Category Archives: Integration

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.

Investing and Sustaining: Lessons from Rwanda on World Malaria Day

Rwanda on track to zero deaths from malaria by 2015

By Dr. Corine Karema

Today, April 25th, the world will be commemorating Malaria Day as stipulated in the Abuja Declaration of 2000. Just like the previous years, Rwanda will join the rest of the world in commemorating this day by highlighting achievements in controlling Malaria while also renewing commitment of achieving zero targets of malaria related deaths by 2015.

The theme for this year’s World Malaria Day is “Sustain Gains, Save Lives: Invest in Malaria”, a theme that is testimony to the renewed global commitment of finding lasting solutions for eliminating Malaria from our midst.  For Rwanda, a country that has registered significant progress in combating Malaria, this commitment is a shared vision for which we attach greater value.

Coming up with sustainable and investment solutions for Malaria control is a new discourse which underlines the importance of continued investment in combating this disease with the view of propelling malaria-endemic countries along the path of achieving the health and poverty related Millennium Development Goals by 2015. Here in Rwanda, the battle against Malaria has not been an easy one. It has called for strategic interventions, committed leadership of our government and support from development partners to register progress that we see today across the country.

I will share with you some of the outstanding achievements we have registered over the past years, many of which are captured in the recently released 2010 Demographic Health Survey (DHS). The recent scaling up of interventions has made significant progress:

  • reductions in morbidity by 87% from 1,669,614 malaria cases in 2005 to 212,200 cases in 2011 and
  • reduced mortality by 76% from 1,582 deaths in 2005 to 380 deaths in 2011.

dscn7129asm.jpgThis reduction is as a result of scaling up of preventive measures especially coverage and use of long lasting insecticidal nets (LLINs) which according to the 2010 DHS results…

  • 82% of households have at least one LLIN
  • 72% of pregnant women slept under their nets and
  • 70% of children under-five years were using bed nets

Previously and as the case is in most developing countries, Malaria is treated based on signs and symptoms. However, Rwanda is one of the few countries in the world today where up to 94 percent of Malaria cases are laboratory through microscopy or rapid diagnostic tests at all levels of health care structure including the community level.

The involvement of Community Health Workers (CHWs) in early diagnosis and treatment of children Under-five years has also had an impact on malaria incidence throughout the country as currently 95% of children are tested and treated for malaria within 24 hours of symptoms onset.

In addition, Malaria control activities have been integrated and decentralized at all levels including –

  • a strong CHWs network which facilitates community involvement and participation,
  • the community health insurance scheme also known as Mutuelles de Sante and
  • a strong Health Management Information Systems (HMIS) including the web based community health information system (SIS.com)

The above interventions are strengthened by use of mobilisation and sensitisation campaigns using different channels of communication. The advocacy and social mobilisation is oriented towards intensifying different efforts to sustain the gains made as the country moves towards pre-elimination phase of malaria as outlined in the new Malaria Strategic Plan (2012-2017).

To emphasize on the importance of the World Malaria Day, this year’s event will be held during the scheduled Rwanda Malaria Forum that will be held in Kigali in mid June 2012. The Forum will bring together malaria experts from international community who will deliberate on the challenges African countries and in particular, Rwanda, face in malaria control and how to overcome them.

The recommendations of the forum will guide our sector in finalizing the new Malaria Strategic Plan that outlines Rwanda’s strategies from malaria control to pre-elimination phase by 2017. A series of activities to run for a week have also been planned to reach community levels where different interventions of promoting awareness on preventive measures will be discussed with input from community leaders.

Therefore, as we mark this day in Rwanda, we take pride of our achievements but also remain mindful and conscious of the challenges ahead a in realising the ambitious target of having a Rwanda that is free from Malaria.

The Author is Head of Malaria and Other Parasitic Diseases Division Rwanda Biomedical Center/IHPDPC, Follow: Twitter @ckarema

Bhutan: Community Action Groups – Building local participation for improvement in public health

Participants at the Asia Pacific Malaria Elimination Network’s Community Engagement for Malaria Elimination Workshop shared their country experiences on community participation.  Below is a summary of experiences shared by participants from Bhutan, which shows how we can integrate malaria activities into broader community development efforts.

dscn5601-sm2.jpgBhutan is a small country of 39,000 km2 with a population of 634,982. It is bordered by large countries – China to the north and India to the south. The northern reaches of the country are in the Himalayas and have high elevation and cooler climates thus there is no malaria transmission in this region (4 districts). The middle section of the country is considered at risk for seasonal transmission (9 districts) and the southern zone bordering India is considered endemic (7 districts).

One of the main community participation methods in public health, including malaria control and elimination, is the formation of Community Action Groups (CAGs). In the rural communities, these groups have been formed at the village level in four southern districts in Bhutan from 2009 to 2011. The CAG initiative aims to create community ownership of health activities, stimulate decentralization of health work to the grassroots level, and to motivate and build capacity for local leadership. CAG members receive a three-day training which covers sanitation, community motivation, nutrition and child care. The training, meeting costs and monitoring of the CAGs are funded by Global Fund.

Members of the CAG are elected by the community:

  • Chairperson (Tshogpa): this representative is paid by the Government for a five year term
  • Secretary: this is a Village Health Worker, who provides the message delivery on preventive and curative services and are involved in LLIN distribution. These workers attend training on communication methods and receive refresher training.
  • Allied sector representative
  • Water caretaker: this person has strong community ties
  • Female representative
  • Religious group member: this is typically a monk

The CAGs discuss priorities and develop a community action plan. The groups meet quarterly with monitoring every six months and reports are sent to block level with feedback going up to the national level.

One CAG has been successful in achieving sanitation improvements. CAGs are also seen as a platform for multi-sector involvement. A challenge of this strategy is the high turnover of village health workers because they are no incentives. In the future, Bhutan hopes to increase the number of districts with CAG groups, but the source of funding is not yet available.

[Thanks to Yeshi Nidup, Tshewang Phuntsho and Cara Smith-Gueye for the presentation and this summary.]

Malaria and Mental Health

Some time ago we were studying local perceptions of what constitutes malaria illness in eastern Nigeria and came across some syndromes during focus group discussions that verged on mental health problems.

dscn3913-brakina.jpgHeavy/strong malaria or Oke Eya was attributed to too much work, too much exposure to the sun, too much thinking (worrying), or drinking too much wine. This form of malaria was evidenced by senseless talk, appearance of being mad, high fever, and strong headache.

Shaking malaria or Eya Mbaka Ise was also thought to be caused by too much thinking, charms (witchcraft), drinking too much alcohol, or taking drugs like hemp. The person suffering this form of malaria would exhibit abnormal talk and behavior, headache, and appear restless.

It is not uncommon for communities to call many conditions by the local name for “malaria”, but if mental illness is involved, it is not a simple mater of letting a rapid diagnostic test help one decide whether to use artemisinin-based combination therapy or antibiotics.

Though not speaking specifically of malaria, Prince and colleagues in the Lancet noted that, “The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury.” Furthermore, they explained that, “Conversely, many health conditions increase the risk for mental disorder, and co-morbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis.”

Severe malaria itself can also lead to mental health problems.  Specifically Bangirana et al. highlighted the problem that, “Cerebral malaria results in short- to long-term cognitive impairments in many of its child survivors. Although some of the risk factors for impairments have been identified, no attempts have been made to address the plight of those who develop cognitive impairments.”

So far there is no Global Fund for mental health programs.  This puts an extra burden on those programs that receive international support to ensure that they deliver their malaria, TB and HIV services in the context of an integrated primary health care that can address the total person, especially the poor and vulnerable.

Ivermectin against malaria: novel idea, but can it be scaled

Several news sources have picked up on a new article in the American Journal of Tropical Medicine and Hygiene that reported when communities take annual ivermectin doses for controlling onchocerciasis and lymphatic filariasis, they may also be protecting themselves or their neighbors from malaria. Specifically the researcheds reported that ivermectin Mass Drug Administration (DA) “reduced the proportion of Plasmodium falciparum infectious Anopheles gambiae sensu stricto (s.s.) in treated villages in southeastern Senegal.”

The process works the same way that ivermectin treats head lice in that when insects take a bloodmeal from someone who has swallowed the drug, the medicine kills the insect. Sarah Boseley points out that some of the attractions of ivermectin are that it has been safely used in humans for 30 years and that it is inexpensive.

The Merck company has been supplying ivermectin (under its brand name Mectizan) free through the Mectizan Donation Program (MDP) to the African Program for Onchocerciasis Control for 16 years.  Over time coverage has reached over 100,000 villages in 18 African countries. Annual distribution in Africa contrasts with more frequent distribution in the smaller focal transmission points in Latin America where the diseases has almost been completely eliminated.

MDP reports that, “Currently, more than 70 million treatments are approved for onchocerciasis in Africa and Latin America and 80 million for lymphatic filariasis in Africa and Yemen each year.” That is a lot of free medicine and one of the largest and far reaching corporate social responsibility programs known.

Back to Senegal – the researchers found that the effect of ivermectin on mosquitoes lasted up to two weeks. They also raise the question of whether more frequent ivermectin distribution in onchocerciasis or filariasis MDA communities during the main malaria transmission season would be feasible.  Possibly a small scale operations research proposal could be submitted to the Mectizan Expert Committee.

cdi_report_08.jpgOf importance is the fact that the Community Directed Treatment with Ivermectin (CDTI) approach utilized by APOC projects has been tested and found quite accommodating to the addition of other Community Directed Interventions (CDI) such as community case management of malaria, ITN delivery and use monitoring and Vitamin A distribution among other basic health services.

The availability of tens of millions of exra ivermectin doese in communities where MDA is already occurring is unknown at present, let alone the feasibility of starting free ivermectin in malarious areas that have no onchocerciasis or filariasis.  In addition, for onchocerciasis, the idea time for distribution is before the rainy season so that microfilariae loads are seriously reduced before the black fly vectors emerge. This timing may not benefit malaria control fully.

Regardless of the unknowns, it is encouraging that people are thinking of synergistic ways to control the various endemic diseases that inflict suffering on poor communities.

Two for One – ivermectin and mosquitoes

Suppose that when mosquitoes bit you, they died. The possibility that a human blood meal can kill mosquitoes sounds far fetched, but has been observed as a by-product of mass community mass drug administration (MDA) of ivermectin for lymphatic filariasis in Senegal.

Researchers in Senegal compared villages where MDA was performed with a control set of villages and concluded that, “Ivermectin MDA significantly reduced the survivorship of An. gambiae s.s. for six days past the date of the MDA, which is sufficient to temporarily reduce malaria transmission. Repeated IVM MDAs could be a novel and integrative malaria control tool in areas with seasonal transmission, and which would have simultaneous impacts on neglected tropical diseases in the same villages.”

This is not the only time links have been made between malaria and lymphatic filariasis. A good example was community distribution of insecticide treated nets were provided in Nigeria, which curtailed the mosquitoes that carried both diseases.

In MDA programs for filariasis control “The goal is to treat 80% of the eligible, at risk population yearly, for at least 5 years, in order to interrupt transmission and prevent children from becoming infected.” The window of opportunity for collaboration between MDA and malaria control programs is therefor, very focused.

A smaller scale study reported in July of this year found that, “In mosquitoes feeding on volunteers given ivermectin the previous day, mean survival was 2.3 days, compared with 5.5 days in the control group (P < .001, by log-lank test). Mosquito mortality was 73%, 84%, and 89% on days 2, 3, and 4 in the ivermectin group." Since ivermectin started as a drug for veterinary parasites, it is useful to note that similar results on mosquitoes were found after cattle were given ivermectin. Researchers from Michigan State University* reported that, "Most (90%) of the An. gambiae s.s. that fed on the ivermectin-treated cattle within 2 weeks of treatment failed to survive more than 10 days post-bloodmeal. No eggs were deposited by An. gambiae s.s. that fed on ivermectin-treated cattle within 10 days of treatment." The authors concluded that, "Treatment of cattle with ivermectin could be used, as part of an integrated control programme, to reduce the zoophilic vector populations that contribute to the transmission of the parasites responsible for human malaria." community-ivermectin-distribution-in-buea-cameroon.jpgIvermectin distribution of course has been the major strategy of the the African Program for Onchocerciasis Control (APOC) for the past 15 years.  APOC’s efforts will continue much longer than those of lymphatic filariasis in over 100,000 communities throughout the continent.

More attention to joint planning and coordinating of malaria and other disease control efforts should be synergistic and mutually beneficial for the populations, who according to APOC, live beyond the end of the road.

*http://www.ingentaconnect.com/content/maney/atmp/2009/00000103/00000006

Health Posts – meeting rural needs

People living in rugged rural terrain often go without formal health services. The population may be remote and even migratory, as some herd cattle.

dscn0659a.JPGAngola is working to ensure that at minimum there are Health Posts staffed by trained nurses to provide services beyond the municipal/district headquarters. And since onchocerciasis is common in many of such areas, we are also talking about providing integrated disease control and health care ‘beyond the end of the road,’ as advocated by the African Program for Onchocerciasis Control.

Life for these nurses is not easy as there is usually just one staff member to run the post. Also this situation means that male nurses predominate – one reason why it is presumed that antenatal care may not be easy to provide.

dscn0699-sm.JPGA visit to such a health post recently showed that not only was the nurse enthusiastic, but that he could provide some of the basic components of antenatal care in all but name.

The post had a good supply of sulphadoxine-pyramethamine that is required for intermittent preventive treatment of malaria in pregnant women. There were other medicines and supplements routinely given pregnant women such as ferrous sulfate and de-worming drugs.  The nurse even had a fetal stethoscope.

Strengthening these rural outposts is a priority for malaria control and health equity. These rural populations do not even have access to medicine shops as found in some areas.

Regular supplies of nets, RDTs, ACTs and SP will guarantee that all parts of Africa can work toward reducing malaria deaths by 2015.

Malaria Integrated into Secretary Clinton’s Address

With the greater emphasis on maternal and child health evidenced in the U.S. Global Health Initiative, the Gates Foundation, the G8 Summit and DfID, one might question whether health development assistance is veering away from diseases like malaria.  Secretary Hillary Clinton set that concern to rest today in her speech at the Johns Hopkins University’s School of Advanced International Studies.

Below are some excerpts that refer to malaria in a variety of contexts and show the continued commitment of the US Government to malaria control and elimination:

  • I’ve met … children in Angola who wake up every morning under bed nets and then head off to school eager to learn, unafflicted by malaria
  • We help prevent and treat malaria for more than 50 million people every year
  • We want to align our efforts with that of other donor countries and multilateral organizations, many of which do outstanding work to improve global health. Let me just mention one in particular: the Global Fund to Fight AIDS, Tuberculosis, and Malaria
  • Consider the life of a woman in one of our partner countries … Sometimes health services come right to her door, in the form of health volunteers bringing bed nets to protect her family from malaria
  • angola-children-get-nets-an-child-welfare-clinic-sm.JPGWe are taking the investments our country has made in PEPFAR, the President’s Malaria Initiative, maternal and child health, family planning, neglected tropical diseases, and other critical health areas – building on the work of agencies across the federal government, such as the Centers for Disease Control – and expanding their reach by improving the overall environment in which health services are delivered

This last quote shows clearly that the US Government aid effort sees malaria as part of the broader health development picture. We encourage all partners not to lose sight of the need to reduce child and maternal morbidity and mortality by integrating malaria control into all MCH efforts.

Comprehensive, Integrated and Hopefully Not Neglected

As we get very close to achieving the Roll Back Malaria Partnership’s 80% target for 2010 in prevention and treatment coverage, there is a tendency to worry when people talk of shifting funding priorities. The HIV community is particularly worried that funding for treatment and control may become stagnant or even decrease. As AFP reported from Johannesburg, “Thousands of protesters marched Thursday against what they say is a softening commitment to fighting AIDS in Africa by the United States and other developed countries.”

Government donors are by and far the biggest contributors to global disease control efforts, but foundations and corporations can set trends and attract attention and thus influence priorities. For example, Melinda Gates, speaking at the recent Women Deliver Conference in Washington addressed the issue of maternal and child health:

We are nurturing a vision that is changing the world. Donors will spend more on women and children, and those donations will be tracked. Developing countries will pass rigorous policies for women’s and children’s health, and fully fund their implementation, and health workers will have the tools and training they need.

Rahim Kanani, reporting on Melinda’s talk, concluded that, “With global leaders convening next week in Canada for the G8 and G20 Summits, maternal and child health is now a top international priority.” And quoted Melinda thus: “The whole world will be looking to us for leadership. We need to be ready with a single plan.”
dscn7723sm.JPGThese thoughts are certainly in sync with the current US administrations Global Health Initiative, which seeks an integrated approach to health care. GHI will “help partner countries improve health outcomes through strengthened health systems – with a particular focus on improving the health of women, newborns and children through programs including infectious disease, nutrition, maternal and child health, and safe water.”

Malaria definitely needs to be part of the integrated mix of maternal and child health (MCH) services. Pregnant women are more vulnerable to malaria; even mosquitoes are more attracted to them. Malaria leads to maternal anemia and death as well as intrauterine growth retardation leading to low birth weight babies, who have a poor chance of survival. Research is finding more about possible links between malaria and pre-eclampsia and postpartum hemorrhage.

There ultimately should be no reason to fear a loss of malaria funding given the strong advocacy initiatives built by RBM partners. Even more, efforts of the integrated approach to strengthen health systems will benefit malaria control and elimination, which requires a strong health system.

And in closing we are reminded that the wealthy people behind foundation and corporate giving can be advocates themselves.  As NPR reported, “Microsoft Corp. co-founder Bill Gates and billionaire investor Warren Buffett are launching a campaign to get other American billionaires to give at least half their wealth to charity.” We trust that malaria control within an integrated MCH program will remain part of this charitable urge.

Can International Institutions Change Government Behavior?

A headline in BBC News today reads, “International Criminal Court ‘altered behaviour’ – UN.” United Nations Secretary General, Ban Ki-moon was quoted saying, “In this new age of accountability, those who commit the worst of human crimes will be held responsible.”

These comments were made at the opening of a ‘stock-taking’ conference of ICC impact on justice for Victims opening today in Uganda. A discussion paper for the conference concludes that …

By engaging victims in trial proceedings, reparation programs, and outreach activities, the Court not only acknowledges and recognizes their suffering and losses, it also helps to make proceedings in The Hague more relevant to communities affected by mass violence. Indeed, if done in a meaningful and consultative way, formal recognition of victims, coupled with effective outreach programs, can help cultivate a sense of local ownership of ICC proceedings and lay the groundwork for greater acceptance of facts established by the Court’s judgments. Such efforts can also help reduce the likelihood of future conflict and strengthen a tenuous peace.

Importantly, the same most common victims of mass violence addressed by the ICC are those most affected my malaria – women and children. And the displacement experienced by these groups in fact heightens their risk of exposure to malaria. As has been reported from eastern DRC.

pbf3.jpgOne wonders whether international institutions like the Global Fund to fight AIDS, TB and Malaria has a similar impact on accountability. The mechanism for this potential impact is ‘Performance-Based Funding.’ According to the Global Fund …

Performance-based funding ensures that funding decisions are based on a transparent assessment of results against time-bound targets … Today, the performance-based funding model is used by a number of development organizations and initiatives (including the GAVI Alliance, the Millennium Challenge Account and the European Commission) as a way to ensure the accountability, efficiency and effectiveness of programs being funded.

GFATM grant reviews rate projects according to progress toward their own stated objectives. All this information is publicly available for scrutiny. The following examples where changes resulted from progress ratings are given by GFATM:

  • Mali,HIV (Rated B2): Procurement bottleneck identified; UNDP and UN provided technical support to build local capacity.
  • Ethiopia, Malaria (Rated B2): Government focused on problems and sought technical support from UNICEF; grant became A-rated and delivered ten million insecticide-treated bed nets to protect people from malaria.
  • Senegal, Malaria (Rated C): Grant stopped, Country Coordinating Mechanism reformed, civil society involved, and new grant signed which proved successful. Country benefited from clear performance evaluation, even with a C-rating.
  • Nigeria, HIV (Rated C): Grant stopped, rebuilt monitoring and evaluation system and new grant signed which proved successful. Country benefited from clear performance evaluation, even with a C-rating.

There are also examples where the accountability process resulted in grant suspension when financial improprieties were discovered, as happened in Uganda. A transparent, highly visible system of accountability is necessary, not only to preserve human rights generally, but also specifically to strengthen the right to basic health services including malaria control.