Tropical Health Matters

Kenya Division of National Malaria Program (DNMP) with support from PMI Impact Malaria (IM) and in collaboration with other stakeholders reviewed/developed/updated nine key program documents. Agustine Ngindu and the Impact Malaria/PMI team stress the importance of keeping key malaria technical guidance and tools up-to-date.

Guidelines for the Diagnosis, Treatment, and Prevention of Malaria in Kenya was revised to indicate the start of IPTp at 13 weeks from the prior recommendation of 16 weeks of gestation and updated the IPTp schedule in line with WHO guidance. The program also updated dosing charts for artemether lumefantrine, dihydroartemisinin-piperaquine, and injectable artesunate to include both weight and age range particulars. This update will enhance adherence to treatment guidelines among healthcare workers

The Kenya Quality Assurance Guidelines for Parasitological Diagnosis of Malaria was in draft form for nearly 10 years. Revisions were motivated by the lack of a functional quality assurance (QA)/quality control (QC) system for malaria diagnosis. Sections were added to guide implementation of internal quality control and external quality assurance programs. Updates also provided guidance on surveys to determine the extent of gene deletion and its effect on routine RDT-based malaria diagnosis.

Implementation Framework for Malaria Rapid Diagnostic Tests was developed to facilitate rollout of malaria diagnostics QA/QC in line with Kenya Malaria Strategy (KMS) of 2019-2023. As p[art of this effort, the M&E framework was expanded to include the performance matrix. A costed implementation matrix to provide guidance was developed on costing of activities in line with KMS 2019-2023.

Biosafety Guidelines for Malaria Rapid Diagnostic Testing at Community Level was highlighted in new guidelines developed to address emerging QA and biosafety concerns at community level. This was a response to requirements by the Kenya Medical Laboratory Technicians and Technologists Board to allow for a new waiver for community health volunteers (CHVs) to conduct testing using mRDTs.

The Guidelines on Community Case Management of malaria and its implementation plan were strengthened as was the Implementation framework for Rapid Diagnostic Testing. Updated job aids included dosing schedules for artemether lumefantrine (AL) and injectable artesunate for use at service delivery points by Health Care Workers in line with the revised guidelines.

Hopefully all national malaria programs will take the Kenya experience as an example of the need to update regularly all the tools needed for front line staff to achieve malaria elimination.

Courtney Emerson and co-workers address the issues of Intermittent Preventive Treatment of Malaria with Sulfadoxine Pyrimethamine and Provision of Insecticide Treated Nets in Geita, Tanzania: Provider Communication and Opportunities at the virtual 69^th Annual Meeting of American Society of Tropical Medicine and Hygiene. See their findings below.

Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is a life-saving intervention to reduce morbidity and mortality among pregnant women and their infants. Additionally, provision and use of insecticide treated nets (ITNs) to prevent malaria is critical to improving pregnancy outcomes.

To assess implementation of malaria in pregnancy services and related health communications, we surveyed 1111 women who had delivered a live born infant in the preceding 12 months (recently pregnant women), as well as 1194 adults from randomly selected households without a recently pregnant woman in Geita Region, Tanzania in 2019. Most (88.2%) recently pregnant women reported receiving any IPTp dose; 45.5% received 3 doses. 72.3% of women received their first dose in the second trimester, as recommended by national guidelines, but only 14.4% received IPTp in the 4th month; 20.3% of women did not receive IPTp until third trimester.

There was a significant difference between ITN ownership and use among households (HH) with and without a recent pregnancy: ownership of at least one net was 95.2% vs 87.9%, respectively (p<0.0001), and use was 90% vs 77.8%, respectively (p<.0001). Despite this, few HHs had enough ITNs to cover all residents; on average, HHs had 1 ITN for every 3 rather than every 2 people, as recommended. Notably, only 21.2% and 26.2% of HH with and without a recent pregnancy had sufficient ITNS (p=0.005), despite 87.3% of recently pregnant women receiving an ITN during their last pregnancy.

Of recently pregnant women, 87% received advice on preventing malaria from a health worker. Of these, 82.7% were advised to sleep under an ITN, but only 66.4% were advised to take SP, and 52.1% to attend ANC regularly. Although uptake of any IPTp was high, there are critical messages that need to be more consistently communicated to pregnant women by ANC providers including the importance of attending ANC regularly during pregnancy. To improve outcomes among pregnant women, additional net distribution may be warranted due to the unexpectedly low access.

Authors and Affiliations

Courtney Nicole Emerson(1), Ryan Lash(1), Ruth Lemwayi(2), Melkior Assenga(2), Alen Kinyina(2), Annette Almeida(2), Samwel L. Nhiga(3), Lia Florey(4), Chonge Kitojo(5), Erik Reaves(6), Miriam Kombe(5), Peter Winch(7), Stephanie Suhowatsky(7), Mary Drake(2), Julie Gutman(1) 1.US Centers for Disease Control and Prevention, Atlanta, GA, United States, 2.Jhpiego, Dar es Salaam, United Republic of Tanzania, 3.National Malaria Control Program, Tanzania, Dar es Salaam, United Republic of Tanzania, 4.US Agency for International Development (USAID), Washington DC, DC, United States, 5.US Agency for International Development (USAID), Dar es Salaam, United Republic of Tanzania, 6.US Centers for Disease Control and Prevention, Dar es Salaam, United Republic of Tanzania, 7.Jhpiego, Baltimore, MD, United States

Today we learn about malaria-carrying A. stephensi invading African cities, how malaria outpaces COVID-19 in Central African Republic, and the need to examine malaria service delivery in the context of strong health services. Malaria Journal looks at ITN use in Uganda and malaria genetic variability even at the household level. Click on links to read full articles.

Spread of city-loving malaria mosquitoes could pose grave threat to Africa

An Asian malaria-carrying mosquito that has adapted to urban life has the potential to spread to dozens of cities across the African continent, a new modeling study suggests.
The mosquito species, Anopheles stephensi, poses a serious new threat for African cities, says Francesca Frentiu, a geneticist at the Queensland University of Technology who was not involved in the research. She praises the work as “an important effort, underpinned by robust methods.” A. stephensi hopped from Asia to the Arabian Peninsula between 2000 and 2010 and then made another jump to the Horn of Africa; scientists first discovered it in Djibouti in 2012, then later in Ethiopia and Sudan.

In times of COVID-19, malaria remains the number one killer of children in CAR

Since the beginning of the year, MSF teams have treated 39,631 malaria cases in Batangafo, compared to 23,642 in the same period last year. The hospital in Batangafo – a town of 31,000 people, including 22,000 displaced from elsewhere in the Central African Republic – is bustling with activity. While a particular focus has been placed on infection prevention and control measures to identify and isolate people with suspected cases of COVID-19, another deadly disease has a much heavier impact on the lives of people living here.

September is the rainy season, when malaria becomes more deadly than ever in the Central African Republic each year. It is the leading cause of death for children under five in the country. During periods when malaria transmission is high, eight out of ten paediatrics consultations in the hospital supported by Médecins Sans Frontières (MSF) in Batangafo are due to complications from malaria, including anaemia and dehydration.

Assessment of health service delivery parameters in Kano and Zamfara States, Nigeria

In 2013, the Nigeria Federal Ministry of Health established a Master Health Facility List (MHFL) as recommended by WHO. Since then, some health facilities (HFs) have ceased functioning and new facilities were established. We updated the MHFL and assessed service delivery parameters in the Malaria Frontline Project implementing areas in Kano and Zamfara States.

In 2016, the US Centers for Disease Control and Prevention (CDC), in collaboration with the Nigeria National Malaria Elimination Program (NMEP), established a 3-year intervention project, Malaria Frontline Project (MFP), with the objectives of strengthening the technical capacity of LGA-level health workers, improving malaria surveillance and facilitating evidence-based decision-making. The project was implemented in Kano and Zamfara States.

Some deficiencies in the list of facilities in DHIS2 and MHFL were uncovered making it difficult to submit and access malaria program data. Also, some facilities were still using the old version of register which did not collect all indicators required by DHIS2. In addition there were a small number of non-functional facilities. Finally the low number of facilities within the PHC category meeting the minimum HR requirement will hamper the countries effort to achieve its goal of universal health coverage. From the foregoing, the study identifies several areas to improve delivery of malaria services specifically and universal coverage in general.

Individual, community and region level predictors of insecticide-treated net use among women in Uganda: a multilevel analysis

ITN use attributable to regional and community level random effects was 39.1% and 45.2%, respectively. The study has illustrated that ITN policies and interventions in Uganda need to be sensitive to community and region level factors that affect usage. Also, strategies to enhance women’s knowledge on malaria prevention is indispensable in improving ITN use.

Genetic diversity and complexity of Plasmodium falciparum infections in the microenvironment among siblings of the same household in North-Central Nigeria

These findings showed that P. falciparum isolates exhibit remarkable degree of genetic diversity in the micro-environment of the household and are composed mainly of multiclonal infections, which is an indication of a high ongoing parasite transmission. This suggests that the micro-environment is an important area of focus for malaria control interventions and for evaluating intervention programmes.

Colleagues from USAID’s Flagship Maternal and Child Survival Program are presenting poster 415 at the 68^th Annual Meeting of the American Society of Tropical Medicine and Hygiene. They include Lauretta N. Se, MPH; George Toe Jr., MPH; Anne Fiedler, MPH;  Thomas Hallie; Mantue Reeves, MSc; Birhanu Getahun, MD, MPH; Lolade Oseni, MD, MPH; Gladys Tetteh, MD, MPH. They have shared key points from their presentation below.

Background

Malaria prevalence in children <5 years is 45% (LMIS, 2016), with regional variations with the highest in South-Eastern regions of the country (69%). Malaria accounts for about 42 % of all clinical consultations (2013 Liberia health facility survey).

The U.S. President’s Malaria Initiative (PMI) has been committed to supporting the MOH strategy since 2008 when it began working in three out of fifteen malaria-affected counties. PMI prioritizes support to CHTs in their responsibility of directly managing the local health systems and providing oversight for efficient malaria service delivery.

In 2017 and 2018 PMI through the MCSP/EMS project expanded support to 11 counties (5 phase 1 and 6 phase II) in Liberia, focusing on malaria case management and malaria in pregnancy interventions. To improve the quality of malaria services in Liberia, MCSP/EMS in collaboration with CHT implemented optimized supportive supervision of health workers.

Methodology

At the beginning of each phase (2017 and 2018), MCSP/EMS conducted an organizational capacity assessment of the CHTs/DHTs. One key gap identified was the inconsistent and low quality of the supportive supervision of health facilities by ALL levels of the health system. Expected supervision schedules are:

• National level (25% of HFs , semi-annually)
• County level (75% of HFs , quarterly)
• District level (100% of HFs, monthly)

MCSP/EMS worked with Ministry of Health supervisors to employ  an optimized supportive supervision program for facility health workers using the updated Joint Integrated Supportive Supervision Tool. The tool has five malaria standards:

1. Screening (with 5 verification criteria)
2. Diagnosis (with 3 verification criteria)
3. Management and Treatment (with 4 verification criteria)
4. Health Education (with 2 verification criteria)
5. Malaria in Pregnancy (with 6 verification criteria)

The assessment team provided prior information to the facility staff about the supervision visit during the entry meetings. The supervision team consisted of  county, district health team supervisors and MCSP/EMS staff. During the supervision the  assessment of malaria standards was done using direct observation, record reviews, and simulation,  after which each standard was scored.

JISS: Process and Benefits

The ultimate goal of supportive supervision is to improve the quality of health services provided at the health facility. During each supervision visit, supervisors:

• Provided on-the-job training, mentoring and coaching on identified gaps
• Reinforced the review of data and its use for program improvement
• Developed an action plan from gaps identified and discussed remedial actions through follow-up
• Initiated subsequent supervision visits based on previous action plans

The Improved Performance on Joint Integrated Supportive Supervision (JISS) and Malaria Standards Assessment at 117 health facilities in the 5 Phase 1 Counties is seen in the attached charts.

Lessons and Conclusions

Training of district and county supervisors in the updated JISS tool improved the quality of supervision and data. Provision of updated MIP and case management guidelines to  both facility staff and supervisors, coupled with training,  improved adherence to standards Action plans developed during supervision visits helped facilities track their own progress and  instill sustained ownership of data and solutions Providing the county and district supervisors the opportunity to lead the supportive supervision planning and execution promoted leadership and ownership among these leaders.

The optimized supportive supervision and mentoring visits fostered health worker adherence to malaria protocols thereby contributing to measurable improvements in meeting and sustaining malaria standards and compliance. MCSP is sharing the lessons learned in fostering quality improvement from targeted supportive supervision of health care workers to scale up and improve the quality of malaria services delivery in Liberia.

Challenges and Recommendations

Most of the county and districts supervisors who were part of the JISS team had not been trained on the revised JISS tools in the EMS supported counties before the start of the project. Supportive supervision is greatly hampered by inadequate and untimely budgetary allocations by the Government of Liberia to the counties, which results in infrequent supervisory visits to the facilities and affects the quality
of services.

Empowerment of DHT and CHT supervisors: To implement optimized and effective supportive supervision to health facilities, DHTs/CHTs need to be equipped with updated tools,  provided mentoring and coaching skills, and timely provision of financial and logistical support. There is need for regular targeted and timely mentoring and coaching of  facility staff to improve adherence standards.

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This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-624-A-13-00010 and the President’s Malaria Initiative (PMI).
The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

This week started with articles that drew attention to the challenges of malaria in low transmission areas and with low density infections. Malaria Journal has provided several insightful articles toward this end.

Being an island has certainly helped Zanzibar make progress toward malaria elimination as witness the fact that malaria prevalence has remained below 1% for the past decade. Not only does Zanzibar still face threats of infection from the mainland, it may also experience an upsurge locally if residual transmission and the role of human behavior and community actions are not well understood. April Monroe et al. conducted in-depth interviews with community members and local leaders across six sites on Unguja, Zanzibar as well as semi-structured community observations of night-time activities and special events to learn more.

While there was high reported ITN use, there were also times when people were exposed t mosquitoes while being outdoors during biting times. This could be around the house, or at special night events like such as weddings, funerals, and religious ceremonies. Men spent more time outdoors than women. Clearly appropriate interventions and needed and should be promoted in culturally appropriate ways in order to further reduce and eventually eliminate transmission.

Angela Early and colleagues presented findings on a diagnostic process of deep sequencing for understanding the dynamics and complexity of Plasmodium infections, but stress that knowing the lower limit of detection is challenging. They present “a new amplicon analysis tool, the Parallel Amplicon Sequencing Error Correction (PASEC) pipeline, is used to evaluate the performance of amplicon sequencing on low-density Plasmodium DNA samples.”

The authors learned that, “four state-of-the-art tools resolved known haplotype mixtures with similar sensitivity and precision.” They also cautioned that, “Samples with very low parasitemia and very low read count have higher false positive rates and call for read count thresholds that are higher than current default recommendations.” Better understanding of the genetic mix of plasmodium infections as countries move toward low transmission and elimination is crucial for selecting appropriate interventions and evaluating their outcomes.

Hannah Edwards and co-researchers examined conditions for malaria transmission along the Thailand-Myanmar border in areas approaching malaria elimination. While prevalence may be less than 1%, residual transmission still occurs. Transmission occurs not only around residences but in the forests where people work. The researchers therefore looked at the behavior of both humans and insects. Overall, they found that, “Community members frequently stayed overnight at subsistence farm huts or in the forest. Entomological collections showed higher biting rates of primary vectors in forested farm hut sites and in a more forested village setting compared to a village with clustered housing and better infrastructure.”

While mosquitoes preferred to bite inside huts, their threat was magnified by those who did not use long lasting insecticide-treated nets (LLINs). While out in the farms and forests, people tended to wake early and increase their likelihood of being bitten. The authors discuss the challenges of dual residences in terms of LLIN ownership and even concerning the potential access to indoor residual spraying. The definition for universal net coverage needs to expand from one net per two people to include adequate nets wherever people are located.

The Amazonian area of Brazil is another area working toward malaria elimination, in particular, Plasmodium vivax. Felipe Leão Gomes Murta et al. also looked at the human side of the equation and identified misperceptions by both community members and health workers that could inhibit elimination efforts. They found, “many myths regarding malaria transmission and treatment that may hinder the sensitization of the population of this region in relation to the use of current control tools and elimination strategies, such as mass drug administration (MDA),” and LLINs.

Problematic perceptions included mention by both groups that the use of insecticide-treated nets, may cause skin irritations and allergies. Both community members and health professionals said malaria is “an impossible disease to eliminate because it is intrinsically associated with forest landscapes.” They concluded that such perceptions can be a barrier to control and elimination.

Efforts to eliminate malaria from low transmission settings are an essential to the overall global goals. These four articles tell us that close attention to and better understanding of humans, parasites and mosquitoes is still needed to achieve these goals.

Jasmine Chadewa, Chonge Kitojo, Goodluck Tesha, Naomi Kaspar, Lusekelo Njoge, Zahra Mkomwa, Dunstan Bishanga, George Greer, Abdallah Lusasi, and Sigsbert Mkude of the USAID Boresha Afya Project, the US President’s Malaria Initiative, the National Malaria Control Program, and the Community Development, Gender, Elderly and Children (Tanzanian Ministry of Health) shared how malaria data quality could be improved at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Below are their findings.

Tanzania has a high malaria burden (see Figure 1) and is facing an increased demand for health services. The Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) developed the Malaria Service and Data Quality Improvement (MSDQI) checklist to guide supportive supervision teams in evaluating the quality of malaria case management (MCM) services at facility level. MSDQI helps with the collection, monitoring, and evaluation of facility-based malaria performance indicators at all levels of service delivery that provide timely, accurate information and data for decision-making at district, regional, and national levels.

USAID Boresha Afya conducted MSDQI assessments in 1,222 health facilities in the Lake and Western zones in outpatient departments (OPDs) and during antenatal care (ANC). The program disseminates malaria and ANC guidelines, tablets, job aids, and standard operating procedures. It also continues to facilitate supportive supervision and mentorship through the MSDQI tool to build providers’ capacity in identified areas.

Among the challenges reported, Supervisors need to be trained in more than one module to reduce cost. There is turnover of MSDQI supervisors. Cases that come back positive for diseases other than malaria are not investigated further. The use of Android smartphones sometimes interfered with data collection and the reporting system. • Regions/districts depend on donor support to implement MSDQI activities.

In conclusion, effective implementation of the MSDQI tool requires regions, districts, and facilities to be well informed and given clear instruction so they can form supportive supervision teams. This should be done by:

• Orienting teams on roles and responsibilities
• Training teams on relevant competencies, resource allocation, and tablet

use for data collection

The team learned that MCM improved in OPDs and during ANC as a result of the MSDQI assessment. Improved access to quality MCM (diagnosis) nationwide. Frequency of malaria testing increased during the first ANC contact. Testing increased from 87% in April–June 2017 to 96% April–June 2018, a 9% change (see Figure 3). Second doses of intermittent preventive treatment of malaria in pregnancy (IPTp2) coverage increased by 15% on average in Boresha Afya-supported regions between October 2016 and June 2018 (see Figure 4).

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of USAID Boresha Afya and do not necessarily reflect the views of USAID or the United States government.

Ousmane Badolo, Stanislas Nebie, Youssouf Sawadogo, Thierry Ouedraogo, Moumouni Bonkoungou, Mathurin Dodo, Danielle Burke, William Brieger, and Gladys Tetteh of Jhpiego and the Improving Malaria Care Project (USAID) in Burkina Faso presented a poster on helping hospitals develop a malaria response plan. Their findings are shared below.

In Burkina Faso Malaria cases peak from June-September (rainy season), exceeding hospital capacity and causing high number of deaths, especially in children under 5 years of age. The Improving Malaria Care Project, funded by USAID/President’s Malaria Initiative, provided support to National Malaria Control Program to develop and implement malaria preparedness and response plans in all 11 regional hospitals

The Objectives of this effort aimed to describe development and implementation of malaria preparedness and response plan. From this the project planned to share lessons learned and challenges Malaria Preparedness and Response Plan Development and Implementation Process is seen in the attached chart.

In preparation of hospital staff for planning, the training reached Nurses and midwives were largest groups of trained providers at 52% and 30%, respectively. Providers were selected by hospital management team from pediatric maternity and emergency units.

Severe Malaria Cases Trend Regional Hospital in Burkina Faso is seen in the attached graph. In a second graph, Malaria Case Fatality Rate Trend at Regional Hospitals in Burkina Faso is shown. Even though there were more cases of severe malaria in 2017, Malaria case fatality rate decreased after implementing malaria response plan.

Challenges faced by the hospitals included Lack of funding for response plan activities, which were not included in the routine hospital work plan. Also there was a Lack of beds in some hospital rooms, especially in pediatric unit. Timing of clients coming to hospital posed a challenge as many do not come early and sometimes come when only complications start.

Lessons learned from the intervention include the fact that On-the-job training is opportunity to improve providers’ skills. Response plans must consider that providers’ refreshment, and securing blood and other commodities may improve severe malaria case management. Monthly data collection and analysis may highlight progress in malaria planning through case management and orient decision-making. Follow-up visits strengthened provider engagement on severe malaria case Management

In Conclusion, Response plans may provide a way to reduce malaria mortality. Each hospital should consider incorporating response plan into its annual work plan

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID) under Cooperative Agreement No. AID-624-A-13-00010 and the President’s Malaria Initiative (PMI). The contents are the responsibility of the authors and do not necessarily reflect the views of USAID, PMI or the United States Government.

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.

Efforts are underway to test the a community-based system for providing IPTp to pregnant women in Burkina Faso as a means of increasing coverage. Justin Tiendrebeogo, Ousmane Badolo, Mathurin Dodo, Yacouba Savadogo, Danielle Burke, Susan Youll, and William Brieger share a formative study among health staff concerning their perceptions of the ability of Community Based Health Workers to provide increased doses. This was presented at the 7th Multilateral Initiative for Malaria Conference in Dakar. Below are the findings.

The Burkina Faso Ministry of Health, with support from its partners, initiated a study on the feasibility of increasing provision of intermittent preventive malaria treatment in pregnant women (IPTp) with sulfadoxine-pyrimethamine (SP). Existing community-based health workers (CBHWs) were enlisted to deliver the third and fourth doses recommended by the World Health Organization. Currently, only facility-based health care providers give SP, and women in rural areas have trouble accessing health facilities for the medicine.

Using CBHWs has the potential to reach more women with a greater number of doses of IPTp-SP. Direct training and supervision of CBHWs is the responsibility of frontline health care staff, including antenatal care (ANC) providers. Therefore, to ensure a successful rollout of community delivery of IPTp, it is crucial that these staff accept the new roles of CBHWs. This baseline study was conducted to learn the frontline staff’s views about existing and proposed CBHW activities.

Study’s Geographic Areas. Three districts (Batié, Pô, and Ouargaye) in the southern part of Burkina Faso. Twelve centre de santé et de promotion sociale (health and social promotion centers [CSPS]) were selected in Ouargaye, Pô, and Batié Health Districts. In each district, two CSPS were randomly assigned as intervention catchment areas, for a total of six centers. Then using matching criteria, the remaining six CSPS were designated as control sites.

Health Worker Interviews were conducted among a total of 35 CSPS staff: 23 were men, and 12 were women. Semi-structured interview guides were used in this formative study. Open-ended questions sought the views of ANC providers and CBHW supervisors about the current work of CBHWs and the feasibility of using this health cadre to administer IPTp to pregnant women. The Study sought to understand provider opinions to design an IPTp-SP intervention involving CBHWs.

Qualitative analysis identified common themes in the open-ended responses. Providers like the CBHW program, noting that “CBHWs come from the community” and help with language barriers. However, CBHWs are not always available or move frequently from one community to another. A few male providers noted issues with timely payment of stipends to CBHWs.

Most providers were open to CBHWs providing IPTp-SP to pregnant women: “It will reduce [our] workload.” Unlike female providers, some male providers stressed the need for CBHWs to be “well trained.”

Providers commented that CBHWs were needed and could contribute. For example CBHWs could increase the uptake of IPTp-SP, prevent deaths and malaria, educate women and the community, and prevent stock-outs of SP. While CBHWs do not currently provide IPTp-SP, several providers noted that CBHWs already conduct community education sessions with pregnant women on taking IPTp-SP.

A few noted that CBHWs already monitor adherence to IPTp-SP doses and send women to the health facility when doses are needed. Providers expressed the importance of including information on malaria prevention and treatment, IPTp-SP administration, stock management, and data collection in the CBHW training.

The findings guided discussions and planning with both district and CSPS staff in the design of the CBHW training and IPTp-SP intervention. The results led to development of the training-of-trainers process that started with the district health team, who then trained CSPS staff—the CSPS staff then trained CBHWs.

Gaining the frontline staff’s acceptance of and perceptions about CBHWs—and building on them—will hopefully lead to greater ownership and better management of project implementation at the community level.

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, PMI, or the United States Government.

Kodjo Morgah, Naibei Mbaïbardoum, Mathurin Dodo, et Eric Tchinda from Jhpiego share their experiences in improving malaria data quality in Kribi District, Cameroon. The project was funded by the ExxonMobil Foundation. Their findings are presented below.

Les indicateurs clés du paludisme En 2015 dans le district sanitaire de Kribi, Cameroun, le mortalité palustre était 19% et le morbidité palustre était 29%. En outre, le couverture du premier traitement de TPI était 76% et 55% pour le deuxième.

Les interventions du projet Amélioration de la qualité des services de contrôle du paludisme au Tchad et au Cameroun sont montrés dans le diagramme ci-joint.

Les activités DQA ont commencé en 2012. Au début du projet, les formations sanitaires de Kribi ne disposaient pas d’une gestion des données suffisante en termes de fiabilité, de complétude et de promptitude des registres des formations sanitaires et des rapports soumis. En 2013 nous avons formé des prestataires de Kribi en prévention et traitement du paludisme, y compris la collecte et la gestion des données, et collaboration avec l’équipe cadre de district (ECD) du Ministère de la Santé Publique (MSP) pour institutionnaliser les réunions mensuelles de vérification et de validation des données. Puis en 2015 nous avons développé et diffusé d’affiches de suivi des données pour aider les formations sanitaires à suivre les indicateurs clés du paludisme afin de soutenir une prise de décision efficace. L’année passe, en 2017, le DQA est réalisé.

Objectifs du DQA sont d’améliorer la qualité des données du paludisme dans le district de Kribi; identifier les erreurs systématiques; apprécier les sous-déclarations et/ou sur-déclarations; mesurer la concordance des données rapportées; apprécier la précision, la validité, la fiabilité, et la complétude des données collectées; et renforcer les capacités des ECD et du PNLP.

Pour mettre en œuvre du DQA, nous avons sélectionné huit indicateurs du paludisme et un indicateur général. Le projet a adapté des outils de collecte des données développés par le projet MEASURE Evaluation financé par l’USAID. Puis, il a facilité le constitution et orientation des équipes d’évaluateurs des données composées du personnel de Jhpiego et des membres de l’ECD. Apres ça, les équipes commencent le réalisation du DQA dans des sites sélectionnés

Modalités :

• Aucun problème de qualité des données, si la mDA est comprise entre 100% et 90%
• Problèmes mineurs de qualité des données, si la mDA est comprise entre 89% et 70%
• Problèmes majeurs de qualité des données, si la mDA est inférieure à 70%

Conclusions: Le DQA a réussi à identifier les problèmes qui ont affecté la qualité des données dans les formations sanitaires de Kribi. Il a aussi révélé une meilleure qualité des données dans les formations sanitaires rurales que dans les formations sanitaires urbaines. Dans l’ensemble, la qualité des données du paludisme est acceptable dans la majorité des formations sanitaires soutenues par le projet.

L’équipe de projet doit soutenir le personnel et les formations sanitaires du MS du district dans l’intégration des recommandations du DQA pour continuer à améliorer la qualité des données.

Recommendations: Il est necessaire de renforcer les capacités des prestataires dans la collecte des données à travers la supervision formative. Dans l’outil de supervision de district, il est utile d’intégrer la vérification et le contrôle des données. Une Aide-mémoire sur la vérification, le contrôle et la validation des données du paludisme devrait être disponible.