Tropical Health Matters

If it were not difficult enough to guide global health during a pandemic, some world leaders are trying to deflect attention from the real dangers at hand to score on their petty political concerns. In the meantime, we need to focus on what tropical health and disease issues may actually be coming under consideration at the virtual WHA 73.

Agenda item 3 (A73/CONF./1 Rev.1) or “COVID-19 response Draft resolution” directly addresses the concerns of many that other major deadly diseases and essential services should not be further neglected. The large group of resolution proponents urge countries and organizations to,

“Maintain the continued functioning of the health system in all relevant aspects, in accordance with national context and priorities, necessary for an effective public health response to the COVID-19 pandemic and other ongoing epidemics, and the uninterrupted and safe provision of population and individual level services, for, among others, communicable diseases, including by undisrupted vaccination programmes, neglected tropical diseases, noncommunicable diseases, mental health, mother and child health and sexual and reproductive health and promote improved nutrition for women and children, recognizing in this regard the importance of increased domestic financing and development assistance where needed in the context of achieving UHC.”

In Provisional agenda item 23 (A73/32) “Progress reports by the Director-General” we find updates on guinea worm eradication and the burden of snakebite envenoming. The report notes the situation in 2019, which is a far cry from the millions of cases in the 1980d when the dracunculiasis eradication effort was launched. “In 2019, three countries reported a total of 53 human indigenous cases of dracunculiasis (guinea-worm disease), namely, Angola (one case), Chad (48 cases) and South Sudan (four cases), from a total of 28 villages. Cameroon reported one human case, probably imported from Chad.”

It is important to note that, “The global dracunculiasis eradication campaign is based on both community and country-focused interventions,” where community members play an important role in surveillance and notification. This includes at-risk and border areas, as is being done in Cameroon. The challenge of human Dracunculus medinensis infection in dogs continues and points to the importance of One Health in the control and elimination of NTDs. Surveillance is not cheap, and the report stresses that funds are still needed so that international partners can continue to ensure that the last case of guinea worm is detected and contained.

Moving from the smaller serpent to the larger variety, the report recalls the May 2018 World Health Assembly resolution WHA71.5 on addressing the burden of snakebite envenoming. A global strategy, “Snakebite envenoming: a strategy for prevention and control” was launched in  in May 2019. The WHO Secretariat has “fostered international efforts to improve the availability, accessibility and affordability of safe and effective antivenoms for all, through assessments of antivenom manufacturing, training programs and stockpile procedures.

Finally, provisional agenda item 11.8 (A73/8) addresses a “Draft road map for neglected tropical diseases 2021–2030.” This builds on resolution WHA66.12 (2013) on WHO’s earlier road map for accelerating work to overcome the global impact of neglected tropical diseases (2012–2020). The proposed interventions build on important principles including:

1. Tackling neglected tropical diseases through support of the vision of universal health coverage
2. Adopting grassroots approaches that enable access to some of the world’s poorest, hard-to reach communities and people affected by complex emergencies
3. Monitoring progress against neglected tropical diseases as a litmus test of progress towards the achievement of universal health coverage

The report notes that “40 countries, territories and areas have eliminated at least one neglected tropical disease,” most notably dracunculiasis (as mentioned above, lymphatic filariasis and trachoma. Although “substantive progress has been made since 2012, it is evident that not all of the 2020 targets will be met.” Hence, a new draft road map for neglected tropical diseases for 2021–2030 is required. The three pillars supporting the new roadmap are outlined in the attached figure.

It is good to know that the 73^rd World Health Assembly will not be completely overshadowed by COVID-19 and politics. Efforts to sustain and improve NTD control and elimination must not be jeopardized.

Elaine Roman and Kristin Vibbert of the Jhpiego malaria team describe below an important community-based intervention to prevent malaria in pregnancy. Follow their links to learn more.

The World Health Organization (WHO) 2018 World Malaria Report revealed that of 33 countries where intermittent preventive treatment (with sulfadoxine-

pyrimethamine/SP) is recommended for pregnant women, only 22% of eligible pregnant women received three doses of intermittent preventive treatment during pregnancy (IPTp3) with SP in 2017 (). Therefore, it is crucial that innovative interventions to scale up the provision of IPTp are needed to protect lives of mothers, fetuses and newborns.

The Transforming Intermittent Preventive Treatment for Optimal Pregnancy (TIPTOP), a five-year project, is one such innovative effort that aims to contribute to reduced maternal and neonatal mortality in four countries: DRC, Madagascar, Mozambique, and Nigeria by expanding access to quality-assured (QA) SP.

The TIPTOP project is implementing a community-based approach to expand coverage of IPTp3 to a minimum of 50% in project areas, helping to reach the hardest-to-reach pregnant women and to ensure there are no missed opportunities for pregnant women to receive QA SP. Through rigorous research and routine monitoring, TIPTOP will generate evidence for WHO to inform a potential policy decision on global intermittent preventive treatment of malaria in pregnancy.

TIPTOP is also setting the stage for scale up, supporting Ministries of Health to pilot test SP distribution at the community level in settings that will not only yield quality data in real-life program settings but also lend to program learning, including documenting best practices and lessons learned. Further, in coordination with Medicines for Malaria Venture (MMV), TIPTOP is creating demand for and expanding access to QA SP.

Now that procurement, training, supervision, community education, monitoring and evaluation systems are nearly built, full implementation on the ground will be phased in over the next few months.

The history of community intervention in Burkina Faso dates back to immediately after the declaration of Alma Ata in 1978. The first community health experiments were carried out in 1979 with the support various development partners with an aim of reducing maternal and infant morbidity and mortality difficult to access health districts where village birth attendants where been trained, equipped and supervised. Today as a matter of policy, Burkina Faso aims at improving the quality of health services and increasing access to health services through community-based health workers (CBOs), civil society organizations (CSOs), non-governmental organizations (NGOs) and associations implements community intervention strategies. with the full participation of communities.[1]

Burkina Faso’s draft strategic plan for community health states that, “Community Health is a multi-sectoral and multi-disciplinary collaborative enterprise that uses public health science and some social science approaches to engage and work with communities. Its purpose is to optimize the health and quality of life of all people who live, work in a given community. It is based on community needs, understanding and community priorities for health.”¹ Community participation is seen as central to achieving universal health care.

The Ministry of Health¹ notes that there has been community participation as part of cost recovery (Bamako Initiative). Communities are part of the management committees set up at the level of the first-level health facilities so that the populations thus participate in the management of health facilities, through these committees. “In recent years, there has been renewed interest in community health with a strong mobilization of civil society through NGOs and associations. Community components are integrated into many health programs. This new dynamic has led to significant progress and positive results in the areas of the fight against HIV, tuberculosis, reproductive health (family planning, health of young people and adolescents), malaria, malnutrition, vaccination, etc.”

The Ministry reports that, “Indeed, the community actors have contributed to the achievement of the results obtained through the implementation of community-based health services, which however remain to be rethought not only in its vision but also to be in phase with that of the universal health coverage. For a better involvement of these actors in the achievement of the health objectives, the main challenges remain their motivation, the reinforcement of their capacities and the collaboration with the agents of health.”¹ Systematic evaluation of such results remains to be done.

While there have not been systematic assessments of these participatory processes in community health, researchers did take a close look at the levels and types of community participation attained in water and sanitation projects in Burkina Faso. The following lessons have implications for involving Burkina Faso communities on PHC:[2]

• Users and Neighborhood groups have a lower level of participation than city and government stakeholders
• It is possible that the social structures and traditions in Burkina Faso do not encourage a more participative approach
• Further study of power structures in Burkina Faso may determine why participation is lower than expected
• There is a significant decrease in participation levels during the design and selection steps of planning as opposed to the earlier stages of problem identification and definiing objectives, and the later stages of option selection and action planning – a question of planning styles dominated by experts

These issues raise questions about the social and cultural aspects of the planning process and about leadership and governance. It would seem that ‘experts’ also need education about how to work with communities.  There are also concerns about the level of community education employed to help community members and CBOs make informed choices. The authors raise another important question concerning expectations that communities will take ownership in the running of projects when in fact these Users have only been asked about their problems and then been informed about a solution.

In another sector the World Food Program developed a diagnostic and planning approach based using community participation and conducted training and practical exercises on “Community-Based Participatory Planning.” The exercise brought many community actors together to identify food security issues such as land degradation, lack of economic activities for residents in the non-agricultural season and floods that block access to health and other services. participators discussions identified community resources to address these issues and demonstrate resilience.[3]

A recent Global Fund grant to Burkina Faso was entitled, “Strengthening health systems and scaling-up of integrated community case management interventions.”[4] Community-based organizations (CBOs) involved in control of the three diseases commonly addressed through integrated Community Case Management (iCCM) – malaria, diarrhea and pneumonia. The program was also expected to strengthen the community workforce be ensuring adequate numbers of functional CHWs. The project received a high level of regular reporting by CBOs (100%), but less than ideal from individual CHWs (83%). This was in spite of the fact that they achieved recruitment targets for ‘functional’ CHWs. Interestingly the biggest problem for the CHWs was the extremely low availability of essential supplies with which they could work (13%). The grant demonstrated the challenges of involving CHWs in more focused activities as opposed to a broader community agenda. Reorganization of the CHW program in the last few years has created a standardized curriculum so that there are two CHWs per village who respond to a variety of community needs ranging from reproductive health to disease control. The problem of adequate supplies and materials to do their work continues, though.

While Burkina Faso has established the basic participatory structures in the form of committees and community agents, the Ministry of Health is concerned that Community participation is low.¹ Lessons from other sectors show possible reasons and solutions and inter-sectoral collaboration, one of the hallmarks of PHC should be used to address the challenges. the MOH of course has its own ideas (listed below) about the root causes of this problem and having identified the following, it should be encouraged to continue efforts to strengthen the roll of the community in PHC:

• lack of social capital (capacities of communities to work together effectively, to identify problems, to prioritize and take charge of them)

• weak involvement of communities in the whole process of implementation.

• greater focus on community diagnosis of needs, assets, and priorities, to develop appropriate intervention strategies, planning, implementation, evaluation

• lack of capacity (skills, human resources, material and time) of community implementation actors,

• lack of accountability of the stakeholders responsible for the implementation of community-based initiatives (CBIs)

• lack of a multi-sectoral approach in the resolution of health problems

Insufficient strategies to combat social exclusion and to take into account specific groups also constitute a barrier to community participation

Partners worry that there is difficulty sustaining CBIs and demotivation of actors (CHWs, facilitators), which can allow morbidity and mortality to remain high in the community. Clearly, investment in strengthening community participation will go a long way in saving lives and promoting health.

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[1] Ministere De La Sante. Draft Strategie Nationale De Sante Communautaire Au Burkina Faso 2019-2023. September 2018

[2] McConville J, Kain J, Kvarnstrom E, et al. (2014) “Participation in sanitation planning in Burkina Faso: theory and practice”. Journal of Water Sanitation and Hygiene for Development, vol. 4(2), pp. 304-312. http://dx.doi.org/10.2166/washdev.2014.125

[3] Ouedraogo, Celestine (2016). Promoting Community-Led Resilience and Development Solutions in Burkina Faso. World Food Program. https://www.wfp.org/stories/promoting-community-led-resilience-and-development-solutions-in-burkina-faso

[4] Global Fund (2017). Burkina Faso BFA-S-PADS Grand Performance Report. https://www.theglobalfund.org/en/portfolio/country/grant/?k=d8f34742-0d57-410c-b5ba-39615edc5785&grant=BFA-S-PADS

In Rwanda CHWs are male and female resident volunteers elected by members of the village and are accountable of the village they serve. They should have a Primary 6 education minimum. The system guarantees that CHWs are more accessible, acceptable by clients in their communities and less expensive. Each village has a team of three CHWs. Technical supervision is done by the Health Center staff and administrative supervision by the in-charge of social affairs (cell, sector, district). CHWs receive financial compensation through Performance Based Financing (PBF) based on a set of performance indicators from monthly reports. It is this reporting process from village onwards that is explored in this case study. Services include HIV support, integrated community case management of childhood illnesses, family planning and nutrition.

The structure of the health system is based on 4 Provincial hospitals that receive referrals from 35 district hospitals. Within these districts are 465 health centers whose catchment areas contain 2,148 cells and 14,837 villages. With a goal of 3 CHWs per village (1 female & 1 male pair in charge of iCCM and 1 Female in charge of Maternal Health), Rwanda has trained 44,511 CHWs. All CHWs are organized into cooperatives. Each health center oversees one CHW cooperative (which is the basis of performance-based funding as we discuss in Module 6).

The current system has evolved since 1995, when it was completely paper-based. The Community Health Information Systems, that is the M&E system for community interventions, is carried out through different national data collection and reporting tools ultimately managed by web-based interface[1]. Tools include national standard paper-based source document (registers), paper-based monthly summary form, DHIS-2 and the système d’information sanitaire des communautés/CHW information system (SISCOM), and Rapid SMS

Initially, separate systems existed to gather data on the country’s 45,000 community health workers, HIV services, human resources, and other special programs—these data streams were separate and though the systems were web-based, none of the databases could interact. The Rwandan health system was collecting immense amounts of data, and spending considerable time and money doing so, but it was unable to effectively use that information for strategic planning or immediate action. As reported by staff of the maternal and Child Survival Program (MCSP), since the successful launch of the Rwanda-HMIS[2], many new reporting modules have been integrated into the DHIS 2 platform which include weekly and monthly reporting of community-based health insurance indicators and the CHW information system.

The following community services are tracked: Treatment of sick children (iCCM), Community Based Nutrition Program (CBNP), Malaria Treatment Adults (HBM), RDTs carried out, Family Planning, Home based Follow up of pregnant women, mothers and newborns, Nutritional monitoring, Under-5 vaccination, Maternal and Newborn Death Surveillance, Drugs and supplies, IEC activities, and user payments. These are summarized into a CHW monthly report form and ultimately into the web-based SISCOM monthly summary form. The web-based R-HMIS data tools are accessible to health staff with passwords.[3]

The data flow system moves as follows:

  — Electronic – MOH

­­­  ^ Electronic – District Hospital

  ^ Electronic – Health Center

  ^ Paper-based – Cell Coordinator

  ^ Paper-based – CHW

The coordinator of CHW cooperative submits the monthly summary form to Health Center data manager who enters aggregated data into DHIS- 2/SISCOM. The data entry screen of DHIS-2-HMIS/SISCOM can be accessed at the health center.

According to MCSP, Rapid SMS text-messaging tool is used by the CHW assigned to maternal health to track pregnant women and track the first 1000 days of life up to 5 years. Examples of information submitted include 1) Woman’s pregnancy and delivery, 2) Children under five identified with danger sign, 3) Tracking referrals (track alert sent and responses) and 4) Maternal and under five deaths. Rapid SMS data are accessed at District Hospital and used at the primary level health facilities to respond to maternal and child health emergencies. Rapid SMS sends automated, actionable responses to CHWs when reported events indicate risk, or when antenatal care visits or deliveries are due. Health facilities are notified to prepare for an anticipated delivery and/or to provide ambulance transport.

DHIS/SISCOM from the CHW also report on drug and supply management. Primary level health facilities support community health workers within the catchment area to ensure they have timely and adequate supplies.

At the local administration level (village, cell, sector, district) CHWs data are used for planning, setting and monitoring health related performance contracts. At the Central level (RBC/MOH and development partners), these data inform policies, establish strategies, manage the supply chain management, aid in research, and perform PBF

MSCP explains that feedback mechanisms and data quality are promoted through quarterly community sub-technical working group meeting, Quarterly and annual analysis of community data, and biannual integrated supervision including community Data Quality Assurance (DQA). Quarterly analysis of Community Health data informs decisions by the Management Team. The biannual DQA of community data compares paper vs. electronic sources. Monthly meetings at Health Center level review reported data and link data to quality of service provision. Mentorship included community DQA

There are monthly CHWs meetings with cell coordinator to review reported data. This also aids in Community Performance-Based Financing. Incentives are given to CHW cooperatives in exchange of their performance based on two categories of indicators.  First, quarterly payment for reporting is based on the timely submission of quality data reports related to 29 indicators including –

• Report Quality:  Timeliness, Accuracy and Completeness of Report
• Cooperative   Quality: Legal status, Presence of President, Bank account, etc.

Secondly, Pay-for-indicators are additional payment for improvement in five targeted areas (Nutrition, ANC, SBA, FP referrals and FP new users, LTPM). The average quarterly payment is $900 per cooperative for a 100% quality score.

MCSP notes as an example of success that all CHWs are using standard data collection tools (registers, flipcharts and summary forms). All CHWs are equipped with a mobile phone regularly loaded with airtime for Rapid SMS, communication with HC and other CHWs. The DHIS-2/SISCOM functional countrywide. A strong feedback and coordination mechanism is in place and functional. The PBF includes the CHW reporting rate. MCSP reports that the remaining challenges include turnover of trained CHWs, High workload for CHWs, inadequate response rate on alerts sent through Rapid SMS, disaggregation of data (e.g. FP not disaggregated by method), disparities in CHWs activity as per instructions for Rapid SMS, and sub-optimal use of data. Continued mentoring through CHW meetings addresses community level gaps.

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[1] Jean de Dieu Gatete, Jovite Sinzahera, USAID Maternal and Child Survival Program (MCSP), Rwanda. Integrating community data into the health information system in Rwanda. Institutionalizing Community Health Conference, Johannesburg. 27-20 March 2017. www.mcsprogram.org

[2] US Agency for International Development (USAID). THE RWANDAN HEALTH MANAGEMENT INFORMATION SYSTEM: Improving Collection and Management of Health Service Data to Support Informed Decision Making. the Integrated Health Systems Strengthening Project. https://www.msh.org/sites/msh.org/files/ihssp_techbr2_final_webv.pdf

[3] Rwanda Integrated Health Management Information System. https://hmis.moh.gov.rw/

Maya Tholandi, Lolade Oseni, Anne McKenna, Herbert Onuoha, Solofo Razakamiadana, Elsa Nhantumbo, Alain Mikato, Elaine Roman of Jhpiego and the Johns Hopkins Bloomberg School of Public Health shared important Baseline Readiness Assessment Findings from Democratic Republic of the Congo, Mozambique, Madagascar, and Nigeria from the UNITAID-supported TIPTOP on Intermittent Preventive Treatment of malaria in pregnancy at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene as seen below.

Intermittent preventive treatment of malaria in pregnancy (IPTp) is unacceptably low in most of sub-Saharan Africa. A Jhpiego-led consortium is implementing the Transforming Intermittent Preventive Treatment for Optimal Pregnancy (TIPTOP) project, which supports community distribution of quality-assured sulfadoxine-pyrimethamine (SP).

TIPTOP aims to increase IPTp3 coverage from 19% to 50% of eligible pregnant women in project areas in Democratic Republic of the Congo (DRC), Madagascar, Mozambique, and Nigeria. The project, operating from 2017 to 2022, provides quality-assured SP, promotes community awareness, and supports supervision and coordination efforts between health facilities and community health workers (CHWs).

In 2017, a baseline assessment examined facility readiness for malaria in pregnancy management, antenatal care (ANC) provider knowledge, CHW characteristics and health facility linkages, and health management information system (HMIS) quality. TIPTOP assessed 140 facilities and interviewed 175 ANC providers and 67 CHW supervisors.

At project startup, the teams examined SP stock, ANC providers and CHW availability. SP Stock assessment showed a disparate stock maintenance processes and stock-out next steps indicate lack of a coherent and consistent approach to stock monitoring. In half of all cases, caregivers offer a prescription when stock is not available in the facility, with smaller numbers requesting.

Among ANC providers, 80% on average correctly reported that at least three doses of IPTp are recommended. On average, 64% correctly responded that SP should be initiated in the second trimester. Out of the 170 providers interviewed across countries, only five knew all the key signs of suspected malaria.

A low numbers of CHWs in some districts may limit their reach and capacity. Inadequate CHW education and ANC familiarity may diminish training effectiveness. In particular, low numbers of female CHWs may decrease community acceptance and pregnant women’s acceptability of receiving IPTp from CHWs.

Data Quality and Availability from the routine services would affect monitoring of interventions. Over-reporting of ANC contacts and IPTp service provision is a data quality challenge. The HMISs in Nigeria and Mozambique record IPTp3 provision, but only at the local level. Supervising facilities do not always review data before HMIS entry for accuracy.

Concerning Monitoring and Evaluation System Components, Mozambique’s HMIS is the strongest of the four countries in terms of linking to the national system, current tools and reporting forms available in the facilities, and providers reporting an understanding of indicators and data reporting processes. Nigerian facilities had limited knowledge of indicators and their definitions, despite this information being available in Federal Ministry of Health-provided registers. Madagascar struggled with indicator definitions and data management processes. DRC faced the most challenges: Tools and reporting forms were not available in health facilities, and there were limited monitoring and evaluation structures and processes.

In Conclusion, Results from the baseline assessment are Informing efforts to improve data quality and CHW facility data flow in TIPTOP implementation areas. There is need to strengthen ANC provider knowledge through TIPTOP-supported trainings. One also needs to address CHW variation by country and support health facilities to monitor their SP stock. These findings are being shared with ministries of health and key stakeholders to inform malaria implementation and data quality efforts.

Moumouni Bonkoungou, Ousmane Badolo, Stanislas Nébié, Justin Tiendrebeogo, Mathurin Dodo, Thierry Ouedraogo, Youssouf Sawadogo, Danielle Burke, Bethany Arnold, William Brieger, and Gladys Tetteh of the USAID/Jhpiego Improving Malaria care Project and the Burkina Faso National Malaria Control Program presented implementation of the SMC program at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene as seen below.

Malaria remains a serious problem in Burkina Faso, a high burden country. Data from the 2016 Health Management Information System reports 9,852,097 malaria cases, and 4,440 malaria Deaths. Malaria accounts for 43.38% of Outpatient department visits, 44.63% of Hospitalizations and 21.84% Deaths. The burden of Malaria is highest during the months of July– October. During these months, malaria transmission is intense due to heavy rainfall and intensive biting behavior

Seasonal Malaria Chemoprevention (SMC) is the Intermittent administration of full treatment of antimalarial medicines to children under 5 (age 3-59 months) in areas of high seasonal transmission. It is an important malaria elimination strategy in the West African Sahel. Effective prevention intervention takes place where Malaria transmission is concentrated within a high transmission season. The bulk of clinical malaria cases (> 60%) occur during short rainy season over 4 months.

SMC Implementation started when Burkina Faso adopted SMC in 2013 as key part of National Malaria control strategy. SMC uses Sulfadoxine-pyrimethamine plus amodiaquine (SP+AQ). Four monthly doses are given to children 3?59 months old from July to October by community health workers and other volunteers.

The Improving Malaria Care (IMC) project is implemented by Jhpiego and funded by the U.S. President’s Malaria Initiative (PMI). IMC supports National Malaria Control Program (NMCP) to improve quality of malaria prevention, diagnosis and treatment. NMCP expanded SMC implementation to 7 districts in 2014 and then 59 districts in 2017.

Process of SMC Planning and Implementation in Boromo and Dano Districts in 2017 provides an example of how the program works. Treatment Coverage during the 2017 campaign treated 58,246 children in Boromo District and 50,007 children in Dano,  or 97.3% of target population. The attached flow chart shows the Process of SMC Planning and Implementation in Boromo and Dano Districts in 2017. Microplanning is an important component. Reviewing lessons learned was crucial for planning SMC in 2018.  The attached charts show a Reduction of Severe Malaria Cases in Boromo over the implementation period of SMC as well as a Reduction of Severe Malaria Cases in Dano.

These successes were or without challenges to SMC Scale-up in Burkina Faso. It is difficult access to some villages during the rainy season. Limiting SMC administration to children below 5 years of age makes some parents with older children unhappy, and they also demand the service. As of 2017 there was lack of resources to cover all districts.

In conclusion, the NMCP continues to scale up SMC to reach all eligible children with support of implementing partners/projects like IMC. Moving forward, the NMCP aims to increase efficiency of SMC campaigns, achieve effectiveness of intervention, mitigate known challenges, and anticipate new challenges.

Our partners recommend that to improve coverage, safety, efficacy and health impact we should strengthen interpersonal communication with communities, conduct independent monitoring, optimize coordination of partners’ interventions, and synchronize with neighboring countries.

Acknowledgments: US President’s Malaria Initiative, United States Agency for International Development, Burkina Faso Ministry of Health, National Malaria Control Program

During the first poster session at the 2018 Annual Meeting fo the American Society of Tropical Medicine and Hygiene, Noella Umulisa, Aline Uwimana, Cathy Mugeni, Beata Mukarugwiro, Stephen Mutwiwa, and Aimable Mbituyumuremyi of the Maternal and Child Survival Project (USAID)/Jhpiego and the Ministry of Health, Rwanda, presented findings from a review of community health workers in malaria case management. Their findings follow:

Rwanda has achieved near universal coverage of long-lasting insecticide nets, artemisinin-based combination therapy (ACT) and diagnosis, and targeted indoor residual spraying. Even so, there was an unprecedented increase in malaria cases from 2012-2017 despite optimal coverage of preventive and curative key interventions. The increase was caused by higher temperature, more rainfall, and increased resistance to insecticides.

With more cases, the need for community case management (CCM) is crucial. Rwanda therefore trains, equips and supports community health providers to deliver high- impact treatment interventions and aims to supplement facility-based case management. Rwanda introduced integrated CCM 2008. Trained community health workers (CHWs) provide iCCM based on empirical diagnosis and treatment of pneumonia, diarrhea, and malaria. They also conduct malnutrition surveillance, comprehensive reporting and referral services.

Given the changing status of malaria in the country, it was necessary to evaluate the performance of the CHWs. The evaluation aimed 1) to evaluate CHW performance in managing malaria, pneumonia and diarrhea in 8 districts of Rwanda based on national guidelines, and 2) to identify areas to reinforce and empower community health interventions. Using proximity (near/far) to hospitals and health centers, CHWs who had a minimum of 3 months experience using malaria rapid diagnostic tests (RDTs) were selected for interview. Slightly over half of CHWs were Males (56.2%). Most were over 40 years of age and nearly one-third were 50 years and older. Only 2% were between 25-29 years old.

Based on National Guidelines, CHWs were judged to have provided “adequate” treatment more frequently than “correct” treatment. Overall, 90% of cases were adequately treated; only 70% correctly treated. Among the three main conditions, malaria was most often adequately and correctly treated. Incorrect treatment was due to lack of adherence to guidelines. For malaria incorrect treatment often meant using the wrong does for age packet for treatment when the correct packet was not in stock.

In conclusion, CHWs correctly treat 70% of children for all IMCI pathologies according to national guidelines. Malaria was the most seen/treated pathology; cases increased during study period. Overall, cases more often treated adequately than correctly. CHWs use complex tools thus lack adequate time to follow all steps correctly when providing services.

The study team recommends the need to strengthen iCCM commodities supply chain, especially at community level through supervision and mentorship conducted at health centers, district hospitals and central level. Also it is necessary to revise and simplify iCCM tools used by CHWs to decrease burden and improve quality of services.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

Among the poster presentations on malaria from Jhpiego, the President’s Malaria Initiative and partners at the 2018 ASTMH Annual Meeting, WR Brieger, J Tiendrebeogo, O Badolo, M Dodo, D Burke, K Vibbert, SJ Youll, and JR Gutman shared the findings from a 15-month intervention that tested the ability of community health workers to deliver intermittent preventive treatment of malaria in pregnancy in 3 districts in Burkina Faso. Please check out the poster and talk to one of the co-investigators at Poster Session A on Monday 29 October. Their results are found below.

Malaria in pregnancy is responsible for a substantial proportion of low-birthweight and stillborn infants in sub-Saharan Africa. To prevent this, the World Health Organization (WHO) recommends that pregnant women receive intermittent preventive treatment of malaria in pregnancy (IPTp) using sulfadoxine-pyrimethamine. Specifically, WHO recommends an optimal three or more doses (e.g., IPTp3, IPTp4).

In stable malaria endemic countries, IPTp coverage remains unacceptably low, at around 19% for IPTp3. Community IPTp might provide an answer. Community delivery can improve coverage as seen in previous study in Nigeria and Malawi, but its effects on antenatal care (ANC) attendance have been mixed. Additional data are needed to determine whether delivery of IPTp-SP by community health workers (CHWs) is effective and does not detract from ANC attendance. Hence the Burkina Faso intervention was designed and implemented

The study piloted community delivery of IPTp (c-IPTp) in three districts of Burkina Faso with high malaria transmission: Po, Ouargaye, and Batie.  Four health facilities per district were randomly selected to participate (two intervention and two control).

In 2017, following a baseline household survey of women who recently became pregnant, implementation of c-IPTp began in intervention areas by existing CHWs trained and supervised by health staff. At Baseline in each of the three study districts, four health centers (CSPSs) and the villages in their catchment areas were selected—two as intervention and two as control. A random sample of 374 women who had been pregnant within the last 9 months were interviewed in CSPS catchment villages. There were no significant differences in ANC attendance (ANC1=90%, ANC4=62%) or IPTp coverage between intervention and control areas:

• IPTp3 was 81% (intervention) and 86% (control).
• IPTp4 was 22% (intervention) and 16% (control).

The Intervention consisted of building on Burkina Faso’s existing CHWs. They were trained and monitored by clinic staff. The CHWs encouraged women to attend the first ANC visit to obtain IPTp1. Then the CHWs provided monthly doses of IPTp, submitted monthly reports, and continued to promote ANC. ANC attendance and IPTp uptake were monitored through monthly clinic and CHW reports. The catchment area populations were roughly the same, and monitoring showed that the additional provision of IPTp by CHWs resulted in more women being reached while at the same time ANC attendance remained high.

An endline survey was conducted after 18 months of implementation. Changes over time were compared between baseline and endline in intervention versus control villages. Attendance at ANC1 and ANC4 increased in both groups between baseline and endline but was significantly better for the intervention group. Likewise, coverage of IPTp3 and IPTp4 increased between baseline and endline for intervention and control women, but the difference was significant only in the intervention areas.

Monthly monitoring of CHW and ANC registers and the household surveys both documented that community delivery of IPTp resulted in the desired increased uptake of services without detracting from ANC attendance. Community IPTp may be a promising strategy to improve coverage of IPTp.

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

Below is a list of Jhpiego Sessions at this week’s American Society of Tropical Medicine Annual Meeting in New Orleans (28 October-1 November). Please attend if you are at the conference:

Poster Session A, Monday, October 29 (Posters in Marriott Grand Ballroom – 3rd Floor )

• Poster Number 098: Performance of community health workers in providing integrated community case management services (iCCM) in 8 districts of Rwanda
• Poster 380: Contribution of quarterly malaria data review and validation to data quality and malaria services Improvement
• Poster LB-5117: Community based health workers can enhance coverage of intermittent preventive treatment of malaria in pregnancy and promote antenatal attendance

Poster Session B, Tuesday 30 October

• Poster 1088: Assessing organizational capacity to deliver quality malaria services in rural Liberia
• Poster 1092: Contribution of IMC project in transforming the face of malaria control for vulnerable populations in Burkina Faso
• Poster 1093: Malaria response plan in times of high transmission: An approach to improving the quality of hospital malaria management
• Poster 1111: Setting the stage to introduce a ground breaking approach to prevent malaria in pregnancy in Sub-Saharan Africa: baseline-readiness assessment findings from Democratic Republic of Congo, Mozambique, Madagascar, and Nigeria
• Poster 1337: Institutionalizing infection prevention and control practices in health facilities in Liberia following the Ebola epidemic

Scientific Session 87, Tuesday, 1:45 – 3:30 p.m. Marriott – La Galerie 1 & 2 – 2nd Floor: Improving procurement and redeployment of district level malaria commodities using SMS and web mapping in Madagascar

Poster Session C, Wednesday 31 October

• Poster 1816: Experiences and perceptions of care seeking for febrile illness among caregivers and providers in 8 districts of Madagascar
• Poster 1818: Improving adherence to national malaria treatment guidelines by village health workers in selected townships through a low-dose, high-frequency training approach
• Poster 1819: Improving malaria case management through national roll-out of Malaria Service and Data Quality Improvement (MSDQI): A Case study from Tanzania
• Poster 1820: Collaborative quality improvement framework to support data quality improvement, experience from 10 collaborative facilities in Uganda
• Poster 1821: Using malaria death audits to improve malaria case management and prevent future malaria related preventable deaths
• Poster 1833: Multiple approaches for malaria case management in the struggle to reach pre-elimination of malaria.

Scientific Session 182, Thursday, November 1, 10:15 am – 12:00 p.m. Marriott – Balcony I,J,K – 3rd Floor: Seasonal malaria chemoprevention, an effective intervention for reducing malaria morbidity and mortality