Category Archives: Health Systems

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

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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

AHI: Achieving People Centered Health Systems in Five African Countries

The African Health Initiative (AHI) will be presenting a second panel During the upcoming Third Global Symposium on Health Systems Research in Cape Town (30 September-3 October), entitled “Achieving People Centered Health Systems in Five African Countries: Lessons from the African Health Initiative.”

AHI was established in 2008 by the Doris Duke Charitable Foundation and seeks to catalyze significant advances in strengthening health systems by supporting partnerships that will design, implement and evaluate large-scale models of care that link implementation research and workforce training directly to the delivery of integrated primary healthcare in sub-Saharan Africa.

globalsymposium_logosThe five AHI country projects (Ghana, Mozambique, Rwanda, Tanzania and Zambia) will be sharing their experiences during the panel presentation. We will be tweeting at each panel presentation, and you can follow at: #HSG2014 and “Health  Systems Global” and “Bill Brieger Malaria“.

Highlights of the second panel follow:

Community health workers in Tanzania

Community health workers in Tanzania

It is a common claim that randomized controlled trials (RCT) are the ‘gold standard’ for scientific inference, with rigor derived from the imposition of stable interventions and statistically robust controls, and power derived from operational units as study observations. In health systems research, however, the ‘gold standard’ is more appropriately based on the relevance of research to decision-making. As a consequence, impact research is appropriately combined with implementation research, and units of observation are based on the way that systems function and decisions are made.

Mixed method complexity trials are indicated, with units of observation that integrate research with management processes. Presentations by scientists who are engaged in complexity trials in Ghana, Mozambique, Rwanda, Tanzania, and Zambia will highlight statistical designs that violate conventional standards of RCT, but derive rigor from mixed method research, hierarchical observation and modeling, and plausibility trials.

“Proof of utility” is derived from the operational adaptation of project implementation to local realities, monitoring process and outputs, testing impact, and revising strategies over time as needed. A learning process approach produces evidence-generating localities where operations serve as realistic models for large scale change in national systems.

DSCN6602aVarious terms used in the scientific literature to characterize this theme, such as ‘open systems theory’, the strategic approach, or participatory planning, each embracing the perspective that people centered service systems are essential to health systems strengthening. Practical examples of how to achieve people centered programming, however, are rare.

This panel presents five case studies that have confronted the challenge of developing, testing, and sustaining people-centered health systems in resource constrained settings of sub-Saharan Africa. These are outlined below.

– The Ghana Essential Health Interventions Programme tests the child survival impact system strengthening interventions. When monitoring identified perinatal health problems, priority was shifted to improving newborn and emergency referral services. Combined with political advocacy, changes increased access, improved quality, and expanded the range of services.

DSCN6373– The Mozambique project improves service quality by giving facility, district and provincial managers skills for identifying and fixing systems problems. Initial skills-building through training in leadership and management had only transitory effects. An evidence-driven redesign improved facility and district level operations and improved accountability.

– In Rwanda health-center-focused quality improvement data identified strategies for compensating health centers for reaching specific operational goals. Initial results show that the scheme has enhanced performance and fostered cross-center learning.

– The Tanzania Connect Project tests the survival impact of deploying community health workers. Connect monitoring showed that unmet need for family planning was inadequately addressed. Connect was redesigned to include comprehensive doorstep family planning services.

Zambia’s Better Health Care Outcomes through Mentorship and Assessment project was developed from people centered lessons emerging from scaling up an HIV program. A 42 cluster stepped wedge tests the impact of improving outpatient care with training, structured forms, electronic data capture, and community engagement. In response to implementation challenges, volunteer density was increased and mortality and clinical data capture operations were reformed.

While the studies employ contrasting designs, the projects share an adaptive approach to implementation. A concluding session summarizes lessons learned and implications for health systems strengthening in Africa.

Attending Antenatal Care Does Not Guarantee Antimalaria Services

A new article by Clementine Rossier and colleagues compares access to maternal health services in Ouagadougou, Burkina Faso and Nairobi Kenya.  In both settings a very large proportion of pregnant women registered for antenatal care (ANC).  Twice the proportion of Nairobi women (47%) attended up to four times compared to those in Ouadougou (22%).  In both settings, the likelihood of attending four ANC visits increased with educational level of the women.

ANC Does Not Mean IPTp AccessAlthough the article does not discuss services received at ANC, we can consider the implications for malaria in pregnancy (MIP) control since ANC is a major platform for MIP service delivery. Here the demographic and health survey (DHS) and its malaria indicator survey (MIS) component are of help.  Both countries had a national survey in 2010 (their most recent).

Interestingly in 2010 Burkina Faso overall had better ANC registration (05%) than Kenya (86%). In neither country was intermittent preventive treatment in pregnancy (IPTp) coverage good. 25.7% of pregnant women in Kenya received one dose of sulfadoxine-pyrimethamine for IPTp, while 20.8% did so in Burkina Faso. IPTp2 coverage in Kenya was similar at 25.4%, but in Burkina Faso it dropped to 10.6%

DSCN7718The important lesson here is that even with good ANC registration, women have no guarantee of receiving life saving malaria prevention services.  If registration was lower we might suspect issues of local beliefs and other community barriers, but the situation in both countries points to health systems failures like inadequate drug supplies and health worker lapses.

The service delivery situation in both countries has changed dramatically since 2010. Kenya has refined its malaria map and is focusing IPTp on areas of stable and high transmission. Burkina Faso has received greater influx of financial support from the Global Fund and the US Agency for International Development. Hopefully the 2014 DHS/MIS studies currently in progress in both countries will paint a better picture. Of course, unless health systems issues are being addressed, funding alone will not solve the malaria service gaps.

Malaria at AIDS2014

Malaria and HIV/AIDS interact on several fronts from the biological, clinical, pharmacological to the service delivery levels.  The ongoing 20th International AIDS Conference in Melbourne, Australia (July 20-25, 2014) provides an opportunity to discuss some of these issues. Abstracts that are available as of 20th July are mentioned below and deal largely with integrated health service delivery issues. Details can be found at http://www.aids2014.org/. Also keep up to date on twitter at https://twitter.com/AIDS_conference, and on Facebook at https://www.facebook.com/InternationalAIDSConference.

8577_760104147337737_5024191_n1. Increasing HIV testing and counseling (HTC) uptake through integration of services at community and facility level (TUPE358 – Poster Exhibition). E. Aloyo Nyamugisa, B. Otucu, J.P. Otuba, L. Were, J. Komagum, F. Ocom, C. Musumali (USAID/NU-HITES Project, Plan International – Uganda, Gulu, Uganda).

HTC integration at community outreaches and facility service points increases service uptake by individuals, families and couples that come to access the different services that are offered concurrently such as immunization, family planning, cervical cancer screening, circumcision, Tuberculosis, malaria, nutrition screening services and other medical care.

2. Asymptomatic Malaria and HIV/AIDS co-morbidity in sickle cell disease (SCD) among children at Mulago Hospital, Kampala, Uganda (TUPE074 – Poster Exhibition). B.K. Kasule, G. Tumwine, (Hope for the Disabled Uganda, Kampala, Uganda, Watoto Child Care Ministries, Medical Department, Kampala, Uganda, Makerere University, College of Veterinary Medicine, Animal Resources & Bio-security, Kampala, Uganda).

The prevalence of HIV/AIDS and asymptomatic malaria in children attending SCD clinic were quite high with the former exceeding the national prevalence supporting the view than Ugandan children with SCD die before five years. Children were significantly stunted and underdeveloped which could have made them prone to increased clinic visits. National health programmes should focus on the health needs of children with SCD by integrating HIV/AIDS care, nutritional therapy, and malaria control programmes.

3. Technical support (TS) needs of countries for preparation of funding requests under the Global Fund’s new funding model (NFM) (THPE427 – Poster Exhibition). A. Nitzsche-Bell, B. Hersh (UNAIDS, Geneva, Switzerland).

The results of this survey suggest that there is very high demand GF funding in 2014 and a concomitant high demand for TS to assist in the preparation of funding requests. TS priority needs span across different technical, programmatic and management areas. Increased availability of funding for TS and enhanced partner coordination through the Country Dialogue process are needed to ensure that countries have access to timely, demand-driven, and high-quality TS to maximize mobilization of GF resources under the NFM.

4. Optimizing the efficiency of integrated service delivery systems within the existing scaled-up community health strategy in Kenya: pathfinder/USAID/APHIAplus Nairobi-Coast program experience (THPE351 – Poster Exhibition). V. Achieng Ouma, D.M. Mwakangalu, P. Eerens, J. Mwitari, E. Mokaya, J. Aungo Bwo’nderi, S. Naketo Konah (Pathfinder International, Nairobi, Kenya, Pathfinder International, Service Delivery, Mombasa, Kenya, Ministry of Health, Division of Community Health Strategy, Nairobi, Kenya, Pathfinder International, Research and Metrics/Strategic Information Hub, Nairobi, Kenya, University of Portsmouth, Geography, Portsmouth, United Kingdom).

APHIAplus (a USAID sponsored health program in Kenya) supports the implementation of integrated government strategies that center around HIV, AIDS, and tuberculosis prevention, treatment, and care; integrated reproductive health and family planning services; and integrated malaria prevention and maternal and newborn health services. Lessons learned include the finding that integrated outreach holds potential to meet clients’ needs in an efficient, effective manner. For example, during a single contact with a service provider, a mother obtains immunization services and growth monitoring for her infant, counseling and testing for HIV, counseling on family planning, cervical cancer screening, and treatment of minor ailments. Results indicate better integration of HIV prevention, care, and treatment within complementary efforts that address key drivers of mortality and morbidity. Success in integration was fostered by a stronger focus on outcomes throughout the APHIAplus implementation cycle.

5. Long term outcomes of HIV-infected Malawian infants started on antiretroviral therapy while hospitalized (THPE070 – Poster Exhibition). A. Bhalakia, M. Bvumbwe, G.A. Preidis, P.N. Kazembe, N. Esteban-Cruciani, M.C. Hosseinipour, E.D. Mccollum (Albert Einstein College of Medicine and Children’s Hospital at Montefiore, Pediatrics, Bronx, United States, Baylor College of Medicine Abbott-Fund Children’s Clinical Centre of Excellence, Lilongwe, Malawi, Baylor College of Medicine, Pediatrics, Houston, United States, University of North Carolina Project, Lilongwe, Malawi, Johns Hopkins School of Medicine, Pediatrics, Division of Pulmonology, Baltimore, United States).

AIDS2014 bannerOne-year retention rates of HIV-infected infants diagnosed and started on ART in the hospital setting are comparable to outpatient ART initiations in other Sub-Saharan countries. Further studies are needed to determine if inpatient diagnosis and ART initiation can provide additional benefit to this population, a subset of patients with otherwise extremely high mortality rates.  Of the 16 children who died, median time from ART initiation to death was 2.7 months. Causes of death include pneumonia, diarrhea, fever, anemia, malnutrition, malaria and tuberculosis.

6. Killing three birds with one stone: integrated community based approach for increasing access to AIDS, TB and Malaria services in Oyo and Osun States of Nigeria (MOPE435 – Poster Exhibition). O. Oladapo, E. Olashore, K. Onawola, M. Ijidale. (PLAN Health Advocacy and Development Foundation, Programs, Ibadan, Nigeria, Civil Society for the Eradication of Tuberculosis in Nigeria, Programs, Ibadan, Nigeria, Community and Child Health Initiative (CCHI), Programs, Ibadan, Nigeria, Community Health Focus (CHeF), Programs, Ibadan, Nigeria).

Community Systems Strengthening (CSS) is a tested and successful strategy for providing integrated AIDS, TB and Malaria (ATM) services in resource-limited settings. 20 selected community based organizations (CBOs) working on at least one of AIDS, TB or Malaria were trained by PLAN Foundation on basics of ATM-related project management including monitoring and evaluation; demand generation through active referrals; and community outreaches. Empowering CBOs is an effective and low-cost strategy for increasing demand for ATM services in resource-limited settings. Integrating referral for ATM services increases effectiveness of and public confidence in primary healthcare services at the grassroots.

7. (Upcoming on 21st July) The health impact of a program to integrate household water treatment, hand washing promotion, insecticide-treated bed nets, and pediatric play activities into pediatric HIV care in Mombasa, Kenya (MOAE0104 – Oral Abstract Session). N. Sugar, K. Schilling, S. Sivapalasingam, A. Ahmed, D. Ngui, R. Quick. (Project Sunshine, New York, United States, U.S. Centers for Disease Control and Prevention, Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infections, CDC, Atlanta, United States, New York University, New York, United States, Bomu Hospital, Mombasa, Kenya).

Model World Health Organization at UNC Gillings School of Public Health

UNC GillingsNeha Acharya, who is the Director of the American Mock World Health Organization conference, set to be held within UNC’s Gillings School of Public Health from October 3rd-5th, has shared the following announcement with us:

AMWHO is the nation’s very first simulation of the World Health Assembly, and seeks to educate undergraduate and graduate students on the proceedings of global health affairs. This conference will invite over 200 students from all across the nation, and is America’s very first model WHO event.

DSCN0367The American Mock World Health Organization (AMWHO) is an authentic simulation of the World Health Assembly, the sole decision-making body of the World Health Organization. Participants assume the role of a WHO ambassador, non-governmental organization member, or media representative, and form health related positions based upon their respective roles. Throughout the conference, participants will engage in debates and discussions about a thematic health topic, and work together to create a final working resolution to send to the World Health Organization in Geneva, Switzerland.

Modeled after the Ontario and Montreal World Health Organization conferences set in Canada, the primary focus of all three is to raise student awareness of pertinent health issues facing the world today, as well as to promote understanding of the many roles students can engage in through global health policy. The conference hopes to establish an environment similar to that of the World Health Organization’s Assembly, and educate future global health leaders in the proceedings of international health entities.

This simulation will be the United States’ first model-WHO conference, and is set to take place in Rosenau Hall within the University of North Carolina at Chapel Hill’s campus from October 3rd-5th, continuing in the years to come. Register at www.amwho2014.com? and purchase your $45 ticket! You can also follow plans and progress on twitter.

Launching of Improved Malaria Care Project, Burkina Faso

Guest Posting from Jhpiego.

Tulinabo Mushingi, the US Ambassador to Burkina Faso, was on hand in Louargou, Burkina Faso this week to launch USAID’s $15 million award to reduce by half malaria deaths in the West African country. As he noted, the 5-year project  is another example of the Obama administration’s commitment to prevent children in Africa from dying of preventable causes.

US Ambassador & wife greeting the Louargou communityMushingi, a veteran foreign service officer who served throughout Africa before being named ambassador, underscored the importance of the Improving Malaria Care project to the future of Burkina Faso:  “Investing in the fight against malaria will have an important benefit for child survival. Healthy children are at the heart of the prosperity of each nation and its sustainable development. Healthy children are more likely to live longer, stay in school, become active members of society and contribute to the development of Burkina Faso.”

Malaria is the leading cause of health consultation, hospitalization and death in health facilities across Burkina Faso. Over 4 million cases of malaria were reported in 2011, and approximately 70 percent of children have been hospitalized for the disease by the time they turn five.

IMG_8923The Improving Malaria Care project is a collaboration of the Ministry of Health, Jhpiego and PROMACO (le Programme de Marketing Social et de Communication pour la Santé). The partners will focus on improving the quality of prevention, diagnosis and treatment services in 100 percent of public health facilities with the aim of keeping the most vulnerable — pregnant women and children – alive and healthy.

Behavior Change for Malaria: Are We Focusing on the Right ‘Targets’

Two articles caught my attention this morning. One reviewed the merits of improved social and behavior change communication (BCC) for the evolving malaria landscape. The other addressed the damage institutional corruption is doing in Africa. And yes, there is a connection.

When I was trained as a community or public health educator in the MPH program at UNC Chapel Hill, the term BCC had not yet been coined. We were clearly focused on human behavior and health.  What was especially interesting about the emphasis of that program was the need to cast a wide net on the human beings whose behaviors influence health.

DSCN7742 CHW flipchart

BCC of individuals and communities may not be enough

While the authors in Malaria Journal state that, “The purpose of this commentary is to highlight the benefits and value for money that BCC brings to all aspects of malaria control, and to discuss areas of operations research needed as transmission dynamics change,” a closer look shows that the behaviors of interest are those of individuals and communities who do not consistently use bed nets, delay in seeking effective treatment, and do not take advantage of the the distribution of intermittent preventive therapy (IPTp) during pregnancy. The shortfalls in the behavior of other humans is lies in not “fully explaining” these interventions to community members.

The health education (behavior change, communications, etc. etc.) program at Chapel Hill taught us that a comprehensive intervention included not only means and media for reaching the community, but also processes to train health workers to perform more effectively, to advocate with policy makers to adopt and fund health programs, and intervene in the work environment using organizational change strategies to ensure programs actually reached people whose adoption of our interventions (nets, medicines) could improve their health.

At UNC we tried to focus change on all humans in the process from health staff to policy makers to ensure that we would not be blaming the community for failing to adopt programs that were not made appropriately accessible and available to them. We did not call it a systems approach then, but clearly it was.

This brings me back to the article on corruption. Let’s compare these two quotes from the IRIN article …

  • The region accounts for 11 percent of the world’s population, but carries 24 percent of the global disease burden. It also bears a heavy burden of HIV/AIDS, tuberculosis and malaria but lacks the resources to provide even basic health services.
  • Poor public services in many West African countries, with already dire human development indicators, are under constant pressure from pervasive corruption. Observers say graft is corroding proper governance and causing growing numbers of people to sink into poverty.

Illicit cash transfers out of countries and bribery of civil servants, including health workers, are manifestations of the same problem at different ends of the spectrum resulting in less access to basic services and health commodities.  Continued national Demographic and Health Surveys show that well beyond 2010 when the original Roll Back Malaria Partnership coverage targets of 80% were supposed to have been achieved, we see few malaria endemic countries have achieved the basics, and some have regressed. Everyone is bemoaning the lack of adequate international funding for malaria (and HIV and TB and NTDs), but what has happened with the money already spent?

Without a systems approach to health behavior and efforts by development partners to hold all those involved accountable, we cannot expect that the behavior of individuals and communities will win the war against malaria.