Tropical Health Matters

The APMEN Community Engagement for Malaria Elimination Workshop today provided the ten participating countries opportunities to share and learn from each other. One approach was a round table session or World Café where visitors to each country table could learn about innovative strategies for community engagement and offer suggestions and ideas.  The second format was an exhibition where countries presented materials they had developed for BCC, training and program management.

Below are some of the lessons learned which were posted, discussed and sorted after the roundtable session. Some of these lessons are general for community engagement while others are especially relevant to the malaria elimination phase.

Countries found that interest malaria may wane in the community as experience fewer and fewer cases.  Therefore it was suggested that malaria activities be fully integrated into other community level disease control activities so the community will not ‘forget’ malaria.  Funding may also wane, and community engagement can be the basis for advocacy efforts to also keep health systems engaged in malaria work. Another aspect of integration is the need for community case management capacity for treating other febrile illnesses since the community will perceive and still be concerned about ‘fever’ even in the absence of malaria.

A lesson of general value include the need to build on community achievements. Communities have their own participation ‘culture’. Therefore communities have their own mechanisms for solving problems, and these can be used as a foundation to address new issues like malaria elimination. Ultimately we need to look toward the community for innovative ways to tackle the problem of malaria elimination on their own terms.  Another aspect of the participatory culture in a community may be seasonality based on the variying demands on community members’ time at different times of the year.

We will present some of the individual country experiences in subsequent postings.

The APMEN Community Engagement for Malaria Elimination Workshop started by establishing the broader context of community participation in disease control efforts.  Dr. Wichal Satimal, Director of Vector-borne Disease Control in the Thailand Ministry of Health first welcomed the Asia Pacific Malaria Elimination Network members  to Chiang Mai and Thailand, host country of the Workshop.

Dr Charles Delacollette of WHO reminded participants that community engagement is not new to the World Health Organization and member states, and in fact was the foundation of the 1978 Alma Ata Declaration on Primary Health Care.  Reaching back farther, Dr Delacollette recalled that the malaria eradication effort begun in the 1950s was possibly the first international disease control program to reach out to the remotest communities.  He explained that these foundations today manifest in hundreds of thousands of community health workers and volunteers based in villages throughout the Asia Pacific Region.  Other trends in health system reform include decentralization that can give more power to consideration of local priorities.

Dr. Maxine Whittaker of the University of Queensland, and one of the workshop organizers, stressed that a key theme of this meeting is “bringing the human back into malaria control and intervention.” She drew attention to the fact that at the heart of the six WHO key health systems elements should be a seventh, the ‘people’ who must be partners in strengthening health systems.

Jo-An Atkinson, also of the University of Queensland reviewed the 60-year history of community participation in disease control and elimination.  An important lesson was the need for better documentation of evidence of what works in terms of community engagement strategies, especially in terms of impact on diseases. Jo-An outlined a variety of factors that influence a community’s ability and willingness to engage in disease control activities ranging from gender and power relationships to lack of congruence between community perceived priorities and agency targets.

Ultimately the challenge to participants posed during this first session was the need to begin the process of establishing best practice guidelines for community engagement in malaria elimination before the end of the meeting.

The Asia Pacific Malaria Elimination Network (APMEN) is starting a workshop entitled ‘Building Competence in Connnunity Engagement for Malaria Elimination,’ tomorrow (22 November) in Chiang Mai, Thailand. APMEN includes 11 countries that are making clear progress to malaria elimination in the region.

The meeting will feature discussions on topics such as …

• Lessons from 60 years of community participation in communicable disease control and elimination
• Going to scale with community engagement for malaria elimination (models for equitable access and sustainability)
• Experiences and challenges in achieving synchronous cross‐border community engagement for malaria elimination
• Embedding community engagement for malaria elimination in comprehensive Primary Health Care delivery: A systems strengthening approach

Country case studies will be shared by Bhutan, China, Indonesia, Malaysia, Philippines, Republic of Korea, Solomon Islands, Sri Lanka, Thailand and Vanuatu. Discussions will focus on identifying intervention, training and research strategies to support elimination efforts.  Reports on the meeting will begin tomorrow.

The Malaria Communities Program (MCP) of the US President’s Malaria Initiative gives non-governmental organizations a chance to make an impact at the local level in 15 endemic countries. Ronald Apunyo of Medical Teams International provides us an update on MCP activities in Uganda.

The Malaria Communities Project in Uganda is currently being implemented (With funding from USAID) in Lira, Otuke, Alebtong and Dokolo Districts, part of the Lango sub-region of northern Uganda, with a population of approximately 765,458 and 166,190 households. Primary beneficiaries include 159,895 children under five years of age and 39,578 pregnant women.

According to a recent report from the World Health Organization, Uganda has the world’s highest malaria incidence, with a rate of 478 cases per 1000 population per year. Malaria is the leading cause of morbidity and mortality in Uganda and is responsible for up to 40% of all outpatient visits. Malaria is the leading cause of morbidity and mortality nation-wide, and is particularly high in the northern region, where Dokolo and Lira Districts account for 54% of the sub region’s malaria cases and only 46% of the population.

Northern Uganda is a transitional environment, and communities are in the process of resettling in their ancestral lands after 20 years of insecurity and internal displacement due to attacks from the “Lord’s Resistance Army.” The project has endevoured to fill gaps identified in Uganda Malaria Control Strategic Plan by meeting training, support and supervision needs for VHTs who have been trained by MOH and by strengthening community-level behavior change and health promotion efforts to complement PMI and National Malaria Control Program (NMCP) broader malaria prevention interventions.

The project has had two years of uninterrupted implementation in all the Sub-counties of Dokolo district, in the past two years (Since 2009/10). The project focuses on reducing malaria-related morbidity and mortality among pregnant women and children under 5 years of age in the project areas by

1. Increasing the percentage of pregnant women and children under 5 years of age sleeping under an LLIN each night.
2. Increasing the percentage of pregnant women who receive 2 or more doses of IPTp during their pregnancy
3. Increasing the percentage of children under 5 years of age with suspected malaria who receive treatment with ACT within 24 hours of onset of symptoms

A review of Dokolo district Health Management Information System between 2006/7 and 2010/11 indicates an improvement in some of the key projects target indicators pertaining to ANC attendance by pregnant women, new malaria cases in OPD IPTp uptake and stockouts of key medicines.

SUCCESSES

• There is a steady increase in ANC fourth visit in Dokolo district since project start in 2009/2010.
• Proportion of Pregnant women receiving IPTp2 increased from 60% to 69% between 2009/10 and 2010/11

LESSONS LEARNED

The successful use of Social and behaviour Change communications interventions in malaria control should be coupled with reliable supply of malaria commodities at the health facilities inorder to attain satisfactory results.

Use of community volunteers like female VHTs at the ANC to mobilize and conduct less technical work like providing clean water to pregnant women,observing Directly observed treatment (DOT), carrying out health education sessions and providing other support to pregnant mothers at the health units greatly reduces workload of health workers as well as waiting time of pregnant
women during ANC (a key reason why pregnant mothers do not attend ANC).

The role of community structures like the village health teams (VHTs) has made significantly positive contributions towards the fight against malaria within the communities.

Today I shared a link to a new publication on the Tropical Disease Research (TDR) website entitled, “Community case management of malaria in urban settings,” to members of our Malaria Update Listserve (see link at right).  A major conclusion from the multi-country study in Burkina Faso, Ethiopia, Ghana and Malawi was …

The use of the ACT (Artemisinin-based Combination Therapy) unit dose pre-pack is feasible and acceptable. When CMDs (Community Medicine Distributors) are properly trained, the community is properly sensitised and pre-packed drugs are provided either free or sold at an affordable cost, the quality of services delivered by CMDs and adherence by caregivers are similar to those seen in rural CCMm settings. The proportion of cases seen by CMDs, however, tended to be lower than was generally seen in rural CCMm. Urban CCMm is feasible, but it struggles against other sources of established healthcare providers.

One member of the listserve responded by raising a question about access and quality to malaria treatment services in urban settings. Jim Ricca from Jhpiego’s office in Maputo made the point that …

I’m interested to know why CCM was done in an urban setting where geographic access should not be a problem. If other access issues were a problem for people using facility-based services (e.g., cost, cultural/linguistic barriers), then I wonder why these barriers to use of facility based services were not addressed instead of moving to community-based services.

In places I’ve seen CCM implemented, the planners took great pains to do a situation analysis beforehand to see where there were geographic access problems for use of facility-based services and it was there that the CCM services were implemented. As much of an advocate as I am of community-based services, if CB services are the answer for ALL the shortcomings of the current health system, is there any sense having facility-based services at all?

TDR has led the way in operational research over the years and has been trying out community engagement strategies or community directed interventions (CDI) in a variety of settings – rural, urban, nomadic, migratory, etc. The question about the value of CDI when one could hopefully improve the quality of existing health services is certainly valid. But a basic question has been whether the willingness of rural community members to volunteer will work in urban areas where ‘community’ is much more diffuse. Even if the CDI approach does not translate culturally into diverse, anomic urban settings, access to care in urban areas, there are other challenges such as the plethora of provider types.

Jim is right that there have been studies about urban access that show geography is not the main issue – there may be social and financial barriers as well as perceptions of quality barriers.  To complicate the picture these issues must be addressed not only in the public sector but with private clinics and patent medicine shops.These private formal and informal sources usually provide desirable options like convenient hours, convenient locations and the ability to purchase on credit that the public sector does not.

While these private provider must be considered in any effort to improve the quality of health care in urban areas, they are also elusive. From experience in Nigerian cities, I can vouch that registries of private clinics and medicine shops are out of date and incomplete.  These entities may fail to register in the first place, move location or go out of business, and noe one seems to be responsible for updating the list.  In Kaduna, for example, an effort to study medicine shops started with a state ministry registry of 200 shops for the whole state and found by going street by street over 500 shops in one half of Kaduna alone. These providers too need to be considered as part of the total picture, and quality assurance mechanisms must be extended to them -if only we can find them.

So the answer to the basic question – is community volunteerism in the delivery of health services really necessary in urban area? – does depend not only on whether the volunteer spirit works in an urban setting, but whether quality services are already or potentially accessible thus, negating the need for community members delivering services.

A different model may be appropriate – that is the Community Navigator. Such a volunteer would help community members find the right care and get there. The Navigator could also serve as a patient advocate once she or he arrives at the point of service with their neighbors in tow.

Urban and rural settings differ dramatically in terms of culture, economy and social structure – we need to find the right community engagement model for each.

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World Malaria Day 2011 celebrates “Achieving Progress and Impact.” Major increases in intervention coverage and reductions in morbidity and mortality have been documented. Yet we are still a long way to go in achieving targets, especially for protecting pregnant women and treating vulnerable children.

In 2011 key interventions like prompt and appropriate diagnosis and treatment still do not reach all endemic communities. In several countries the health services still do not trust community members, and this is impeding progress, let alone impact.

A common belief among health workers in some countries, from upper level Ministry officials to front line primary care staff, is that the community cannot be expected to handle malaria diagnosis with RDTs and treatment with ACTs. In these locations Roll Back Malaria has yet to roll back the medical model of malaria elimination and trust the affected populations to play a major role in providing their own care.

Years of experience with onchocerciasis control tells a story of initial skepticism that communities could handle ivermectin, and yet 16 years after the African Program for Onchocerciasis Control was launched, over 100,000 communities regularly control and direct their own ivermectin distribution.

Studies by the Tropical Disease Research Program of UNCP/World Bank/UNICEF/WHO have shown that these same communities can effectively develiver malaria control services (ITNs and ACTs) along with their ivermectin duties. 

In Rwanda village health workers are the major providers of malaria diagnosis and treatment using RDTs and ACTs.  It can be done if there is willingness to form working partnerships with communities.

The problem goes beyond malaria case management.  Recently the Global Fund pointed out to a grant recipient that coverage targets could not be met without an active role of communities in malaria case management. Communities needed to do more than provide behavior change communication telling residents to trek dozens of kilometers to the nearest health facility for care. 

In fact the Global Fund learned that this country had no policy for community case management of any illness. The nature of such medicalized and inaccessible health care is to condemn thousands of malaria sufferers to death.

Community members can make a difference, as Jhpiego has found in Akwa Ibom State, Nigeria.  Through training and supervision, communities can effectively take charge of meeting their health needs.

Progress will come only when health officials recognize that they cannot achieve impact alone. They must actively involve communities in decision making, planning, service delivery and evaluation of malaria is ever to be eliminated.

Volunteer community or village health workers (CHWs) are crucial human resources to increase and sustain coverage of malaria interventions. Small and large scale training programs have abounded over the years stimulated by the philosophy of the Alma Ata Declaration on Primary Health Care. Unfortunately, CHW programs often fade after a few years because a donor supported project closed or funds dried up for a public health program and the health staff who trained the CHWs loose touch with them.

Without supervision and encouragement CHWs loose interest and forget what they learned. The challenge therefore is to design an appropriate supervisory system for limited resource settings.

Experience with village health workers for primary care and community community directed distributors for onchocerciasis control have demonstrated that effective and appropriate supervision of CHWs requires three main components or partners as seen in the attached diagram.

Staff of the health facility nearest to the community should have initially reached out to the community to assess their interest in community health interventions and helped them organize. Included in this organization is selection of trusted community volunteers to serve as CHWs.  These health staff provide technical supervision on the health services being provided (case management, net distribution) and management processes (good service records and reports).

Health staff may not be able to visit each village in their service catchment areas frequently, but they can host monthly or quarterly meetings where CHWs bring their service records, collect new supplies and receive technical updates. Health staff review the records for accuracy and give pointers to improve data and service quality.

The second partner in CHW supervision are the community members who actually selected the volunteers. The CHWs must be held accountable to the people who selected them. CHWs can be asked to report at community meetings about progress and services provided, and community members can give feedback on the quality of these services.

The third partner is the CHWs themselves.  Often CHWs in a locality form an association and meet regularly.  These meetings create a form of peer supervision.  CHWs share their experiences and lessons learned. They advise each other and jointly solve common problems such as community refusal to talke certain medicines or hand up their bednets. CHWs can even take turn reviewing the basic lessons they learned at the start.

Supervision does require that people get together and have a dialogue about their work. This often means some degree of travel. Here is where we need to rely on local knowledge and make supervision convenient for all. for example, health staff can schedule such gatherings on market days when CHWs and other villagers would normally come to town.

Until we move to the local level and find locally appropriate solutions to supervision, we will not be able to achieve universal coverage.

Thanks for the recognition of the efforts of Peace Corps Volunteers worldwide in malaria prevention. PC Volunteers and our partners here in Senegal pioneered the universal bed net coverage and malaria prevention education approach that has now been adopted by PMI and the Senegalese national malaria control program.

Already 7 of the nation’s 14 regions have achieved true universal coverage, including a pre-distribution house by house sleeping area/bed net census, village distribution and education events, and post-distribution hang checks. There is much left to do, but Senegal has made tremendous progress, and Peace Corps Volunteers have been at the center of the fight.

Looking forward as the agency celebrates 50 years, Peace Corps across Africa is developing a comprehensive campaign to replicate and adapt the experiences of PC/Senegal to the other two dozen PC programs on the continent.

Thanks again for recognizing the important role that our Volunteers can and will play in the effort to reduce malaria in Africa.

Chris Hedrick
Country Director, Peace Corps/Senegal
www.pcsenegal.org

the United States Peace Corps is celebrating its 50th anniversary this year.  Volunteers have been working in malaria endemic countries since the beginning of the program. Here we will share a few recent Peace Corps malaria activities. We encourage current and former volunteers to share with us their experiences and lessons learned in controlling malaria.

In Zambia the Peace Corps has partnered with a local NGO called Youth Activists Organization to bring advocacy messages and educational materials to the community level. Peace Corps Senegal reports that …

Peace Corps Volunteers in all regions of Senegal are leading efforts to prevent malaria, the leading cause of child mortality in Senegal. Volunteers are providing malaria prevention education and have led insecticide treated mosquito bed nets distribution campaigns that have become a model for the rest of Senegal. These efforts are leading to the first large scale universal bed net coverage in the history of Senegal, aiming to significantly reduce malaria caused disease and deaths.

Individual volunteers have written about their experiences, as seen in the following account from Senegal …

I worked with three phenomenal community health workers to organize and distribute nets to every family. In the weeks leading up to the distribution, we surveyed all of the families, counting their sleeping areas and numbers of nets in good repair. Working over three days, we traveled house-to-house distributing nets. The chief of Goudel Comi was overcome with gratitude. 

Peace Corps volunteers have even been the subjects in malaria research. One study examined self-reported adverse events associated with long term antimalarial chemoprophylaxis in over 1700 Peace Corps Volunteers. Another study monitored mefloquine resistance in Peace Corps Volunteers.

The Peace Corps even enters into classrooms in U.S. schools from grades K-12 to offer curricular ideas and share experiences from the field. Students can simulate the role of a Peace Corps Volunteer working to prevent the spread of the disease.

The success of malaria control ultimately rests in and with the community. Peace Corps Volunteers are strategically placed to help make sure this happens.

Uduak, a community directed distributor (CDD) for Jhpiego’s malaria in pregnancy (MIP) prevention program in Akwa Ibom State, Nigeria, was involved with pregnant women long before the MIP program started in 2008. She normally works as a traditional birth attendant attached to one of the churches in Atiamkpat community in Onna Local Government Area (LGA).

So, when Jhpiego introduced the ExxonMobil Foundation funded program that required volunteers selected by the community members to deliver MIP services, Uduak volunteered along with 38 other women to serve the villages and kin groups in the catchment area of Atiamkpat Clinic. On their part, the community leaders were happy that she volunteered because, “Uduak has been resourceful in the past and always committed in whatever assignment given to her”

Jhpiego had formed a state training team, which trained LGA health team members who in turned trained staff at the front line health facilities to deliver malaria in pregnancy services and enable communities to provide community directed interventions. These health facility staff trained volunteers like Uduak.

During the training that followed, Uduak was elected by her colleagues to be the chairperson that coordinates the activities of these volunteers. Asked the colleagues why they selected Uduak as their leader, one of the CDDs responded that, “Uduak is responsible and one who respects other people’s opinion.” In addition to providing malaria prevention services such as insecticide treated nets (ITNs) and intermittent preventive treatment of malaria in pregnancy (IPTp) to pregnant women in her own local community, she supervises and coordinates the other women volunteers, ensuring that they do not run out of stock of anti-malarial drugs and update their community registers for accurate service provision.

Uduak also organized and mobilized the traditional birth attendants in her community to send their clients for antenatal care that is a platform for providing MIP prevention services. She accomplished this with the support of the nursing officer attached the Atiamkpat Clinic and the traditional ruler. Uduak also provides community counseling sessions on malaria to pregnant women in her community as well as health talk to women in her church.

One of the project beneficiaries who received nets from Uduak shared her profound gratitude to Uduak because according to her, “Without Uduak I would not have started using the net but her consistency and persistence in reminding me to use the net prompted and encouraged me to do so.”

Prior to the activities of Uduak and her colleagues, Atiamkpat health facility was not patronized by pregnant women. The community members complained that the staff were not usually on duty at the time pregnant women visited the facilities. Uduak and colleagues met with the health staff and got their commitment to be at the facilities. This coincided with Jhpiego’s training of health staff to improve the quality of ANC and malaria control services they provided.

Now the staff have started receiving antenatal care clients. This increased from just two pregnant women in the three months preceding the intervention to fifty pregnant women in the first three months of intervention. The clinic is now also taking delivery of babies. Because of the way Uduak has been able to organize her group of CDDs, the catchment area of Atiampat Clinic has achieved on average 43% better coverage of the required two doses IPTp relative to its population compared to the three other clinics/catchment areas in the LGA.

Uduak has been a source of encouragement to her follow volunteers, one of whom noted that, “We would have stopped this work since we are not paid, but Uduak as continued to encourage and motivate us.”

Uduak was once asked what motivates her to carry out this assignment in absence of any financial reward or personal gain. She responded that, “The life and survival of pregnant women is my concern and much more important than money.”

One of the women beneficiaries noted that, “Uduak is selfless and committed to helping people. Her life is a testimony and challenging to us.” Uduak on her own part has vowed to keep doing the CDD job even though she does not benefit financially, explaining that, “There is an inner joy in providing quality community service, and this motivates me.”

[This story was compiled with the help of Bright Orji of Jhpiego Nigeria and Eno Ndekhedehe of Community Partners for Development, Akwa Ibom State, respectively.]