Tropical Health Matters

Arsenio Manhice from Mozambique reports on a program that will be launched shortly in the northern part of the country …

More than 100,000 people are covered by the Program of Communities against Malaria (PCM) to be launched in Pemba-Metuge in Cabo Delgado Province, northern Mozambique, on Monday, December 20.

The act will be directed by the provincial governor, Elisha Machava and will be attended by the Interim Director of USAID as well as representatives of Mozambique and the Aga Khan Foundation of Advancement Organization supporting the initiative.

Among the population of the nine communities of the province, estimated at about 396 000 people, about 87 000 and 500 children under five and pregnant women and 21 000 and 700 people living with HIV and AIDS will benefit from the program in allusion.

The PCM is a partnership between the U.S. President’s Malaria Initiative (PMI) with Mozambique Aga Khan Foundation (AKF Mozambique), the Progress Organization and the Ministry of Health (MOH). This program will run for three years and will be implemented in nine districts of Cabo Delgado Province.

The districts were selected based on their health indicators, malaria, poverty, lack of community interventions and firm long term commitment, the AKF and Progress, to develop these areas.

The purpose of PCM is to reduce morbidity and mortality caused by malaria in Mozambique, particularly among pregnant women, children under five and other vulnerable groups of population in the districts of Quissanga, Meluco, Ibo, Pemba Metuge, Macomia, Mueda, Nangade, and Muidumbe Ancuabe.

The program was designed in collaboration with all key stakeholders and specifically aims “to broaden the scope and coverage of existing interventions, while making the local capacity for sustained control of malaria” in Mozambique

The total program cost is $ 1,625,997 (one million, six hundred twenty-five thousand, nine hundred ninety-seven U.S. dollars), of which USAID provided $ 1,482,502 (one million four hundred and eighty-two thousand, five hundred and two U.S. dollars), and will be co-financed by U.S. $ 143,495 (one hundred forty-three thousand, four hundred ninety-five U.S. dollars) of nongovernmental funds.

Two of Jhpiego’s community participatory interventions in Nigeria were featured in the Keynote address at the 8th International Scientific Conference of the Society of Gyneacology and Obstetrics of Nigeria (SOGON) in Abuja today.

William Brieger, Jhpiego’s Senior Malaria Advisor, who was introduced by SOGON member and Jhpiego Country Director, Emmanuel Dipo Otolorin, explained that communities have cared for their pregnant women and mothers since time immemorial. Simply building a modern service does not mean women will come. Ultimately the community and the health system need to be partners so that the best of ideas and resources from both can be pooled, making for stronger services for women.

Jhpiego has tested two successful interventions that involve the community in improving maternal health in Nigeria. Community Directed Intervention in Malaria in Pregnancy Control is being sponsored by Sponsored by the ExxonMobil Foundation and based in Akwa Ibom State. The Household-to-Hospital Continuum of Care approach to saving mothers’ lives is sponsored by USAID’s ACCESS and MCHIP programs AND IS Based in Kano, Zamfara and Katsina States.

Prior to intervention in Akwa Ibom State in 2007 only 17% of pregnant women had slept under an insecticie treated bednet. Only 6% had received the recommended minimum of two doses of intermittent preventive treatment. Therefore a two-pronged intevention was implemented that improved performance standards at local goverment antenatal clinics and also enabled clinic staff to organize a community directed approach with local volunteers to the distribution of IPT and nets in catchment areas surrounding the intervention health facilities.

After two years ANC attendance improved. Coverage of two doses of IPT rose to 65% in the intervention communities, and 27% in the control areas where IPT was provided only through the health center.

The program demonstrated that a linked community-clinic delivery system for preventing MIP increases coverage of pregnant women with lifesaving interventions. Strengthening both the health system and the community is intended as a way to sustain MIP prevention. Community Directed Interventions in MIP can be scaled up through support from Global Fund and World Bank Grants and links with other public health efforts.

SOGON members were challenged to think of other life saving interventions that could be delivered through community directed intervention such as misoprostol. The Minister of Health, who opened the conference, declared that misoprostol had been added to Nigeria’s essential drug list at the meeting.
Five key community intervention were included in the USAID Sponsored ACCESS program: Community Mobilization Teams, Community Core Groups around health facilities, Household counselors to educate women and their families, Male Birth Spacing Motivators, and Mothers’ Savings and Loans Clubs.

This combination of community action and planning, advocacy, social support and health information provided by the community resulted in an increased knowledge among women of danger signs in pregnancy from 53% to 80%.  The number of women who actually made a birth preparedness plan rose from 32% to 68%. One-third of the women who made use of the microfinance loans used the funds to access emergency health services they would have otherwise foregone. Antenatal clinic attendance nearly doubled.

In conclusion, communities offer valuable human, social and economic resources to improving health care. Our formal health services cannot go it alone and succeed. A true partnership will bring together the best of what communities and clinics, households and hospitals have to offer in order to save the lives of mothers and children.

Because Akwa Ibom State is one of the seven States involved in the World Bank Malaria Booster Program in Nigeria, the Bank became aware of Jhpiego’s ExxonMobil Foundation supported work in Community Directed Interventions (CDI) to improve coverage of malaria services in seven local government areas in the State.

CDI was pioneered by the African Program for Onchocerciasis Control with Ivermectin and in the past 15 years has reached over 100,000 villages in Africa. CDI places responsibility for distribution of basic health commodities in the hands of community members who made decisions on distribution mechanism and timing and selection of volunteer community directed distributors (CDDs). The value of CDI beyond onchocerciasis control was proven through a 3-year, 7-country study sponsored by the Tropical Disease Research Program of UNDP/World Bank/UNICEF/WHO.

The World Bank included CDI as a key strategy for the additional funding provided to its seven Nigerian states.  To enable these states to deliver malaria services through CDI, the Bank encouraged the National Malaria Control Program (NMCP), one of the managers of the Booster Funds, to contract Jhpiego to provide CDI training for teams from the seven Booster states.

Two 5-day CDI took place between 22 November and 3 December 2010.  Participants included staff from each States’ Malaria Control Programs and Ministries of Health along with representatives of NGOs and consultants contracted by the states to help them implement CDI.  The Workshop was delivered in 11 main sessions as follows:

1. Overview and Objectives for Workshop on Implementing Community Directed Interventions
2. The Value of Community Involvement
3. Community Structure Networks & Organization
4. The CDI Process; Roles of Partners & Focal Persons
5. Applying CDI to Home Management of Malaria; Sample CDD Lesson on CCM/HMM
6. Applying CDI to LLINs and Vector Management
7. Applying CDI to Controlling Malaria in Pregnancy
8. Record Keeping and Reporting (M&E)
9. Supply Chain Management for CDI
10. Applying CDI to Deliver Malaria Plus Packages
11. Follow-up Activity Planning

Trainers included Bill Brieger, Jhpiego Senior Malaria Specialist; Dipo Otolorin, Jhpiego Nigeria Country Director; Bright Orji, Jhpiego Program Officer for Akwa Ibom State; Gbenga Ishola, Jhpiego M&E Officer, Nigeria; Oyedunni Arologun, Department of Health Promotion and Education, University of Ibadan; and Godwin Ntadom, National Malaria Control Program.

A total of 42 participants attended from Akwa Ibom, Anambra, Bauchi, Gombe, Jigawa, Kano, and Rivers states and 8 from the NMCP. They took part in role plays, crafting educational songs, producing sample CDD lessons and developing follow-up action plans. The NMCP will now follow-up with these states to ensure that CDI training is rolled out to the local governments, the primary health care facilities (PHCs) and ultimately the small villages, settlements, clans and hamlets in the catchment areas of PHCs. In this way prompt and appropriate malaria treatment can reach people within 24 hours and all recipients of recently distributed insecticide treated nets will hang and use them to prevent the disease.

Linking health and microfinance is the goal of an opinion piece by Leatherman and Dunford in the current Bulletin of the World Health Organization. While they recognize the real and potential stumbling blocks of equitably and honestly serving the 155 million household worldwide that are serviced by more than 3500 microfinance institutions, they also see evidence that microfinance can have a positive health impact.

Where it occurs, the link between health and microfinance occurs through an organized health education component during member meetings and through individual loan counseling. Areas that have seen positive health outcomes include child nutrition, diarrheal disease control, HIV prevention and malaria, among others.

The malaria example cited by Leatherman and Dunford is a Freedom from Hunger Foundation (FFHF) project in Ghana. The project researched the effect of malaria health education on microfinance clients by comparing them with a group of clients receiving education on diarrheal diseases and a group of non-clients. By the end of the project a greater proportion of the malaria group …

• had appropriate malaria knowledge
• identified groups most vulnerable to malaria
• reported that insecticide-treated nets (ITNs) provide the best protection against malaria
• agreed that pregnant women should use ITNs
• had improved knowledge of malaria complications during pregnancy
• owned at least one bed net
• reported at least one child or woman of reproductive age sleeping under a bed net
• increased in ITN ownership and use

Those who did not have nets complained of both cost and access.  Learning sessions alone could account for knowledge changes listed above, but not necessarily the behavior change. Although FFHF does not claim so directly, the authors set the stage for one to hope that improved living standards afforded by microfinance enabled some to use their knowledge and obtain nets. Otherwise, there would be less reason to justify coupling health education and microfinance.

An indigenous microfinance group in Orissa, India also has tackled malaria. BISWA (Bharat Integrated Social Welfare Agency), a nongovernmental organization tried three interventions with their microfinance self-help groups (SHG): 1) health education on ITN use, 2) health education with free nets, and 3) health education on ITNs that encouraged use of microfinance money to but nets. Nearly 60% of SHG members offered the opportunity to buy ITNs through micro-credit did purchase at least one net, and the majority of those were bought on credit.

Knowledge and access to credit may not be the only factors at work in changed health behaviors. The FFHF group concludes that, “When MFIs provide culturally sensitive education and support to poor women, they not only improve health but also empower women by enhancing their self-confidence and promoting their status in households and communities.”

This hints at what Bamidele has defined as personal agency belief. Personal agency is the multiplication of locus of control and perceived self-efficacy, and he used it as a measure of entrepreneurial spirit of participants in microfinance enterprises in Nigeria. Members of credit societies had greater personal agency beliefs than non-members. This may be why Deji found that, “Membership of cooperative societies is very significant to favorable adoption behavior of women farmers towards agricultural innovations, hence should be encouraged as a strategy for improving the agricultural productivity and livelihoods of the women farmers.”

The FFHF project acknowledged that during the span of intervention their project did not affect malaria treatment behaviors. Finance of course makes a big difference in treatment seeking by poor people as pointed out by Chuma and colleagues. The poor in Kenya used borrowing from friends and relatives and getting medicines or care on credit as major coping strategies. Purchase of medicines on credit from drug shops was also identified as a common practice by Rutebemberwa et al. in Uganda.

Microcredit services may make access to malaria medicines more reliable with a combination of knowledge, financial resources and enhanced personal agency belief – this is an idea that deserves further research.

Jhpiego, through USAID Kenya’s AIDS, Population and Health, Integrated Assistance (APHIA II) Program in Eastern Province, supported observance of World Malaria Day 2010. The Provincial Malaria Control Coordinator has written to share their experiences and express they appreciation as seen below. (Photo: drying nets in Isiolo District

From: Alfred Maina
Sent: 27 April 2010 16:01
To: Kennedy Manyonyi, Deputy Project Director, APHIA II Eastern
Subject: World Malaria Day Eastern Province

Hi Dr Manyonyi,

Hope this finds you well. I wish to confirm to you that we had a successful world malaria day launch at Kibugua, Meru south district yesterday. We had a good attendance that I would estimate to about 700.We feel the involvement of the Kathatwa community unit attached to the dispensary did a lot in mobilization of the community. The Mugirirwa community unit as well as the Magnet theatre group were also involved in the event which resonated well with the local community and this is the way to go if we are to collaborate with the community in improving their health.

The Provincial health team was led by the Provincial Director of Public Health who was accompanied by the Provincial Public Health Officer, the Provincial Health Education Officer,Provincial Clinical officer and the Provincial Records and Information Officer. The Meru South DHMT was fully represented and other government departments such as Water, Children’s Office, Education, County Council and Registration. The Meru South D.C. was the guest of honour.

The main highlights of the day included:-

1. A road show/procession that started at Chuka district hospital,throughout the town streets onto the Chuka Runyenjes road, through the market centres in Magumoni and finally into the venue.
2. Involvement of Kathatwa and Mugirirwa community units through:
• Demonstration of IRS using sprayers owned by the Kathatwa unit
• Demonstration of proper use of ITNs
• Demonstration of net re-treatment by the CHWs
• Presentatin of a skit by Mugirirwa CU on malaria control interventions
• Presentation of a play by the magnet theatre group.
3. About 600 nets were distributed to the vulnerable members of the community including pregnant mothers,children under 5 and a few elderly individuals.
4. Speeches by the following people:- DPHO, APHIA 2 representative from Meru south, PSI representative, Provincial Malaria Coordinator and PDPHS.

The main speech was given by the D.C who implored the community to partner with all stakeholders in malaria control interventions in the district.

All in all the activity was a huge success and on behalf of the PHMT, I wish to register our appreciation for the financial support and the great collaboration we had in this event. We look forward to even greater partnership towards improving the health of the communities in this province.

Regards,
Dr Karagu Maina, Provincial Malaria Control Coordinator, Eastern Province

The Reproductive Health Forum discussion group on Yahoo reports plans that the “Federal Ministry of Health in its effort to revitalize the health system in the country is holding a one day Consultative Health Forum in Lere Local Government Area (LGA) of Kaduna State,” on Thursday 17th December 2009.

The town hall style meeting “will focus on maternal and child health along with related issues of water, sanitation and Malaria and will primarily be discussed with women and men of reproductive age, representatives of key health oriented Civil Society Organizations, Community Based Organizations, and Faith Based Organizations.” This is billed as the first of six such meetings that will cover all the geopolitical zones in Nigeria.

This process is in keeping with the pledge by Professor Babatunde Osotimehin Honorable Minister of Health as seen on the Ministry’s website that, “We want feedback to ensure this dialogue is dynamic, vibrant and continuous.”

The Permanent Secretary of the Ministry of Health, Mr. Linus Awute, in a recent press release acknowledged some of the problems that forum participants may also raise:

He said that it is glaring that health service delivery is not often available for the rural populace adding that 75% of Nigeria’s population is rural and cases of maternal mortality rate is very high in the rural areas. He attributed this ugly situation to the non-availability of skilled workers in the rural areas stressing that the Ministry is working round the clock to address the bad situation. He added that the Ministry is revitalizing primary healthcare as an avenue to delivering healthcare to its citizens.

As noted, the fora will address basic issues of water and sanitation.  This comes on the heels of a recent cholera outbreak in the country, about which Nigeria Health Watch observes …

Cholera is not a disease anyone should be getting in October 2009 … definitely not in Nigeria. To understand the absurdity of this; the last major outbreak of cholera in the United States occurred in 1910-1911! If we want to pursue grand dreams such as becoming one of the 20 largest economies by the year 2020 … maybe we should start with some of the apparently small steps such as preventing cholera!

Dialogue on health is definitely needed in Nigeria. Consumer out-of-pocket expenditures account for 65% of health spending in Nigeria – so citizens are definitely interested and involved in health care. The question is whether health system can be responsive to community needs. We look forward to hearing the results of the Lere LGA and the 5 other health fora.

The Americas have the lowest rates of malaria among the major endemic areas of the world. So when concerns are raised that Guyana may not be able to keep its total cases in 2009 below 10,000, countries like Nigeria, Tanzania and DRC may wonder what the fuss is all about. We must remember therefore, that for malaria eradication to succeed, the disease must be eliminated in EACH endmic country, no matter how few the number of current cases appears to be.

Success in Guyana has been mixed, with great reduction in some target communities, but now “There are areas in the country which did not have a problem now, but are not recording measurable and or moderate levels of malaria.” In the Omai area, “hundreds of small miners have appeared on the scene.” They are not paying attention to environmental control, but instead are responding to the increasing price of gold on the world market.

Guyana has received Global Fund grants from Round 3 and 7 for malaria control. Though the country has around three-quarters of a million people, the proposals focused on the more endemic regions. For example, Regions 7 and 8 are populated mostly by a little over 20,000 Native American peoples. These regions have also been inundated by another 20,000 informal miners and loggers.

The GFATM performance report on case management in the Round 3 grant shows that while appropriate malaria drugs are available in all target communities, actual appropriate treatment of vivax and falciparum malaria hovers around only 60% of cases. (Round 7 was signed only in May 2009 so a detailed progress report is not yet available.)

Community participation indicators also show high marks, but then one needs to consider that the non-indigenous miners and loggers may not really be part of a community.

The 2006 Multiple Indicator Cluster Survey found that sleeping under bednets by children under five years of age increased from 6.5% to 70% between 2000 and 2006. Of course this leaves open the question of whether adult migrant miners are using nets and are harboring the disease. Palmer and colleagues describe one typical mining camp in this region –

The mining camp … was approximately 400 km inland from Georgetown, the capital of Guyana, in the heart of the Amazon region of the country. It was typical of many of the mining camps in the jungle. Men sleep in rows of 20 to 40 hammocks strung underneath a large tarp-like covering. The tarp coverings are not enclosed, but the men usually sleep under mosquito netting, as malaria infection is a constant problem.

If Guyana is to meet its 2012 target of only 8,000 annual cases of malaria some serious thinking is needed about strategies to reach the diverse populations in the endemic regions.  The indigenous peoples have their community structures, and it appears that these have been reached.

The challenge then is to distinguish the other residents of these endemic regions and organize malaria control activities that will be appropriate to their social context, recognizing at the same time that their mining practices may be detrimental to the environment and the elimination of malaria.

Pneumonia, diarrhoeal diseases and malaria are the biggest killers of children in the tropics. Malaria is the recipient of major funding efforts from the World Bank, the Global Fund, US President’s Malaria Initiative, DfID, Unicef plus many other bilateral, corporate and NGO donors.  Efforts to place a spotlight on diarrhoeal diseases and prevent mortality using oral rehydration in the 1980s and ’90s never really took off.  Pneumonia likewise has been a neglected disease.

The fate of pneumonia may change this year. One reports that during this year’s “World Health Day, a group of organizations and activists launched an effort to encourage the United Nations to declare November 2nd as World Pneumonia Day. Pneumonia which is the leading killer of children around the world taking upwards of 2 million lives of children under 5 every year is rarely discussed in the media as a childhood killer and is often thought of only as a disease of the elderly.”

GAVI observes that, “Pneumonia has been overshadowed as a priority on the global health agenda, and rarely receives coverage in news media. World Pneumonia Day will help bring this health crisis to the public’s attention and will encourage policy makers and grass roots organizers alike to combat the disease.”

Likewise Save the Children says, “We’re thrilled that so many people and organizations want to join forces for World Pneumonia Day to reduce the impact of the largest killer of children. Through our efforts, we expect to change the lives of millions of young children and parents by making childhood pneumonia deaths a part of history.”

Attention to Pneumonia does not detract from efforts to control malaria.  In fact the attached maps from the Malaria Atlas Project (MAP) and pneumoADIP show that the two diseases share common ground in the tropics. What is needed is an integrated at the community and household level that empowers local people to prevent and control childhood diseases through such actions as prompt and appropriate home management, hand washing, bednet use and vaccination.

Coordination at the local level is the key to success. District health systems must be strengthened for us to realize the full potential that communities have to deliver the goods for child survival.

On Wednesday the Globe and Mail reported on efforts of a malaria vaccine trial in the Kenyan coastal district of Kilifi.  The researchers are happy that the “vaccine reduced the risk of clinical episodes of malaria by 53 per cent over an eight-month period.”  According to GSK, “large-scale phase lll vaccine efficacy trials in seven African countries across 11 sites. If these trials confirm the safety and efficacy of the candidate vaccine, it could be filed for registration.”

The villagers in Kilifi may have other concerns. Zoe Alsop in the Globe and Mail outlines several of these:

• the Caduseus medical symbol on project vehicles contains a snake, but this is a ‘demonic symbol’ to the villagers
• as a research project, blood samples are taken, but villagers fear this is ‘a lot’ and may be used for evil purposes
• villagers are generally skeptical because of “a long history of neglect and corruption in Kenya’s public health-care sector and government in general”
• people do not fully understand the nature of research trials and believe the vaccine is already approved

The researchers are facing the practical problems of any drug trial in communities that do not have good experiences with or full understandings of the workings of western science.  ‘Meticulous explanations‘ may not be enough to overcome fears, and trust can be shattered when a person in a control group gets sick from the drug that was supposed to prevent or heal. The process of signing formal consent documents itself may cause suspicion.

Vaccine programs over the years have faced their own hurdles, even when the offered on a regular basis.  One only has to witness the enormous challenges that the polio vaccine effort confronted in the face of widespread community resistance in Nigeria.  Ordinary occurrences such as side effects like fever or redness/pain at the immunization site discourage people.

Then there are the unethical research practices like Pfizer’s testing of a meningitis antibiotic in Kano, Nigeria that result in death and widespread fears of any future effort to help people.

The malaria vaccine researchers have conducted the perfunctory meetings with village chiefs and village information sessions.  It is not clear if the team involved social scientists in advance to learn more about people’s views and experiences of malaria and vaccines and engage the community in full dialogue about these issues.  It is not too late, but a word to the wise for any health research or intervention program: learn from the people first before you can expect them to learn something new from you.  These villagers have lived in the community for generations and will be left behind when your program finished – show them some respect, and your own efforts will be rewarded.

In the past couple months I have presented information on the community directed intervention (CDI) approach at several meetings. The common question arises, “Can volunteers handle all those different interventions?”  This made me realize that the CDI approach, though well accepted in the onchocerciasis control community, may not be understood by others.

CDI was developed through field research in 1995 as a way of ensuring that the ‘people beyond the end of the road’ would be able to get annual ivermectin treatments to control onchocerciasis by reducing microfilariae loads and reducing the fertility of the adult female Onchocerca volvulus worms.  CDI was adopted as the official mechanism for ivermectin (Mectizan) distribution by the African Program for Onchocerciasis Control (APOC) when it was launched in 1996.

CDI means that the community takes responsibility for ivermectin distribution in terms of conducting a village census and maintaining a village register, deciding on distribution days, times and modalities, collecting the ivermectin from the nearest health facility, managing simple side effects and referring adverse events and finally submitting simple records of treatment. In the process the community may select one or more volunteer community directed distributors (CDDs) to handle the different tasks, but at the same time community members like chiefs, opinion leaders, and others such as traders and teachers, may equally help with tasks like mobilization to take the medicine, collecting the ivermectin from the health center and returning the tally sheets after distribution.

In short CDI is not specifically a ‘volunteer’ program. It is a program where the community takes responsibility and divides up the tasks. The community can decide to change its approach, select new CDDs, ask other community members to help, try new distribution mechanisms – e.g. change from a house-to-house format to a central place distribution event.  In short, the process is not and should not be dependent on an individual volunteer.

Recently APOC and the UNICEF/UNDP/World Bank/WHO Tropical Disease Research Program (TDR) have documented that other health and development programs have taken advantage of the existence of CDI to promote activities ranging from immunization coverage to agriculture extension. Subsequently APOC/TDR have intentionally tested the addition of specific tasks to the CDI process and found that not only does the community approach guarantee better coverage of these additional services (home management of malaria, bed net use and vitamin A consumption), but those communities that add these services to their ivermectin CDI activities actually achieve better ivermectin coverage than communities without the additional interventions.

The project did find that not every task is appropriate for CDI. For example, efforts to carry out Directly Observed Therapy Short-course for Tuberculosis were not possible in five of the seven research sites because of health worker resistance and community perceptions of stigma.  Alternatively recent study has found that CDI can be used to provide intermittent preventive treatment for malaria in pregnancy because the CDDs and the community can be effectively linked to the nearest health center for ogistical and technical support.  Additionally a new report from APOC documents how the CDI approach can strengthen health systems.

APOC’s strategy of community-directed treatment has brought continent-wide success for onchocerciasis control in Africa while other health initiatives have floundered. This report explores how community-directed treatment is helping to supplement and reinforce health systems, while empowering communities to control disease.

Finally CDI works best when it is introduced at the most basic unit of community.  A town may be too large. In southeastern Nigeria, for example, towns are composed of several villages and each village contains several kin groups or clans (extended families of 100-200 people). These kin groups are the best level to implement CDI because even when volunteers are selected, they are accountable to close friends and relatives whom they would be helping anyway.

So to borrow from a former US President – don’t ask what community volunteers can do for you, ask what you and your whole community can do for each other.