Category Archives: Health Workers

Contribution of the Standards-Based Management and Recognition (SBM-R) approach to fighting malaria in Burkina Faso

Quality improvement tools play an important role in ensuring better malaria services.  Moumouni Bonkoungou, Ousmane Badolo, and Thierry Ouedraogo describe how

Standards Based Management and Recognition Approach to Quality Improvement

Jhpiego’s quality approach, Standards-Based Management and Recognition, was applied to enhancing the provision of malaria services in Burkina Faso at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their work was supported through the President’s Malaria Initiative and the USAID Improving Malaria Care Project.

In 2015, Burkina Faso recorded 8,286,463 malaria cases, including 450,024 severe cases with 5379 deaths. The main reasons for these death are:  Inadequate application of national malaria diagnosis and treatment guidelines, delays in seeking health care and poor quality of case management.

The Standards-Based Management and Recognition (SBM-R) approach is used to improve quality of care using performance standards based on national guidelines. SBM-R includes the following steps:

  • set performance standards
  • implement the standards
  • monitor progress and
  • recognize as well as celebrate achievements

Areas or domains assessed by the approach are: services organization, case management at both health center and community, Intermittent Preventive Treatment in Pregnancy (IPTp), promotion of Long Lasting Insecticide treated Nets (LLIN) use and infection prevention and control.

Since June 2016, 26 health facilities in three regions have been implementing SBMR. Therefore, 105 health workers have been trained. Performance progress was measured through 5 evaluations including baseline. Baseline has shown the highest score was 47% (Kounda) while the lowest was 9% (Niangoloko).

The main issues observed were: lack of program activities, management tools, handwashing facilities, LLINs and misuse of Rapid Diagnosis Tests. Their cause was determined and an improvement plan was developed by each site. The second, third and final evaluations revealed a change in performance scores for all sites.

The external evaluation showed 17 out of 26 health facilities with a score higher than 60%; among them 10 with a score above 80% (Bougoula, 94%). At the same time, IPTp 3 increased from 34.48% in 2014 to 78.38% in 2016 and no malaria death has been registered since October 2015.

For the site under 80% the key reasons were: staff turnover, commodities stock-out and lack of infrastructure. The process continues with recognition of health facilities and supporting others (those at less than 80%) to reach the desired performance level. The SBM-R approach appears to be a great tool for improving quality and performance of health facilities.

Health provider orientation to national malaria case management guidelines in regional hospitals in Burkina Faso

Good clinical practice in managing malaria requires awareness and understanding of national case management guidelines. Moumouni Bonkoungou, Ousmane Badolo, and Thierry Ouedraogo of Jhpiego in Collaboration with the National Malaria Control Program and sponsorship from the “Improving Malaria Care” project of USAID/PMI explain how health workers in Burkina Faso were oriented to the national guidelines at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene. They have found that short orientations are less expensive and reach more health workers that traditional training sessions.

Malaria remains the leading cause of consultations, hospitalization and death in health facilities in Burkina Faso. In 2015, 23,634 cases of severe malaria were recorded in hospitals with 1,634 deaths, a mortality rate of 7% at this level compared to 1% nationally. Since April 2014, 1,819 providers from 49 districts have been trained in malaria case management, specifically at the first level (health center – CSPS). Conversely, at referral centers – medical centers with surgical units (CMA), regional hospitals (CHR) and university hospitals (CHU) – providers are not well educated on the new WHO guidelines for malaria prevention and case management.

Health worker orientation session

This situation led the United States Agency for International Development-supported Improving Malaria Care (IMC) project and the National Malaria Control Program (NMCP) to organize orientation sessions for providers in 8 CHR in September 2016. The sessions were conducted by trainers at the national level, supported by clinicians from hospitals including pediatricians and gynecologists.

A total of 298 health workers were oriented, including 24 physicians, 157 nurses, 56 midwives, as well as pharmacists and laboratory technicians. 39% of participants were female and 43% have less than 5 years of service in these hospitals. The sessions have provided participants with an opportunity to familiarize themselves with the new guidelines for malaria prevention and case management.

The orientations have also made it possible to identify the difficulties encountered by referral structures in malaria case management, which include: insufficient staff, inadequate capacity building, no blood bank in some hospitals, reagent stock-outs, inadequacies in the referral system, and insufficient equipment.

To address these difficulties, staff redeployment, internal supervision, development of tools to monitor reagents stocks have been proposed. To move forward, response plans for the period of high malaria transmission is expected to be developed for these referral facilities.

Using rapid task analysis to strengthen Pre-Service Education (PSE) learning and performance of critical malaria interventions in Liberia

Understanding the tasks that health workers perform in real life can improve their basic Training. Marion Subah of MCSP and Jhpiego shares experiences in using Task Analysis to improve pre-service training of midwives and lab technicians in Liberia. Her findings summarized below, are presented at the American Society of Tropical Medicine’s 66th Annual Meeting.

Health worker task analysis helps human resource planners and managers update pre-service education (PSE) curricula and plan needed in-service training. In Liberia, a task analysis was conducted focusing on Liberia’s midwives’ and Medical Laboratory Technicians’ (MLT) work practices.

Task lists were developed using curricula, job descriptions and professional scope of practice, and validated by key stakeholders for each cadre. Responses from 25 MLTs and 26 midwives were examined that addressed the following questions:

  1. How often do you do the task (frequency)?
  2. Where did you learn to do the task (location)?
  3. How well do you think you are able to perform the task (performance)?
  4. How critical is the task in terms of patient and/or public health outcomes (criticality).

Eligibility criteria included those currently practicing between 6 months and 5.5 years following graduation. Midwives were assessed for five tasks relating to malaria service provision, including provision of preventive treatment for malaria in pregnancy, management of vector borne diseases, diagnosis and management uncomplicated malaria in adults and children (respectively), and provision of malaria preventive services.

Lab technicians were assessed for one malaria task, performance of parasitological tests. On average 61% of midwives learned these malaria tasks in PSE, 74% said they performed these tasks daily, 80% felt proficient in performing the tasks, and 82% rated the tasks moderate to high in criticality. For MLTs, 88% learned malaria testing in pre-service education, 100 % performed this task daily, 77% felt they were proficient and 93% said the task was of moderate to high criticality.

Task Analysis Flow Chart

The results from this rapid task analysis are being applied to the current curricula review. Courses that could be updated or strengthened have been identified. Malaria Case Management Technical Update and Effective Teaching Skills Training are being organized for tutors at the training schools. Finally, integrated supportive supervision tools are being strengthened to improve performance of these malaria tasks by midwives and lab technicians.

Performance assessment of laboratory technicians on Malaria Microscopy in 5 high endemic districts of Rwanda

Parasitological diagnosis plays an increasing role in malaria control and elimination. Noella Umulisa, Angelique Mugirente, Tharcisse Munyaneza, Aniceth Rucogoza, Aline Uwimana, Beata Mukarugwiro, Stephen Mutwiwa, Aimable and Mbituyumuremyi of the
Maternal and Child Survival Program, Jhpiego, the National Reference Laboratory, Rwanda Biomedical Centre (RBC), and the Malaria and Other Parasitic Diseases Division (Mal & OPDD) in Rwanda will present their experiences building the capacity of lab technicians during Session 47 at the American Society of Tropical Medicine and Hygiene Annual Meeting on 6 November 2017.  Their abstract is found below.

Accurate malaria diagnostics help to establish the true prevalence of each Plasmodium species and can ensure appropriate treatment. Light microscopy is the gold standard for malaria diagnosis and sufficient training of laboratory staff is paramount for the correct microscopy diagnosis of malaria. In Rwanda each of about 400 health centers has a laboratory able to perform malaria microscopy, at least 2 trained lab technicians and 1 to 2 functioning microscopes.

The objective of the study is to evaluate the performance of laboratory technicians in detecting and quantifying malaria parasites in 81 health centers from 5 highly endemic districts (Huye, Nyanza, Ngoma, Kirehe, Kayonza, Gatsibo). In October 2015 the Rwanda Biomedical Center and partners trained 1 lab technician per health center from these districts in malaria microscopy.

The training emphasized determining parasite density and detection of malaria species. From August to September 2016 a follow-up assessment was conducted. Of the 81 technicians trained, 30 were randomly chosen and assessed at their health facilities.

A standardized pre-validated slide panel of 5 slides was distributed, a comprehensive checklist used to collect information and conduct visual inspection and maneuvers used in routine malaria diagnosis. During the training a significant increase was found between pre and post tests with median scores improving from 47% to 85%.

As part of the assessment 150 lab tech-prepared slides were analyzed to evaluate the quality of thick and thin blood smears. There was a significant increase in quality of both blood smear types. The sensitivity and specificity of participants in detection of malaria parasites were 100% and 86% respectively, while species identification and parasite quantification accuracy were 79% and 75% respectively.

The findings of this assessment support the need for continuous capacity building for laboratory staff to ensure accurate malaria diagnosis for appropriate treatment and suggest that District hospitals may benefit from conducting regular malaria microscopy diagnosis quality control/assurance activities at health center laboratories.

World Health Workers Week, a Time to Recognize Health Worker Contributions to Malaria Care

Since the beginning of the Roll Back malaria Partnership in 1998 there has been strong awareness that malaria control success is inextricably tied to the quality of health systems. Achieving coverage of malaria interventions involves all aspects of the health system but most particularly the human resources who plan, deliver and assess these services. World Health Worker Week is a good opportunity to recognize health worker contributions to ridding the world of malaria.

We can start with community health workers who may be informal but trained volunteers or front line formal health staff.  According to the Frontline Health Workers Coalition, “Frontline health workers provide immunizations and treat common infections. They are on the frontlines of battling deadly diseases like Ebola and HIV/AIDS, and many families rely on them as trusted sources of information for preventing, treating and managing a variety of leading killers including diarrhea, pneumonia, malaria and tuberculosis.”

The presence of CHWs exemplifies the ideal of a partnership between communities and the health system. With appropriate training and supervision CHWs ensure that malaria cases are diagnosed and treated promptly and appropriately, malaria prevention activities like long lasting insecticide-treated nets are implemented and pregnant women are protected from the dangers of the disease. CHWs save lives according to Nkonki and colleagues who “found evidence of cost-effectiveness of community health worker (CHW) interventions in reducing malaria and asthma, decreasing mortality of neonates and children, improving maternal health, increasing exclusive breastfeeding and improving malnutrition, and positively impacting physical health and psychomotor development amongst children.”

CHWs do not act in isolation but depend on health workers at the facility and district levels for training, supervision and maintenance of supplies and inventories. These health staff benefit from capacity building – when they are capable of performing malaria tasks, they can better help others learn and practice.

A good example of this capacity building is the Improving Malaria Care (IMC) project in Burkina Faso, implemented by Jhpiego and supported by USAID and the US President’s malaria Initiative. IMC builds capacity of health workers at facility and district level to improve malaria prevention service delivery and enhance accuracy in malaria diagnosis and treatment. Additionally capacity building is provided to health staff in the National Malaria Control Program to plan, design, manage and coordinate a comprehensive malaria control program. As a result of capacity building there has been a large increase in malaria cases diagnosed using parasitological techniques and in the number of women getting more doses of intermittent preventive treatment to prevent malaria during pregnancy.

Malaria care is much more than drugs, tests and nets. Health worker capacity is required to get the job done and move us forward on the pathway to eliminate malaria.