Category Archives: Integration

World Tuberculosis Day: United We Can End TB and Tropical Diseases

The theme of World TB Day is to Unite to end TB: leave no one behind. The communities affected by TB are also ones where tropical diseases like onchocerciasis and malaria are endemic. A successful strategy to control one disease should ideally be “united” with all basic primary health care interventions, thereby truly leaving no one behind.

While the causative agents differ between TB and tropical diseases such as malaria, lymphatic filariasis and Dengue, control of these diseases shares a common goal – “an urgent need to develop new vaccines for HIV/AIDS, malaria, and tuberculosis, as well as for respiratory syncytial virus and those chronic and debilitating (mostly parasitic) infections known as neglected tropical diseases (NTDs).” In addition to prevention, there is also need for integrated “treatment pipelines directed at NTDs, Malaria, tuberculosis (TB), and human immunodeficiency virus (HIV)/AIDS,” according to Asada.

There is also a need for integrated primary health care (PHC) programming. In the Journal of Infectious Diseases. Simon reports on linkages showing that, “Recent research suggests that NTDs can affect HIV and AIDS, tuberculosis (TB), and malaria disease progression. A combination of immunological, epidemiological, and clinical factors can contribute to these interactions and add to a worsening prognosis for people affected by HIV/AIDS, TB, and malaria.”

The possibility of integrating directly observed treatment (DOT) for TB treatment into community health worker (CHW)/PHC programs that addressed malaria treatment and onchocerciasis control was tested by the Tropical Disease Research Program (TDR) some years ago. CHWs in a few of the study sites were able to successfully include DOT for TB in their community duties, but in other sites community and health worker fears about stigma inhibited action.

TB, malaria and NTDs are among the conditions referred to as the infectious diseases of poverty. We will not eliminate poverty by tackling these diseases one-by-one. A “United” and integrated approach from national to community level is needed.

Joint efforts, a key to success for the Malaria in Pregnancy Program in Luanda, Angola

A poster entitled “Joint efforts, a key to success for the Malaria in Pregnancy Program in Luanda, Angola” was presented by Jhony Juarez, Adolfo Sampaio, William R. Brieger, and Domingos F. Gueve from Jhpiego’s Angola Team at the 65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

sbmr-visit-baia-farta-dscn0523Angola, in response to WHO’s 2012 updated guidance on Intermittent Preventive Treatment in pregnancy (IPTp), revised its national malaria protocol to better address the fact that 25% of maternal mortality is caused by the disease. The new protocol was a collaborative effort of a national technical working group assisting the National Malaria Control Program (NMCP) including the National Reproductive Health Program, the national AIDS Institute, WHO, UNICEF, UNFPA and implementing partners of the U.S. Presidents Malaria Initiative (PMI).

The updated Prevention and Treatment Manual for Malaria in Pregnancy, based on the revised protocol, was approved in 2014, and efforts continued with reviewing and updating training modules, job aids and monitoring tools that would reflect the additional doses of IPTp. The Ministry of Health, with support from partners, then disseminated these materials in the provinces and municipalities where they worked. USAID’s ForçaSaúde program, with support from PMI, worked with the Provincial Health Directorate of Luanda to build capacity of 297 health professionals to implement the new guidance in 78 health facilities of four municipalities, Belas, Cazenga, Cacuaco and Viana, with a combined population of 4.3 million.

ipt-1234Comparing the IPTp data from the four municipalities between 2014 and 2015, one can see that the new guidance has started to take effect. In both years approximately 70,000 pregnant women received the first dose or around 60% of women registering for antenatal care (ANC). For the new third dose there was an increase of 85% (from 12,490 women to 23,046), and receipt of the fourth dose rose by 164% (3,345 to 8,839).

Two major challenges remain: increasing ANC registration and addressing missed opportunities to provide ANC doses for those who do attend including ensuring regular supplies of sulfadoxine-pyrimethamine for IPTp. Future progress requires continued inter-departmental collaboration among NMCP, Reproductive Health and the AIDs Institute, on-the-job training, enhanced statistical capacity, and supervision.

AIDS and Malaria: The Challenge of Co-Infection Persists

While the International AIDS Society is holding its 2015 meeting in Vancouver, it is important to remember that individual infectious diseases do not exist in isolation, but in combination make life worse for infected people. The co-infective culprit with HIV/AIDS that usually received the most attention is Tuberculosis, but malaria is not without its dangers. Herein we highlight a few recent studies and publications on the interactions between HIV and malaria.

Just because today malaria is primarily a tropical disease, it does not mean that people living with AIDS (PLHIV) in other parts of the world are not at risk. Schrumpf and colleagues point out that people living with HIV frequently travel to the tropics and thus may be at risk of infection by one of the species of malaria parasite. PLHIV are not unlike other travelers who do not always adhere with travel recommendations for using bednets and taking appropriate prophylaxis, but the consequence of non-adherence may be more severe.

In areas endemic for both malaria and HIV the effects of co-infection continue to be studied.  In westernDSCN6373 Kenya Rutto and co-workers report that, “HIV-1 status was not found to have effect on malaria infection, but the mean malaria parasite density was significantly higher in HIV-1 positive than the HIV-1 negative population.” So do malaria prevention and treatment interventions mitigate any of these problems?

Co-infection is not the only shared problem of these two diseases in areas where both are endemic. Yeatman et al. reported that, “In malaria-endemic contexts, where acute HIV symptoms are commonly mistaken for malaria, early diagnostic HIV testing and counseling should be integrated into health care settings where people commonly seek treatment for malaria.”

Mozambique has updated its guidelines for managing anemia among HIV-infected persons. The updated “guidelines for management of HIV-associated anemia prompts clinicians to consider opportunistic conditions, adverse drug reactions, and untreated immunosuppression in addition to iron deficiency, intestinal helminthes, and malaria.” Brentlinger and colleagues concluded that the guidelines are valuable in helping clinicians address anemia through a variety of interventions.

In areas where anti-retroviral treatment may be delayed, use of long lasting insecticide treated nets (LLINs) might help. Again in Kenya, Verguet and fellow researchers conducted a cost analysis and concluded that, “Provision of LLIN and water filters could be a cost-saving and practical method to defer time to ART eligibility in the context of highly resource-constrained environments experiencing donor fatigue for HIV/AIDS programs.”

Introduction of universal cotrimoxazole prophylaxis for all HIV positive patients in Uganda is seen to have a positive effect on reducing malaria infections among HIV positive patients. Rubaihayo and research partners found this effect as well as reported on several other studies with similar results.

One key overall lessons from these studies is the need to have integrated services for prevention, detection and management of both malaria and HIV. National health programs as well as global donors should make integrated service delivery a priority.

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.

Is community case management sustainable in Mozambique? A qualitative policy analysis

The recently concluded Global Health Systems Research Symposium in Cape Town featured a number of abstracts that touched directly or indirectly on malaria. Malaria services and movement toward malaria elimination cannot be achieved in a country without a strong health system that involves both communities, program staff and policy makers.

globalsymposium_logosBelow is an abstract by Baltazar Chilundo, Julie Cliff, Alda Mariano, Daniela Rodrigues, and Asha  George of the University Eduardo Mondlane, Mozambique and the Johns Hopkins School of Public Health on the sustainability of community case management, building on longstanding community health worker programs.  They stress the importance of community commitment, an often missing factor when CHW and CCM programs are organized by national agencies.

“In Mozambique, community case management (CCM) of diarrhoea, malaria and pneumonia is embedded in the national community health worker (CHW) programme. Since 1978 this programme functioned fitfully and was relaunched in 2010, with a target to train and retrain over 6000 CHWs.

MOZ_mean“Considering the checkered history of the CHW program, sustainability lies at the heart of concerns related to the design and implementation of CCM in CHW programs at scale in Mozambique and in people centred health systems more broadly.

“Using qualitative retrospective case study methodology, we reviewed 54 national documents and interviewed 21 key national informants for a policy analysis of CCM in Mozambique. The data were analysed thematically according to a sustainability framework and validated though a national debriefing workshop.

“The sustainability of CCM was facilitated by embedding it in the national CHW programme, which was relaunched after wide consultation within government and with supportive donors and non-governmental organizations (NGOs).

“Although communities were not widely consulted, they were eager for CHWs to provide curative services. The new CHW program aimed to improve CHW retention, by paying them a salary and giving priority to females. However, salary costs come from partners and in practice most CHWs are male.

“The poor capacity of the health system to adequately supervise CHWs and guarantee drug supplies for CCM, the dependence on external partners for funding, and on NGOs for implementation and the lack of mobilization of communities and top policy makers remain critical concerns.

“Embedding CCM in the national CHW programme favoured sustainability, however this made CCM susceptible to the same factors that undermine sustainability of the CHW programme. Moving forward, these policy concerns need to be addressed to ensure a national CHW program, responsive to community needs, supportive of CHW themselves and owned by national governments.”

 

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).

iCCM needs collaboration among varied stakeholders

CAM02760Integrated community case management (iCCM) of common illnesses, as we learned at the just completed evidence review symposium on iCCM in Accra, Ghana, requires a number of key inputs ranging from adequate procurement and supply of commodities, well stated supportive policies and human resources from the district to the clinic to the community.  One input, the collaboration among stakeholders needs constant reinforcement.

Although the project was not iCCM, an implementation research study in 8 sites in Africa that added a package of interventions to existing ivermectin distribution illustrates the need for stakeholder concurrence and collaboration. This 3-year community directed intervention (CDI) Tropical Disease Research Program effort (UNDP/World Bank/Unicef/WHO) was designed to add a package of interventions to the community’s ‘portfolio’ each year in a step-wise manner.  These included antimalarials for community case management, insecticide treated nets, vitamin A and drugs for directly observed treatment of tuberculosis.

While ultimately the community directed approach to distributing these commodities resulted in better coverage in intervention districts than facility based service provision in the control areas, an important lesson from the project occurred in the start-up process the very first year. In fact no real commodity distribution took place that year as originally planned.

What the teams learned is that while community distribution of ivermectin had been taking place for at least 10 years in most of the districts, not all members of the district health teams (DHT) were fully aware of what the onchocerciasis focal person was doing.  It had been hoped a bit naively that the DHT member in charge of immunization and vitamin A, the DHT focal point for malaria and the DHT member in charge of TB/Leprosy would gladly join their onchocerciasis colleague in making their services available through community volunteers.

CAM02763In reality the advocacy process took up the whole first year before other DHT members could be convinced that it was safe and appropriate for community members to take charge of a package of basic health commodities. In some locations, the TB/Leprosy program managers were never convinced.

Even at start-up of onchocerciasis programs in the late 1990s it took much convincing of health workers to ‘allow’ communities to handle drugs like ivermectin. When introducing a larger package through CDI, it became necessary to start this process of convincing and seeking collaboration anew.

A basic iCCM package of ACTs, RDTs, ORS, Zinc and amoxicillin may not appear as complicated as the CDI package added to ivermectin distribution, but in truth a lot of stakeholder advocacy work is still needed.  We learned at the Accra meeting that at minimum malaria and child health programs need to collaborate to provide the basic package and the funding that does with it.  Different programs may in fact have different policies and guidelines. Different donors and different sections of the Ministry of Health must be willing to bring their efforts and resources together and share. This is as much a political as it is a technical process, and scientific evidence that health care interventions delivered in the community save lives may not be enough to overcome politics and vested program interests.

The 300+ delegates to the iCCM symposium are returning home over the next few days.  Hopefully the momentum of the conference will carry them on to engage in collaboration, not only with their colleagues who also attended, but also with those who did not attend and benefit from the sharing of evidence and experience.  It will take a team of people with varied interests to make iCCM a success.

iCCM – collaboration for commodities

The integrated Community Case Management Symposium (iCCM) in Accra, Ghana this week provides an ideal opportunity to examine the practical issues of getting the commodities to manage cases of malaria, pneumonia and diarrhoea at the community level.  http://iccmsymposium.org/

cropped-iCCM-web-banner6Ordinarily one would expect the medicines needed for iCCM would be obtained through a country’s normal essential drug management system. ACTs, ORS, amoxicillin, etc., should be available through the regular primary health system of a country to all front line health facilities. It is from this frontline facility that community health workers (CHWs) delivering iCCM would normally receive training and stocks/supplies.

The reality is that many front line facilities experience frequent stock-outs. They cannot meet the demands for their own clinic services, let alone provide supplies for community volunteers. Whether it is an issue of financial resources or political will, lack of essential medicines makes it difficult to guarantee child survival more than 25 years after UNICEF, WHO, USAID and other partners launched various initiatives to save children’s lives.

Currently countries are placing hopes in international financial programs such as the Global Fund to solve their commodity needs and scale up to prevent child deaths.  http://www.theglobalfund.org/en/ In particular opportunities to develop a basic iCCM infrastructure and obtain appropriate malaria commodities are potentially available through Global Fund malaria grants. Child health program managers must work with national malaria control program staff to access this resource.

The Global Fund’s new funding mechanism is based on the national malaria strategic plan. If that plan does not address iCCM, it is unlikely countries can use their ‘envelop’ of funds for that purpose. Regardless, the Global Fund support will provide only malaria commodities. Where can counties get ORS, zinc and amoxicillin, especially if they do not have well-funded national medical stores/essential drugs program.

The RNMCH* Trust Fund with support from Norwegian and British aid agencies is being established and may help provide these pneumonia and diarrhoea commodities in stocks large enough to scale up iCCM. USAID child health projects also include diarrhoea and zinc. The long term sustainability of iCCM based on donor assistance is questionable. We are far from eliminating malaria, and there is no serious discussion of eradicating diarrhoeal diseases and pneumonia.

A pilot project to improve access to quality child illness case management that is being designed in Bauchi State, Nigeria demonstrates the challenges of coordinating commodities. Some were available through a World Bank Malaria Booster Program under a malaria plus package concept. USAID was providing ORS and zinc to child health projects. The US President’s Malaria Initiative could provide ACTs and RDTs, but the local governments and medicine shops involved in the project would have to buy amoxicillin through their normal wholesale channels. Getting the right mix of medicines at the right time in the right amounts to the right places is not easy.

Collaboration among different disease and health programs is always a challenge, but in the short term, program managers in both malaria control and child health need to work together to tap all available resources for iCCM. In the long run donors need to address health system strengthening so countries can manage their own essential drug programs successfully.

*Reproductive, Neonatal, Maternal and Child Health

Exploring integration between Neglected Tropical Diseases and Malaria Control Programs

Oladele Olagundoye MD, MPH, an Atlas Corps Fellow at the Corporate Alliance for Malaria in Africa (CAMA), GBCHealth, New York, provides a perspective on the recently concluded Neglected Tropical Diseases meeting in Washington….

yola-cdd-helping-a-community-memebr-to-fix-an-itn-to-the-wall-sm.jpgThe Neglected Tropical Diseases (NTDs) community convened at the World Bank for a 2-day conference tagged “Uniting to Combat NTDs: Translating the London Declaration into Action” on November 17 – 18, 2012 in Washington DC. The objective was to provide a forum where all stakeholders in the fight against NTDs can identify the priorities, discuss the challenges and suggest strategies towards achieving the World Health Organization’s (WHO) targets to control and eliminate at least 10 NTDs by 2020.

Leveraging on the London Declaration of January 30, 2012 by leading pharmaceutical companies, donor agencies and non-governmental organizations (NGOs), to supply the drugs required for preventive chemotherapy (PCT) and the treatment of NTDs, the participants identified three priority areas necessary for the actualization of the WHO’s 2020 targets:

  1. Bridging the estimated $US 4.7 billion funding gap by sustaining international commitments and increased domestic funding for NTDs by endemic country governments.
  2. Building the human resource capacity and health infrastructure at the country-level to effectively absorb the increased supply of drugs, and for the scale-up of delivery services.
  3. Effective integration of intervention programs and incorporation of water and sanitation interventions (WASH), to complement the mass drug administration, and intensified disease management of NTDs.

It was encouraged that Malaria & NTDs (Lymphatic Filariasis & Dengue fever) programs should integrate their services, because the scale-up of vector control interventions (LLINs) will benefit the populations served by both programs. However, a critical barrier limiting this collaboration is the suspicion by malaria programs that NTDs managers intend to leverage on the availability of more funding for malaria programs, to achieve specific NTDs targets.

I recommend that program managers for malaria and NTDs (LF & Dengue fever) should adopt the partnerships and four One’s approach, which has contributed greatly to the success of WHO’s African Program for Onchocerciasis Control (APOC) –

  • 1 collaboration mechanism
  • 1 budget
  • 1 package of interventions and
  • 1 monitoring and evaluation framework

Can Community Health Workers Provide Quality Integrated Community Management of Febrile Illnesses?

A Case study of Community Health Workers in Two Selected Local Government Areas of Akwa Ibom State, Nigeria. A Poster Presentation at the 61st Annual Meeting of the American Society of Tropical Medicine and Hygiene, 11-15 November 2012, Atlanta.
Bright C. Orji1, William R. Brieger2, Emmanuel Otolorin1, Jones Nwadike3, Edueno V. Bassey4, Mayen Nkanga5 1Jhpiego/Nigeria, Abuja, Nigeria, 2The Johns Hopkins University, Baltimore, MD, United States, 3Dunamis Medical Diagnostic Services, Lagos, Nigeria, 4Etebi Health Center, Esit Eket, Akwa Ibom State, Nigeria, 5Akwa Ibom State Ministry of Health, Uyo, Nigeria

The World Health Organization has recommended improved quality of care as key elements in strengthening health systems in poor resource countries, Engagement of Community Health Workers (CHWs) can reduce challenges such as weak public sector, human resource constraints, and variable quality of the private sector. Efforts to improve access to quality case management of febrile illness in Nigeria included the engagement of Community Health Workers (CHWs) to use Rapid Diagnostic tests as a component of home management of malaria, dispense ACTs and manage pneumonia and diarrhea.

checklist.jpgThis current effort monitored and measured the performance of CHWs in providing quality management of febrile illnesses in two selected LGAs. The authors trained one hundred and fifty-two CHWs and developed simple quality performance standards (one-page tool) for CHWs providing community services in Akwa Ibom State, Nigeria. All 152 trained CHWs providing malaria, pneumonia and diarrhea case management were monitored and assessed using the standards. The tool has 37 performance criteria (PC) to measure CHW knowledge, skills and competence in 3 sections: History taking and Examination; Conducting RDTs for Malaria; and Illness Management.

Trained assessors observed CHWs providing services. Each correctly performed criterion was scored 1 point. Four rounds of assessments were conducted at an interval of two months from June 2011 – March, 2012. During Round 1 CHWs achieved an average of 19 (52.2%) PC. This rose to 25 (67.5%) PC at Round 2; 28 (75. 6%) at Round 3 and 30 (81.1%) and (p = 0.00). PC that needed most improvement included reinforcement on checking RDT expiry date, entering results on records, and safe disposing of sharps.

CHWs can provide quality case management of febrile illness in the current efforts to reduce annual deaths of people at risk while contributing to the achievement of targets numbers 4, 5 and 6 of the Millennium Development Goals (MDGs). In conclusion CHW supervisors can use this tool to enhance the quality of services provided by the CHWs and improve CHW training.