers scored an average of 53% on the pre-test followed by scores of 76%, 74%, 86%, and ending at 80% 9 months following training. CHWs started with an average score of 49% which increased to 67% post-training; subsequent average scores were 83%, 74%, and 94%.

Results were compelling with facility health worker knowledge improving from 76% immediately post-training to 80% 9 months later (p-value<0.05) and for CHWs the improvement was from 67% to 94% (p-value<0.05). These findings suggest that use of SMS can support knowledge retention of key ANC and IPTp guidelines following an in-person training. Program managers, trainers and supervisors may consider using this approach to support health workers where resources and/or movement are restricted.

AUTHOR INFORMATION:

Charity Anoke 1, Orji Bright 1, Joseph Enne 1, Bartholomew Odio 1, Christina Maly 2, Amina Zimro 3, Ibrahim Idris 3, Elizabeth Njoku 1, Oniyire Adetiloye 1, Emmanuel Dipo Otolorin 1, Elaine Roman 2  — 1Jhpiego, Abuja, Nigeria, 2Jhpiego, Baltimore, MD, United States, 3Niger State Ministry of Health, Minna, Nigeria

Kenya Division of National Malaria Program (DNMP) with support from PMI Impact Malaria (IM) and in collaboration with other stakeholders reviewed/developed/updated nine key program documents. Agustine Ngindu and the Impact Malaria/PMI team stress the importance of keeping key malaria technical guidance and tools up-to-date.

Guidelines for the Diagnosis, Treatment, and Prevention of Malaria in Kenya was revised to indicate the start of IPTp at 13 weeks from the prior recommendation of 16 weeks of gestation and updated the IPTp schedule in line with WHO guidance. The program also updated dosing charts for artemether lumefantrine, dihydroartemisinin-piperaquine, and injectable artesunate to include both weight and age range particulars. This update will enhance adherence to treatment guidelines among healthcare workers

The Kenya Quality Assurance Guidelines for Parasitological Diagnosis of Malaria was in draft form for nearly 10 years. Revisions were motivated by the lack of a functional quality assurance (QA)/quality control (QC) system for malaria diagnosis. Sections were added to guide implementation of internal quality control and external quality assurance programs. Updates also provided guidance on surveys to determine the extent of gene deletion and its effect on routine RDT-based malaria diagnosis.

Implementation Framework for Malaria Rapid Diagnostic Tests was developed to facilitate rollout of malaria diagnostics QA/QC in line with Kenya Malaria Strategy (KMS) of 2019-2023. As p[art of this effort, the M&E framework was expanded to include the performance matrix. A costed implementation matrix to provide guidance was developed on costing of activities in line with KMS 2019-2023.

Biosafety Guidelines for Malaria Rapid Diagnostic Testing at Community Level was highlighted in new guidelines developed to address emerging QA and biosafety concerns at community level. This was a response to requirements by the Kenya Medical Laboratory Technicians and Technologists Board to allow for a new waiver for community health volunteers (CHVs) to conduct testing using mRDTs.

The Guidelines on Community Case Management of malaria and its implementation plan were strengthened as was the Implementation framework for Rapid Diagnostic Testing. Updated job aids included dosing schedules for artemether lumefantrine (AL) and injectable artesunate for use at service delivery points by Health Care Workers in line with the revised guidelines.

Hopefully all national malaria programs will take the Kenya experience as an example of the need to update regularly all the tools needed for front line staff to achieve malaria elimination.