Category Archives: Health Systems

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.

Update on Malaria and HIV/AIDS

63719_10152358606695936_7047535049294543967_nWorld AIDS Day is a time to reflect on the broader impact of HIV and its interactions with other infectious and chronic conditions that must be managed through an integrated health system. The past few months have yielded a variety of published studies on the HIV-Malaria link ranging from pharmacological, and physiological to health systems issues. A brief summary follows.

Having HIV does have consequences on malaria infection. Serghides et al. studied malaria-specific immune responses are altered in HIV/malaria co-infected individuals. Fortunately these researchers learned about “the importance of HIV treatment and immune re-constitution in the context of co-infection.”

Malaria, HIV and Pregnancy

Pregnant women are an important group in the population to protect from both HIV and malaria. The link between the diseases may not be one of influencing each other but in the fact that they both appear in the same population with similar negative consequences. Women are at increased risk of anemia in pregnancy due to malaria and/or HIV infection according to Ononge and co-workers. Normally a pregnant woman in a malaria endemic area passes on malaria antibodies to their newborns.

Moro et al. learned that, “Placental transfer of antimalarial antibodies is reduced in pregnant women with malaria and HIV infection.” Chihana and colleagues studied HIV status in Malawian pregnant women and follow-up their children. They reported that, “Maternal HIV status had little effect on neonatal mortality but was associated with much higher mortality in the post-neonatal period and among older children.”

Drug Interactions and Issues

Hoglund and colleagues studied interactions between common antimalarial and HIV medications. They found that, “There are substantial drug interactions between artemether-lumefantrine and efavirenz, nevirapine and ritonavir/lopinavir. Given the readily saturable absorption of lumefantrine, the dose adjustments predicted to be necessary will need to be evaluated prospectively in malaria-HIV coinfected patients.”

DSCN4994 AngolaDrugs taken during pregnancy to prevent malaria are influenced by HIV status. It is known that Intermittent Preventive Treatment with sulfadoxine-pyrimethamine should not be administered to HIV-positive pregnant women taking cotrimoxazole prophylaxis. González et al. wanted to learn whether mefloquine (MQ) could be used by HIV+ pregnant women. Unfortunately they learned that, “MQ was not well tolerated, limiting its potential for IPTp … (and) … MQ was associated with an increased risk of mother to child transmission of HIV.”

Health Systems Issues

Haji and co-investigators reported that malaria care seeking was delayed in Ethiopia because “Children whose guardians believed that covert testing for HIV was routine clinical practice presented later for investigation of suspected malaria.”

The need to adjust clinical guidance and practice as prevalence of malaria changes was addressed by Mahende et al. in Tanzania. They observed that, “Although the burden of malaria in many parts of Tanzania has declined, the proportion of children with fever has not changed.” More accurate diagnosis is needed as demonstrated by the various causes of febrile illness they found including in addition to malaria, respiratory illnesses, blood infections, urine infections, gastrointestinal illness and even HIV.

Finally Mbeye and colleagues report that cotrimoxazole prophylactic treatment reduces incidence of malaria and mortality in children in sub-Saharan Africa and appears to be beneficial for HIV-infected and HIV-exposed as well as HIV-uninfected children. This lesson from HIV programming can have broader implications for malaria control strategies.

Integrated control of infectious diseases is essential for population health, especially at the primary care level. Hopefully research as shown above can assist in planning better services for people living in areas that are endemic to both malaria and HIV.

Health Systems Strengthening: Achieving Lasting Results for IPTp

call to action IPTAt the Call to Action for Intermittent Preventive Treatment of Malaria in Pregnancy (IPTp) during the just concluded American Society of Tropical Medicine and Hygiene Annual Meeting, Elaine Roman of Jhpiego/MCSP advocated for strengthened health systems as a basic approach to enhancing IPTp coverage. Below is a summary of her remarks.

Why should we strengthen the Health System? Addressing the health system at all levels leads to improved outcomes and comprehensive coverage. Increasing IPTp uptake requires strengthening antenatal care (ANC) and other components of the health system.

ANC within a strong health system provides an opportunity to improve the health of pregnant women and their newborns. Malaria in pregnancy (MIP) is a maternal and newborn health issue. When health systems are weak, there is greater likelihood of negative consequences on mother and newborn.

Elaine Picture1Improving Health Systems for enhanced IPTp addresses the following health systems components:

  1. Integration: Reproductive Health Programs and National Malaria Control Programs
  2. Policies and Guidelines: Consistency across national documents
  3. Capacity Development: Bother In-Service Training and Pre-Service Education
  4. Quality Assurance: Linked directly with support supervision
  5. Community Engagement: Promotion of early ANC and Promotion of IPTp uptake
  6. Commodities: Ensuring availability at ANC of sulfadoxine-pyrimethamine (SP) and supplies, as well as long-lasting insecticide-treated bed nets
  7. Monitoring and Evaluation: Facility-level data collection and Data for decision- making
  8. Finance: Sustained and comprehensive services

Elaine Picture2Systems strengthening works. Strengthened Health Systems for IPTp in Kenya resulted from community engagement, training, supervision: leading to IPTp1 coverage of 91.6% and IPTp2 (or more doses) coverage at 61.1%.

In Ghana, Capacity development, commodities, community engagement improvements resulted in IPTp2 (or more doses) coverage of 44% to 65%

In Zambia development of clear policy, integrated training, supervision led to IPTp2 (or more doses) coverage increasing from 63% in 2007 to 72% in 2012.

Moving forward we must advocate for strengthening health systems that will lead to increased IPTp uptake and lasting gains. We must focus on ANC, complemented by efforts at community and policy levels. Finally we must address each health system component, based on country context.

Expanding Health Ministry Capacity to Deliver Malaria and Other Health Commodities at the Community Level in Nigerian States

Bright Orji of Jhpiego‘s Nigeria office presents a poster at the American Society of Tropical Medicine and Hygiene 2014 Annual Meeting at noon on 5th November. The poster represents Jhpiego’s technical assistance provided to seven Nigerian States as part the World Bank Malaria Booster Program. The abstract follows:

CDI ModelThe highly participative process of community directed interventions (CDI) was first pioneered in 1996 by the African Program for Onchocerciasis Control for the delivery of ivermectin. CDI was further tested and found effective in delivering other health commodities.

In 2007 Jhpiego began a proof of concept project in Akwa Ibom State, Nigeria and learned that CDI could be a useful vehicle for increasing access to and coverage of malaria in pregnancy interventions. Building on this success, Jhpiego expanded this work to include integrated community case management of malaria, diarrhoea and pneumonia. through community led efforts.

Number trainedThe World Bank Malaria Booster Program, observing Jhpiego’s efforts in Akwa Ibom State, asked the Nigeria National Malaria Control Program to enlist Jhpiego’s help in building the capacity of seven State Ministries of Health (MOH) to organize CDI for what was termed the malaria plus package consisting of community case management and health promotion activities. The scale-up process started with workshops for state CDI implementation teams consisting of staff from malaria control and primary health care in the MOHs.

services providedThen these state teams developed their own intervention packages and organized workshops for local government teams, who in turn trained staff from their front line health facilities. These facility staff mobilized communities in their facility catchment areas (wards) to select volunteers for training on the CDI process and intervention package.

Although technical assistance was provided to each state, challenges arose including commodity supplies and coordination among different program units within the state MOHs. In conclusion, state teams can train local government teams, ultimately cascading CDI to the community in order to scale up maternal and child health interventions.

Jhpiego at ASTMH: Performance Quality Improvement for IPTp in Kenya

Monday afternoon (3 October 2014) at the American Society for Tropical Medicine and Hygiene Annual Meeting in New Orleans, Jhpiego and USAID/PMI are sponsoring a panel on “Integrating and Innovating: Strengthening Care for Mothers and Children with Infectious Diseases.” If you are at the meeting please attend to learn more about our Malaria activities in Kenya.

Endemic areasOne of the panel presentations is “Performance Quality Improvement Lending to Corrected Documented Outcomes for Intermittent Preventive Treatment in Kenya,” by Jhpiego staff Muthoni Kariuki, Augustine Ngindu Isaac Malonza, and Sanyu Kigondu, who are working with USAID’s Maternal & Child Health Integrated Project (MCHIP).

According to Malaria policy in Kenya all pregnant women in malaria endemic areas receive free intermittent preventive treatment with SP have access to free malaria diagnosis and treatment when presenting with fever have access to LLINs (National Malaria Strategy (NMS) 2009–2017).

By 2013 80% of people living in malaria risk areas should be using appropriate malaria preventive interventions. Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine Pyrimethamine (IPTp-SP) intervention is recommended for use in malaria endemic region.

PQI approachMCHIP broadly implemented Capacity Development and service delivery and improvement interventions that also had impact on the delivery of malaria in pregnancy services through collaboration with the Ministry of Health divisions/units at national level: (malaria, reproductive health, community health).

At county level scale up provision of IPTp at facility level took place in 14 malaria endemic counties. This included 8 counties in the lake endemic region including Bondo sub-county (the MCHIP model sub-county) and 6 in the coastal endemic region.

Quality Improvement through Performance Quality Improvement (PQI) process was instituted to enhance service delivery. The MCHIP era in Bondo Strengthened ANC Services using the following:

  • Development of MIP Standards-Based Management and Recognition (SBM-R) standards
  • Orientation of facility in-charges, supervisors and service providers on the standards
  • Monitoring of IPTp uptake using DHIS2 data
  • Feedback to facility in-charges and supervisors on DHIS2 findings
  • Collection of ANC data from ANC registers (2011-2013)
  • Feedback to facility in-charges and supervisors on ANC data

Quality improvement in the malaria in pregnancy component was undertaken with the objective to improve quality of MIP services including IPTp data management at facility level using PQI approach. An Example of a MIP SBM-R standard is seen below.

Sample StandardIn-service training focused on orientation of facility in-charges on PQI who then continued orientation at Facility Level. Overall we oriented 1200 facility in-charges and 100 supervisors on the standards. Facility in-charges cascaded orientation to 2,441 service providers.

ANC DataWe then analysed ANC data from DHIS (2011-2013) indicated proportion of pregnant women receiving IPTp2 was higher than IPTp1 (IPTp2+ doses reported as IPTp2 dose). We helped improve reporting by  service providers not oriented on use of the ANC register in order to reduce data errors.

In conclusion, PQI is a best practice in provision of MIP services. Standardization of knowledge among service providers is essential in provision of quality MIP services. Development of facility in-charges as mentors in the facility to ensure continued orientation of new service providers.

Use of appropriate monitoring tools is necessary to assist in assessment of quality of services provided including data management. Feedback to service providers is one of the performance rewards and encourages participation in knowledge acquisition



Improved Malaria Services in Malawi: Jhpiego and USAID at ASTMH

ASTMH 2014Monday afternoon (3 October 2014) at the American Society for Tropical Medicine and Hygiene Annual Meeting in New Orleans, Jhpiego and USAID/PMI are sponsoring a panel on “Integrating and Innovating: Strengthening Care for Mothers and Children with Infectious Diseases.” If you are at the meeting please attend to learn more about our Malaria activities in Malawi.

One of the panel presentations is “Improving Malaria Outcomes in Malawi: Focusing on Integration of Services at all Levels” presented by John Munthali, Senior Technical Advisor, Jhpiego/Malawi. John works with Support for Service Delivering Integration-Services (SSDI-S), a USAID bilateral program (2011-2016) with Partnerships in 15 Districts involving the Ministry of Health, Jhpiego, Save the Children International, Care Malawi and Plan International.

Malawi IPTpSSDI-Services focuses on Malawi’s Essential Health Package (EHP) Focal Areas with particular emphasis on Maternal Health, Newborn and Child Health, Family Planning and Reproductive Health, HIV/AIDS and TB, Nutrition and Malaria. Aspects of the Malaria Component include Intermittent Preventive Treatment and Insecticide Treated Bed Nets

SSDI-S is based on Promotion of the continuum of care from household to hospital. Health Facility Approaches address Improved Technical Capacity of Health Workers, Functional Health Facility, and Data-informed Decision Making. Community Approaches involve Improved Technical Capacity of CHWs, Functional Village Clinics, and Community Mobilization. Integration is a major concern such that there are no missed opportunities of EHP services at all levels.

Positive Trends since have been seen since Inception. Malaria in Pregnancy interventions supported the National Malaria Control program to review the Malaria in Pregnancy guidelines and training manuals to adopt the new WHO policy recommendations. 74 Trainers were trained in all 15 districts. MNCH services were established in selected districts. 344 HSAs were trained. 70 community-based Core Groups oriented on MNCH. SSDI supported ongoing MNCH activities through review meetings and distribution of reporting forms.

Malawi IPT2 improvementsAs a result of these integrated high impact interventions there has been a remarkable increase in the uptake of IPTp 2 (16% in June 2012 to 64% in Sept. 2013) by pregnant women in the SSDI-services focus districts. Central to this increase is the integration of services at the facility level where malaria has been highly integrated into maternal, newborn and child health. The project has also seen IPTp 1 uptake maintained at above 91% in all the 15 districts

Malaria Care capacity building has resulted in improved iCCM services delivered by Health Surveillance Assistants (HSAs) at village clinics. iCCM is serving as the foundation for community-based treatment of malaria by HSAs while at facility level IMCI provides an integrated approach to manage childhood illnesses including malaria.

In conclusion, it is feasible to integrate MNCH programs at all levels using SBCC and Systems Strengthening. Having an integrated project looking at the whole spectrum of health services (system strengthening, service delivery and behavior change) can help improve programming & service delivery.

Jhpiego Malaria Team at the American Society of Tropical Medicine & Hygiene Conference

ASTMH 2014Jhpiego’s Malaria Team is co-hosting a symposium on Malaria in Pregnancy and presenting several posters at the upcoming ASTMH 2014 annual meeting in New Orleans, 2-6 November. Below is an outline of these events for those who may be in attendance. Jhpiego also will have a booth in the Exhibition area – please visit it.

Symposium: Integrating and Innovating: Strengthening Care for Mothers and Children with Infectious Diseases, 1:45 – 3:30 p.m., Marriott – Mardi Gras Ballroom D (Third Floor): Co-Faciliators: Elaine Roman, Jhpiego | Erin Eckert, USAID/ PMI

  • Improving Malaria Outcomes in Malawi: Focusing on Integration of Services at all Levels, John Munthali, Jhpiego, Malawi
  • Performance Quality Improvement Lending to Corrected Documented Outcomes for Intermittent Preventive Treatment in Kenya, Muthoni Kariuki, Jhpiego, Kenya
  • The provision of HIV and IPTp Services in Antenatal Care in Malawi: Views of Health Care Providers from a Qualitative Study, P. Stanley Yoder
  • Mothers and Mycobacteria: Implications of the Intersection of TB, Pregnancy, and Maternal and Newborn Health, Charlotte Colvin
  • Wrap-up: The Growing Role of Infectious Disease in Maternal Mortality Reduction: How to Attain the Post-MDG targets, Allisyn Moran



Poster Sessions:

Poster Session A: Monday 12:00 – 1:45 p.m., Marriott Grand Ballroom (Third Floor)

  • Quality Inspired Project – A Key to Achieving Results with Malaria Interventions, Grace Qorro, Jhpiego Tanzania
  • Prevention of Malaria in Pregnancy: Community Health Volunteers (CHVs) Promote Community-based Activities to Increase Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy (IPTp) in Kenya, Augustine Ngindu, Jhpiego Kenya

Poster Session B: Tuesday 12:00 – 1:45 p.m., Marriott Grand Ballroom (Third Floor)

  • Improving Maternal and Neonatal Health: Complementary Role of the Private Sector Increasing Uptake of Intermittent Preventive Treatment for Malaria in Pregnancy in Kenya, Augustine Ngindu, Jhpiego, Kenya

Poster Session C: Wednesday 12:00 – 1:45 p.m., Marriott Grand Ballroom (Third Floor)

  • Expanding Health Ministry Capacity to Deliver Malaria and Other Health Commodities at the Community Level in Nigeria, Bright Orji, Jhpiego, Nigeria