Category Archives: Health Systems

Guinea: The Challenge of Malaria Control in a Post-Ebola Context

The preliminary 2018 Demographic and Health Survey (DHS) data have been released for Guinea (Conakry). Since the last DHS in 2012, Guinea and its neighbors experienced the largest Ebola outbreak in history, an event that damaged already weak health systems.

The previous DHS showed very weak malaria indicators. Only 47% of households had at least one ITN, which averages to 0.8 ITNs per person (compared to the universal coverage of 2.0). Among vulnerable groups only 26% of children below the age of 5 years slept under an ITN, as did 28% of pregnant women. Very few, 18%, pregnant women got two doses of IPTp, and only 5% of febrile children received ACTs (testing was not reported then).

Not much has changed concerning ITN coverage as reported in 2018. Slight improvements are seen in IPTp (which now requires 3 or more doses) and malaria testing and treatment for children. Ironically none of the indicators has passed the original 2006 Roll Back Malaria target of 60%, let alone 80% for 2010 and not of course the drive for universal coverage.

DHS has released a preliminary report for 2018 and the malaria component is summarized in the charts posted here. The national coverage for ITNs is 44%, slightly lower than 2012, but the average per household member is slightly higher at 1.1. Again, these numbers do not mark significant progress. Looking at wealth and ITN ownership there is a slight benefit in terms of equity in net possession among those with lower income, but this must be seen in the overall context of very low basic coverage.

Having a net in the household and using it are different challenges as seen in the reports of sleeping under the net on the night prior to the survey among children under 5 years of age and pregnant women. The sad finding is that even in households that own a net, the coverage of these two groups remains very low. This is reflected in the low net per person ratio nationally (1.1).

One would almost wonder if malaria is a neglected disease in Guinea. The reality is that since 2003, Guinea has received around $172 million US dollars in malaria project funding from the Global Fund. Its most recent annual funding from the US President’s Malaria Initiative (PMI) is around $14 million.  Of that PMI funding 24% was designated for nets and related activities, while 52% was to be spent on medicines, diagnostics and pharmaceutical management. These investments include systems strengthening and capacity building in addition to commodities.

PMI provides the needed context: “Since the country was declared Ebola-free in in June of 2016, Guinea continues to make positive advances towards building a strong health system in line with the health recovery plan. The government continues to mobilize internal and external resources for rolling out the health system recovery plan, but much remains to be done if this plan is to yield the intended results.” Areas in particular need of strengthening within the National Malaria Control Program include coordination, health information systems, leadership, supervision and logistics.

Three years have passed since the last Ebola case in Guinea. Hopefully the country can stave off another outbreak and at the same time strengthen its health system. Guinea may not yet be targeted for malaria elimination, but until systems are strengthened, the resources going into malaria control will not be able to push malaria indicators toward saving more lives.

Malaria funding may never be enough, but better program management should be possible

The World Malaria Report shows that malaria cases are up, and even though there are fewer reported cases in 2017 than 2010, the number is greater than 2016. So once again high burden countries are being targeted. Today this focus is on “High Burden to High Impact”, but in 2012-13 it was the “Malaria Situation Room” that also focused on 10 high burden countries.

Progress was being made up to around 2015-16, it then started to reverse. The challenge was not just funding. As the WHO Director General noted in the foreword to the 2018 World Malaria Report (WMR), “Importantly, ‘High burden to high impact’ calls for increased funding, with an emphasis on domestic funding for malaria, and better targeting of resources. The latter is especially pertinent because many people who could have benefited from malaria interventions missed out because of health system inefficiencies.”

Over the years there have never been enough pledged funds to fully achieve targets, but as funding has never reached desired levels, attention is now being drawn more and more to the source of that funding (more emphasis on domestic/endemic countries) and especially how the health system functions to use the funds that are made available. In 1998 during one of the early meetings establishing the Roll Back Malaria Partnership, a speaker stressed that malaria control could not succeed without concomitant health systems strengthening and reform. That 20-year-old thought was prescient for today’s dilemma.

First, what is the funding situation? As outlined in the World Malaria Report …

  • In 2017, an estimated US$ 3.1 billion was invested in malaria control and elimination efforts globally by governments of malaria endemic countries and international partners – an amount slighter higher than the figure reported for 2016.
  • Governments of endemic countries contributed 28% of total funding (US$ 900 million) in 2017, a figure unchanged from 2016.
  • Funding for malaria has remained relatively stable since 2010
  • To reach the Global Technical Strategy 2030 targets, it is estimated that annual malaria funding will need to increase to at least US$ 6.6 billion per year by 2020

The question remains – does investment lead to results. The WMR shows, for example, that “Between 2015 and 2017, a total of 624 million insecticide-treated mosquito nets (ITNs/LLINs), were reported by manufacturers as having been delivered globally. This represents a substantial increase over the previous period 2012–2014, when 465 million ITNs were delivered globally”.

At the same time the report states that, “Households with at least one ITN for every two people doubled to 40% between 2010 and 2017. However, this figure represents only a modest increase over the past 3 years, and remains far from the target of universal coverage.” Is it simply a matter of funding to reach the other 60% of households, or are there serious management problems on the ground?

Then there is the issue of using nets. The WMR traces new ownership and use from 2010 to 2017, and we can see that overall the proportion of the population at risk who slept under a net increased from around 30% to 50%, but only 56% of those with access to a net were sleeping under them. This can be attributed in part but not completely to the adequacy of nets in a household.

We should ask are enough nets getting to the right places, and also are efforts in place to promote their use. Behavior change efforts should be a major component of malaria program management. Even the so called biological challenges to malaria control have a human element. Monkey malaria transmission to people results from deforestation. Malaria parasite resistance to medicines comes from poor drug management on individual and systems levels.

The target year 2030 will be here before we know it. Will malaria still be here, or will countries and donors get serious about malaria financing AND program management?

Assessing Organizational Capacity to Deliver Malaria Services in Rural Liberia

Swaliho F. Kamara, Wede Tate, Allyson R. Nelson, Lauretta N. Se, Lolade Oseni, Gladys Tetteh of MCSP/Jhpiego are presenting a poster at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene on Malaria Service delivery in rural Liberia. Their findings are shared below:

In Liberia Malaria prevalence in children under 5 is 45% nationally and higher in rural counties (NMCP et al. 2017). The National Malaria Control Program (NMCP) leads the rollout of malaria prevention and control activities to county health teams (CHTs), per the National Malaria Strategic Plan (2016–2020). A key donor supporting malaria prevention and control, the President’s Malaria Initiative (PMI), has been committed to the Ministry of Health and Social Welfare (MOHSW) strategy since 2008, when it began working in three out of 15 malaria-affected counties. PMI supports CHTs in their management of local health systems and service delivery oversight. As part of an expansion program to five additional rural, neglected, high-burden counties in 2017, the United States Agency for International Development (USAID)/ PMI-funded Maternal and Child Survival Program (MCSP) assessed CHTs’ organizational capacity to identify ways to improve the quality of malaria health services.

We assessed CHTs’ capacity using a modified organizational capacity assessment (OCA) tool that was used by the USAID’s Rebuilding Basic Health Services (RBHS) project to assess the capacity of the MOHSW, CHTs, and district health teams (DHTs), capturing four of the six World Health Organization (WHO) building blocks of the Health Systems Framework. We also assessed all 30 districts in five counties. Performed desk review, review of self- evaluations, and face- to-face validation interviews. The assessment focused on processes, not physical systems, so the capacity and knowledge of the respondents may have influenced results in some of counties.

Scoring Structure of the OCA Tool: Following each assessment, MCSP used a detailed summary sheet (Figure 3) to display the aggregate scores for each subarea under all key domains, then generated an overall score for each domain. The total score was then expressed as a percentage for each key domain. The majority of the assessment involved asking specific questions about performing malaria interventions per the project scope.

Effective Interventions were determined:

  • Health Workforce Interventions …
    • Trained health care workers.
    • Trained supervisors on revised supervision tool.
    • Performed quarterly supervision and mentoring.
  • Leadership and Governance
    • Identified a malaria focal point.
    • Activated functional health-sector coordination committees.
    • Held quarterly review meetings.
  • Health Information System
    • Provided health management information systems (HMIS) forms to health facilities.
    • Facilitated in-service training on onsite data verification.

Results showed that CHTs’ overall average score was 87% in service delivery, 65% in health information systems, 78% in health workforce, and 70% in leadership/management. Interventions addressing gaps identified in health workforce, leadership and governance, and health information systems resulted in improved service delivery (see Figure 4).

In conclusion, The OCA tool helps to identify common challenges, assist with systemwide improvements across CHTs or DHTs, evaluate progress, and meet specific needs. Future efforts are needed to improve the tool’s specificity, the weighting attached to different sections and issues, and its relevance to different types of organizations. Training is an important component to capacity-building, but it is just one part of the picture. Need to improve the way organizations and CHTs/DHTs coordinate with partners to improve all health interventions. Need to focus on application and results of capacity-building, not on capacity as an end in itself.

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.

Achieving UHC through PHC Requires an Implementation Plan

The new Astana Declaration says that, “We are convinced that strengthening primary health care (PHC) is the most inclusive, effective and efficient approach to enhance people’s physical and mental health, as well as social well-being, and that PHC is a cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals.” The Declaration outlined a vision, a mission, and a commitment. An opportunity to discuss how to implement this existed at the two-day conference in Astana Kazakhstan celebrating the 40th anniversary of the seminal Alma Ata Declaration.

Ironically the opportunity was not fully grasped. There were many sessions that shared country experiences ranging from finance to information technology.  Youth who will carry PHC forward for the next 40 years gave their opinions and thoughts. Lip-service as well as actual case examples of community involvement were featured. What we did not hear much of was the specifics of how countries, moving forward, will actually implement the commitments spelled out in the document.

One colleague who has worked with the sponsoring agencies was of the view that since much advanced input and work from many partners and countries had gone into the new Declaration, which was already nicely printed, they were reluctant to provide the slightest chance that debate would be reopened.

As they say, fair enough (maybe), but even if one takes the Declaration as a done deal, the matter if implementation needs to be addressed. There was ample criticism that the Alma Ata Declaration was not properly implemented.  This was in part because academics and development agencies jumped the gun and pushed, with focused financial backing, what would be called selective primary health care that was more agency driven, not community directed as envisioned at Alma Ata (now Almaty) in 1978.

In order not to repeat those mistakes and give full voice to the community and key constituents, at minimum the implementation strategies of the pre-agreed Declaration should have been discussed in specific terms. Sure many ideas and examples were aired, but there was no attempt to focus these into workable strategies.

But was the community even there in Astana to take part in strategizing? One community health worker from Liberia received much attention because she was the odd one out. Sure, there were plenty of NGOs, but not the real grassroots of civil society, although the youth involvement aspect of the conference approached that. Some of these NGOs and agencies had themselves been part of the selective PHC agenda.

There was plenty of talk about us involving them, especially when it came to community health workers (CHWs). CHWs should first be integrated into community systems to ensure they are accountable to communities. Then there should be an equal partnership between community systems and health systems. Otherwise CHWs get lost as just front line laborers.

Of course it is never too late. Regional gatherings may be a better forum that can discuss implementation in a more socially,  economically and culturally appropriate way. Let’s hope we don’t look back in another 40 years and with the Astana Declaration had been better and more faithfully implemented.

Progress on Malaria in Pregnancy in 12 PMI Focus Countries

The challenges of implementing programs to control malaria in pregnancy based on experiences with US President’s Malaria Initiative Countries was presented at the Malaria World Congress in Melbourne this week. The team included Katherine Wolf, MCSP/Jhpiego, Marianne Henry, PMI/USAID, Lia Florey, PMI/USAID, Gabrielle Conecker, MCSP/Jhpiego, Betsy Hendrickson, MCSP/Jhpiego, Katherine Lilly, MCSP/Jhpiego, Nicholas
Furtado, GFATM, Maria Petro, GFATM, Susan Youll, PMI/USAID, and Julie Gutman, PMI/CDC, and their findings are shared below.

What is the danger of malaria in pregnancy (MiP)? Each year MIP is responsible for 20% of stillbirths in Sub-Saharan Africa, 100,000 Newborn deaths globally, 11% of newborn deaths in Africa and 10,000 maternal deaths globally. Four interventions are aimed at MIP, Intermittent Preventive Treatment in Pregnancy (IPTp), consistent use of insecticide treated nets, effective diagnosis and treatment and low-dose folic acid during antenatal care. IPTp with sulfadoxine-pyrimethamine reduces low birth weight by 29%, severe maternal anemia by 38% and neonatal mortality by 31%. What can be done?

  • Scale-up and full coverage of the WHO lifesaving interventions
  • Promote early and regular ANC
  • Preserve SP efficacy by avoiding its use for treating clinical cases of malaria
  • Reserve SP stocks for IPTp at ANC clinics

Methodology for MiP country review: Initial survey took place in 23 PMI countries. PMI resident advisors were surveyed, Qualitative and quantitative responses were collected and Input from NMCP/partners was obtained. Country selection resulted in 12 that were Tiptop-implementing countries, represented Geographic diversity, had varied IPTp coverage, and made clear progress or best practices to share.

Desk review including HMIS and house hold survey data, current studies and recent assessments, Selected interviews with PMI resident advisors, Jhpiego field staff and current/former NMCP staff. Analysis was a Review and clarification of qualitative and qualitative data.

The 12 countries included Angola, Benin, Burkina Faso, DRC, Ghana, Kenya, Liberia, Madagascar, Malawi, Nigeria, Senegal, and Zimbabwe (see map). The figure shows that none of these attained 80% of 2 doses of IPTp. The current recommendations are for monthly dosages from the 13th week of pregnancy. Often less that half of those receiving IPTp2 also got IPTp3.

Several health systems findings helped explain the IPT results. For Policy & Implementation, Countries reporting strong, coordinated leadership delivered
high IPTp coverage. With Community Engagement, countries reported a diversity of approaches to community health promotion and service delivery.

Concerning Service Delivery, Many countries struggle to implement MiP policies consistently and with quality in the private sector. Commodities were a challenge. Some countries continue to struggle with SP stockouts at facility level, whether ongoing or episodic. Monitoring and Evaluation processes need to catch up. Countries’ routine information systems are transitioning from tracking IPTp2 to IPTp3.
The team offered several Recommendations.

  1. Strengthen consistency of IPTp policies across malaria and reproductive health programs
  2. Scale up of evidence-based country appropriate
    community engagement strategies
  3. Alleviation of supply chain bottlenecks at peripheral level
  4. Inclusion and harmonization of key MIP indicators in routine information systems

For more information please visit www.mcsprogram.org, facebook.com/MCSPglobal and twitter.com/MCSPglobal

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 AgreementAID-OAA-A-14-00028. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government.

Universal Health Coverage – Where is Malaria?

Universal Health Coverage (UHC) is the theme of the 2018 World Health Day on April 7th. The concept was applied to malaria in 2009 regarding the provision of long lasting insecticide-treated nets (LLINs aka ITNs) with the definition of universal meaning one net for every two persons in a household. Up until that time coverage targets for malaria interventions set at the 2000 Abuja Declaration had focused on achieving by the year 2010, 80% of people (particularly pregnant women and children below the age of 5 years) sleeping under ITNs, 80% of children receiving appropriate malaria treatment with artemisinin-based combination therapy (ACTs) within 24 hours of onset of illness and 80% of pregnant women receiving two doses of Intermittent Preventive Treatment (IPTp) for malaria as part of antenatal care (ANC).

Definitions have evolved since the Abuja Declaration. The target for ITNs was extended to all household members (thus universal). The ACT target was modified to require treatment based on parasitological testing (microscopy or rapid diagnostic tests). IPTp targets were extended to achieving monthly dosing from the 13th week of pregnancy, which depending on the point in pregnancy when a women entered the ANC system could be 3, 4 or more doses. In addition to these changes, the US President’s malaria Initiative upped the Abuja targets from 80% to 85% in the countries where it supported national malaria programs.

We are eight years past 2010. It had been assumed that if scale up to 80% had been achieved by then and sustained for five or more years, malaria deaths would come close to zero and elimination of the disease would be in sight. National surveys have shown that reaching these targets has not been simple.

The example of ITNs is a good place to start, as is Nigeria with the highest burden of malaria. The attached chart shows findings from the Demographic and Health or Malaria Information Surveys in 2010, 2013 and 2015. Whether one measures universal coverage by the house possessing at least one net per two residents or by the proportion who actually use/sleep under the nets, we can see that UHC for this intervention is difficult to achieve. Even when households possess nets, not everyone sleeps under them either because of adequacy of nets, preferred sleeping arrangements, internal household power structure or other factors.

In 2015 the majority of nets that existed in households were obtained through campaigns (77%), 14% were acquired from the health services, and 7% were purchased. These systems are not keeping up with the need.

Four endemic countries reported a malaria Information Survey in 2016, Liberia, Ghana, Madagascar, and Sierra Leone. The chart shows that they too have had difficulty in achieving universal coverage of malaria interventions. Of note the chart only includes whether appropriate malaria parasitological diagnosis was done on children who had fever in the preceding two weeks. Data on provision of ACTs is based on fever, not test results, so there is no way to know whether it was appropriate. Generally 20-30% more febrile children received ACTs than were tested.

All three malaria interventions, ACTs, Diagnostics and ITNs, require contact with the health system (including community health workers). If malaria services are indicative of other health interventions, then universal coverage including seeking interventions, getting them and ultimately using them is still a distant goal. To achieve universal coverage there also needs to be universal commitment by countries, donors and technical partners.

New Fully Online Global Health Learning Programs at JHU

Continuing professional development has often been a challenge for people in the field. They may not be able to get study leave, but they do need advanced training in order to progress. The Johns Hopkins Bloomberg School of Public Health as started a new Online Programs for Applied Learning (OPAL) that offers completely online Masters and Certificate degrees.

The Department of International Health is Offering three Master of Applied Learning (MAS) and one Certificate covering global health. The Certificate can be completed in one year minimum and the MAS in two years minimum. More information on these programs can be obtained at the links below.

Enhancing Core Competencies & Improving Midwifery Quality of Care in Lake Zone, Tanzania

With support from USAID’s Maternal and Child Survival Project in Tanzania Annamagreth Mukwenda, John George George, Mary Rose Giatas, Agrey Mbilinyi, Gustav Moyo, and Justine Ngenda have been addressing the quality of case and services provided by midwives. Their poster at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene is summarized below.

In sub-Saharan Africa, maternal mortality is unacceptably high accounting for 56% of all maternal deaths. Tanzania is not different. It is estimated that five in every 100 children die before their first birthdays and that four women out of 1000 live births die due to pregnancy related causes.

With prompt recognition and timely intervention most maternal and neonatal deaths can be avoided. Access to skilled care at these critical times save lives.

A new initiative is working to improve midwifery care by building capacity of training institutions to prepare highly skilled nurse-midwives to enhance on job live saving skills.
In 2014 A collaboration between the Tanzania Ministry of Health, Jhpiego through Maternal child survival program (MCSP), conducted a baseline assessment to assess the quality of midwifery pre-service education to adequately prepare students with the clinical skills to provide competent nursing and midwifery care.

Four nursing and midwifery schools from two regions of Lake Zone were assessed to identify issues affecting the schools’ ability to produce clinically competent graduates in nursing and midwifery. Among things, the assessment focused on tutors and recent graduates, with findings showing critical deficit on content/skill competencies.

To address these challenges, midwifery tutors from 9 schools (100%) were updated in high impact midwifery interventions through trainings and supportive supervision including coaching and mentorship. Skills labs were also equipped with all mannequins necessary for midwifery training.

The program is in the third year of implementation with tremendous improvement in midwifery training as evidenced by students final examination results as well as tutors’ and students’ testimonies.

Experience of MCSP approach to strengthen competencies of graduates has contributed to improve midwifery quality of care to reduce maternal deaths in Tanzania.

Malaria Programs Implementation in Ebonyi State, Nigeria: Where Are We?

Jhpiego has developed a tool to help malaria programs understand implementation successes and challenges. Bright Orji, Daniel Umezurike, Lawrence Nwankwo, Boniface Onwe, Gladys Olisaekee, Enobong Ndekhedehe, and Emmanuel Otolorin outline the application of this tool for the malaria program in Ebonyi State, Nigeria at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene in the Poster Session of 6th November 2017. Their abstract follows:

Despite important strides in recent years, Nigeria has yet to achieve global targets of universal coverage for malaria case management nor 80% coverage for malaria in pregnancy. While available malaria interventions are effective, critical health system challenges undermine implementation. Jhpiego has developed a health systems framework and planning tool to assist malaria control programs identify and respond to these challenges.

The tool was recently used with the Ebonyi State Malaria Control Program (MCP) with Jhpiego’s guidance. An initial situational analysis used the 2015 Malaria Information Survey to highlight that 89% of state households had long lasting insecticide treated bed-nets but only 50% of children under five used them.

Likewise, intermittent preventive treatment during pregnancy (IPTp) was only 44% for two IPTp doses and 41% for three. Use of parasitological diagnosis for malaria was low and unacceptable. A subsequent meeting among MCP and Jhpiego staff was held to review nine health systems areas to determine reasons for the low performance on malaria indicators. The group reviewed strategies and annual workplans and then ranked each health system area on a scale from 1 (low) to 4 (high) to reflect level of progress, and then the average score computed.

The highest scoring components were human resource capacity (3) and integration and coordination (3), based on findings such as integrated supportive supervision and the holding of monthly coordination and review meetings among partners at the state and local level. Community Involvement (1.9) and finance (1.8) scored lowest, based on lack of community outreach and engagement, in control efforts, and late/ sporadic release of funds for program implementation, respectively.

In response, the group drew up action plans to address identified weaknesses and used monthly partners meetings for advocacy and learning. In conclusion Nigerian health workers can use health systems analysis and planning tools to identify best practices, address challenges, and create an action plan to help advance their state (and country) along the pathway to malaria elimination.

World Health Worker Week – Improving Capacity to Defeat Malaria

The Frontline Health Worker Alliance reminds us that, “Frontline health workers are the backbone of effective health systems – and are those directly providing services where they are most needed, especially in remote and rural areas.” These are the people who make delivery of essential malaria prevention and case management services possible. They further note that April 3-9, 2016 is World Health Worker Week and “is an opportunity to mobilize communities, partners, and policy makers in support of health workers in your community and around the world.”

Nigeria CDD performs RDT in Upenekang Community Ibeno LGA Akwa Ibom StateUnfortunately the very areas of the world that have the most malaria also have the greatest shortage of health workers as seen in Africa, South and Southeast Asia. In this situation skills and dedication of every single available frontline health worker are crucial for defeating malaria. This can only be achieved if they are up-to-date in the latest malaria programs.

For example, most malaria endemic countries in Africa have updated their malaria in pregnancy guidance to reflect the need to provide intermittent preventive treatment (IPTp) at every antenatal care visit after the 13th week of pregnancy with doses at a month interval. This means a pregnant woman may now receive 3 or more doses. What is still needed in many countries is full dissemination of this guidance to all frontline health staff so that they can implement this service correctly and fully.

DSCN3778As we move toward malaria elimination, more people will live in areas with unstable or epidemic transmission. The chances of developing severe malaria will increase. Updated skills on managing severe malaria that results in convulsions, chronic anemia and death are needed for these frontline staff.

Enhanced skills in surveillance are now needed as we move toward malaria elimination. Good diagnostic, record keeping and reporting skills are needed by frontline staff to help identify malaria transmission hotspots. Skills are also needed on treatment regimens that include transmission blocking medicines.

Vector control will remain an essential part of defeating malaria, but health workers will need to learn about new technologies as these become available. They will need skills for better targeting of complimentary interventions like larviciding. Continual efforts to manage routing distribution of long lasting insecticide-treated nets must ensure that health workers have the skills and resources to follow-up and promote actual use of the nets for their intended purpose.

Vaccines and other new technologies will become available for controlling malaria. Health worker capacity building will be needed to ensure each of these new additions to the malaria arsenal are implemented in the most effective manner.

From the foregoing we can see that there are many reasons why the malaria community should observe World Health Worker Week now and continue to build health worker capacity to defeat malaria throughout the year.