Category Archives: IPTp

On World Malaria Day the realities of resurgence should energize the call to ‘Beat Malaria’

Dr Pedro Alonso who directed the World Health Organization’s Global Malaria Program, has had several opportunities in the past two weeks to remind the global community that complacency on malaria control and elimination must not take hold as there are still over 400,000 deaths globally from malaria each year. At the Seventh Multilateral Initiative for Malaria Conference (MIM) in Dakar, Dr Alonso drew attention to the challenges revealed in the most recent World Malaria Report (WMR). While there have been decreases in deaths, there are places where the number of actual cases is increasing.

Around twenty years ago the course of malaria changed with the holding of the first MIM, also in Dakar and the establishment of the Roll Bank Malaria (RBM) Partnership. These were followed in short order by the Abuja Declaration that set targets for 2010 and embodied political in endemic countries, as well as major funding mechanisms such as the Global Fund to fight AIDS, TB and Malaria. This spurred what has been termed a ‘Golden Decade’ of increasing investment and intervention coverage, leading to decreasing malaria morbidity and mortality. The Millennium Development Goals provided additional impetus to reduce the toll of malaria by 2015.

On Facebook Live yesterday Dr Alonso talked about that ‘Golden Decade.’ There was a 60% decrease in mortality and a 40% decreases in malaria cases. But progress slowing down and we may be stalled at a crossroads. He noted that history show unless accelerate efforts, malaria will come back with a vengeance. Not only is renewed political leadership and funding, particularly from affected countries needed, but we also need new tools. Dr Alonso explained that the existing tools allowed 7m deaths be diverted in that golden decade, but these tools are not perfect. We are reaching limits on these tools such that we need R&D for tools to enable quantum leap forward. Even old tools like nets are threatened by insecticide resistance, and research on alternative safe insecticides is crucial.

Dr Alonso at MIM pointed to the worrying fact that investment in malaria overall peaked in 2013. Investment by endemic countries themselves has remained stable throughout and never gone reached $1 billion despite advocacy and leadership groups like the Africa Leaders Malaria Alliance. The 2017 WMR shows that while 16 countries achieved a greater that 20% reduction in malaria cases, 25 saw a greater that 20% increase in cases. The outnumbering of decreasing countries by increasing was 4 to 8 in Africa, the region with the highest burden of the disease. Overall 24 African countries saw increases in cases between 2015 and 2016 versus 5 that saw a decrease. A review of the Demographic and Health and the Malaria Information Surveys in recent years show that most countries continue to have difficulty coming close to the Abuja 2010 targets for Insecticide treated net (ITN) use, prompt and appropriate malaria case management and intermittent preventive treatment of malaria in pregnancy (IPTp).

The coverage gap is real. The WMR shows that while there have been small but steady increase in 3 doses of IPTp, coverage of the first dose has leveled off. Also while ownership of a net by households has increased, less than half of households have at least one net for every two residents.

In contrast a new form of IPT – seasonal malaria chemoprevention (SMC) for children in the Sahel countries has taken off with over 90% of children receiving at least one of the monthly doses during the high transmission season. Community case management is taking off as is increased use of rapid diagnostic testing. Increased access to care may explain how in spite of increased cases, deaths can be reduced. This situation could change rapidly if drug resistance spreads.

While some international partners are stepping up, we are far short of the investment needed. The Gates Foundation is pledging more for research and development to address the need for new tools as mentioned by Dr Alonso. A big challenge is adequate funding to sustain the implementation of both existing tools and the new ones when they come online. Even in the context of a malaria elimination framework, WHO stresses the need to maintain appropriate levels of intervention with case management, ITNs and other measures regardless of the stage of elimination at which a country or sub-strata of a country is focused.

Twenty years after the formation of RBM and 70 years after the foundation of WHO, the children, families and communities of endemic countries are certainly ready to beat malaria. The question is whether the national and global partners are equally ready.

Acceptance of the Contribution of Community-Based Health Workers (CBHWs) to Improving Prevention of Malaria in Pregnancy in Burkina Faso by Health Center Staff

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.

Community-Based Health Workers in Burkina Faso: Are they ready to take on a larger role to prevent malaria in pregnancy?

Community Based Health Worker (CBHW) opinions were sought prior to establishing community delivery of intermittent preventive treatment of malaria in pr4egnancy in Burkina Faso. Bill Brieger, Danielle Burke, Justin Tiendrebeogo, Ousmane Badolo, Mathurin Dodo, Yacouba Savadogo, and Susan Youll report on the findings from the CBHWs at the 7th Multilateral Initiative for Malaria Meeting in Dakar.

In 2012 and 2013, World Health Organization recommended that a minimum of three doses—rather than two doses—of intermittent preventive treatment of malaria in pregnancy (IPTp). This three-dose recommendation has made it more challenging to achieve the 85% national coverage target in Burkina Faso. Existing health services in other endemic countries have also had difficulty achieving the two-dose target. Using a formative approach, this study tested if the 85% target could be achieved by having IPTp delivered to the community through trained community-based health workers (CBHWs) who are supervised by the health system.

Existing training materials for these CBHWs outline a basic role in promoting antenatal care (ANC) and guiding communities to use curative and preventive malaria services. The question was to what extent are the CBHWs practicing what they were taught, and could training in community delivery of IPTp build on their existing roles.

Because of continuous malaria transmission, these three districts in the southern part of Burkina Faso were chosen for the intervention study: Batie, Po, and Ouargaye. Also in these three districts, community health workers have been involved in the implementation of other programs, such as immunization, malaria, nutrition, and family planning.

As part of this formative study to design the community-based IPTp intervention, semi-structured interviews were conducted with CBHWs in three health districts (Batie, Po, and Ouargaye) with a high malaria burden. In general, the Directorate of Health Promotion in the Ministry of Health encourages communities to select one male and one female CBHW, although the actual CBHWs chosen would depend on availability and literacy of the CBHW.

In each district, four centre de santé et de promotion sociale (health and social promotion centers [CSPS] were selected, and their catchment areas were divided among intervention and control groups. Effort was made to reach all CBHWs currently practicing in these 12 catchment areas. Numerical and narrative data were entered in a database and analyzed by gender based on major themes relating to ANC, pregnancy, and malaria services. Interview transcripts were manually reviewed for themes.

Of the CBHWs interviewed, a total of 62 were male and 42 were female.  Both female and male CBHWs provide advice and education to women in their villages, which may include advising women to go to the CSPS for pregnancy or ANC, family planning, immunization, or illness. Some CBHWs stated that they remind women about follow-up ANC appointments. As one female CBHW explained, “on their return [from CSPS for care], I ask [the pregnant woman] what has been said and I shall ensure they practice this.”

A male CBHW noted that he “direct[s] women, in case of amenorrhea, [to] go to CSPS to check for pregnancy, to [receive] follow[-up] care, and be in good health.” Many male CBHWs were likely to mention malaria-related activities, including education about causes and prevention of malaria. A few male CBHWs talked about helping people recognize malaria, seek treatment, and comply with recommended medicine regimens.

A few male and female CBHWs specifically mentioned encouraging women to take sulfadoxine-pyrimethamine for IPTp. Some reported involvement in distributing bed nets. In contrast to the male CBHWs, some female CBHWs may even accompany women to ANC to ensure that the women receive services.

Some challenges were faced by CBHWs. At least a third of the CBHWs noted difficulties in carrying out their work, but they also had encouragements: “Acceptance by the community of my activities facilitates the task.” “Nothing is easy, but with the understanding of people, there are no problems.” While officially, CBHWs were to receive a stipend, one CBHW explained that “nothing is easy, especially that I am not paid for all these activities.” Others also noted that “for the moment, there is nothing that is easy as we lack the tools [for the job].”

CBHWs report being active in promoting the health of pregnant women and encouraging women and the community to prevent and treat malaria. Although their training stresses postnatal care, this area was not mentioned during interviews. Likewise, CBHWs did not address the danger signs of malaria in pregnancy during the interviews, which is in their training. Female CBHWs were more likely to encourage pregnant women to attend ANC at CSPS and follow up with them after the visit, while the male CBHWs were more focused on providing health information. Logistical challenges and payment of stipends need to be addressed before adding more duties for the CBHW to complete. Overall, CBHWs are positioned to deliver IPTp under the supervision of CSPS staff.

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.

Improved IPTp Uptake: MCSP Restoration of Health Services Experience in Liberia

Nyapu D.Taylor, Birhanu Getahun,Topian Zikeh, Anne Fiedler, and Allyson Nelson of the USAID supported Maternal and Child Survival Program/Jhpiego in Liberia are presenting their project aimed at strengthening health services in Liberia to improve uptake of Intermittent preventive treatment of malaria in pregnancy at the 7th Multilateral Initiative for Malaria in Dakar this week. Below are a description of their work and their main findings.

Mother and baby in Liberian Government Hospital, Grand Bassa County, Liberia. Photo by Kate Holt, Jhpiego.

In Liberia more than 170,000 pregnancies occur each year. Provision of two or more doses of SP for IPTp (IPTp2+) merely increased from 50% 2016. Provision of the three or more doses of

IPTp (IPTp3+) remains at 22%.Liberia adopted WHO’s IPTp3+ guideline but it is not practiced all over the country. There is a gap in the competency of the health care workforce. There are recurring stock-outs of SP.The Maternal and Child Survival Program (MCSP) Restoration of Health Services (RHS) intended to address these challenges. Project

Objectives included Prevention at facilities by strengthening infection prevention and control (IPC) practices at 77 health facilities through training, intensive supportive supervision, triage, improvement of waste management, and provision of essential IPC commodities and supplies.  Also the project aimed to Increase utilization of and demand for maternal and child health services bu restoring delivery of quality primary health care services through implementation of integrated reproductive, maternal, newborn, child, and adolescent health as part of the Essential Package of Health Services in 77 facilities.

MCSP RHS supported health facilities in three counties:

  • Grand Bassa: 30 (91% of health facilities in county)
  • Lofa: 17 (27% of health facilities in county)
  • Nimba: 30 (46% of health facilities in county)

Population coverage was 900,000 or 20% of population. This included 45,000 pregnancies per year. The Project timeline is September 2015–June 2018. The quality improvement process used in the project is seen in the attached diagram.

Several achievements were documented. Adherence to malaria clinical standards improved from 25% at baseline to 100% at endline in 39 MCSP-supported facilities—sampled at endline (see Figure 1). Adherence to malaria clinical standards improved substantially from baseline to endline in 39 MCSP-supported facilities—sampled at endline (see Figure 2). Increasing uptake of IPT2+ in the 77 RHS facilities has been observed since the inception of the project (see Figure 3).

The project met and dealt with several challenges. Health facilities were sporadically stocked with SP and mosquito nets (another component of malaria in pregnancy services). Bad roads prevented travel to field during rainy seasons. This affected distribution of malaria supplies and provision of mentorship and supervision for quality service. Clients had huge difficulty accessing health facilities.

Among the lessons learned were that close collaboration and involvement of key actors, especially MOH (National Malaria Control Program) and country health team at all levels, is an effective and efficient approach for project implementation. Regular mentorship and coaching during supportive supervision improves the quality of care provided for malaria in pregnancy. Ensuring availability of IPTp drugs and long-lasting insecticidal nets at health facilities are key to preventing malaria in pregnancy.

In conclusion the project met IPC objectives and achieved 80% Safe, Quality, Health Services score. Thus there was improved service delivery utilization.

The 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.

Community Health Volunteers Contribute to Improved Malaria Prevention and Management in Kribi, Cameroon

Kodjo Morgah, Eric Tchinda, and Naibei Mbaïbardoum of Jhpiego (a Johns Hopkins University Affiliate) in Cameroon are presenting a poster at the Multilateral Initiative for Malaria Conference in Dakar this week. Their findings, seen below, show how community health volunteers can contribute to improving the quality of malaria control services in Chad and Cameroon.

CHV Lilian Kubeh preparing to administer a rapid diagnostic test. Photo by Karen Kasmauski.

Project objectives focused overall on contributing to the reduction of malaria-related morbidity and mortality in Cameroon and Chad. It also aimed to strengthen community-based interventions through the use of community health volunteers (CHVs) to manage simple cases of malaria and conduct awareness-raising activities. The geographic scope of the project was Kribi District in the south of Cameroon. Thirty-two health facilities are supported by Jhpiego. Kribi District has an estimated population of 134,876.

Reports from the National Malaria Control Program show that malaria is the leading cause of morbidity in Cameroon—an estimated 1,500,000 cases occur each year. In 2016, it was the leading reason for medical consultations (23.6% of all medical consultations) and hospitalizations (46% of all hospitalizations). Among children under 5 years of age, malaria accounted for 41% of all medical consultations and 55% of all hospitalizations. Malaria is also a leading cause of mortality. In 2016, Cameroon had 2,639 deaths caused by malaria—12% of all deaths across all age groups and 28% of all deaths among children under 5 years of age were attributed to malaria.

Project intervention strategies target the four levels of the health system. The CHV intervention was mobilized to support the strategy at the community level as seen in the attached diagram. In 2012 and 2014, 38 CHVs were selected by the community and received training to support areas in the district more than 10 km from a health center. (Note: 10 km was the measurement tool used to determine the geographic scope of each CHV for this project.) An initial donation of medications, data collection tools, and small equipment was made available to CHVs using funding from ExxonMobil Foundation.  An evaluation of the training intervention was conducted by an external consultant in April 2016.

CHV Daniel Ze conducting an individual educational session on IPTp. Photo by Karen Kasmauski.

CHVs conduct outreach activities in their communities—via home visits and community education sessions—to provide health education on malaria transmission and prevention, use of long-lasting insecticidal nets, the importance of intermittent preventive treatment in pregnancy (IPTp), and the importance of promptly seeking medical care for suspected cases of malaria. CHVs also support national health campaigns and health promotion events, including World Malaria Day. In Cameroon, where CHVs are also able to test and treat patients, they administer rapid diagnostic tests (RDTs) and treat cases of uncomplicated malaria.

Motivation of CHVs included ongoing training and technical updates, regular replenishment of materials, CHVs are recognized and respected community leaders, provision of per diem and transport costs, and continued advocacy targeting district officials to provide CHV stipends to ensure sustainability. Attached are details of the supervisory activities that provided continual technical support to the CHVs to ensure that they retain knowledge and skills to carry out their activities and track their data.

Between 2013 and 2016 CHVs in these communities were able to reach nearly 20,000 people with a variety of malaria services as seen in the attached table. The project paid close attention to data quality, which was reviewed with the CHVs on a regular basis, resulting in improved data quality.  CHVs improved the accessibility of malaria prevention and care services for communities living in remote areas. Results from April 2016 external evaluation show these results. Knowledge of malaria prevention is significantly higher in households that did not receive CHV support (p = 0.001). Use of long-lasting insecticide-treated nets is higher in households that benefitted from CHV support (88%) than in households that did not benefit from CHV support (73%) (p = 0.023). There was an increase in the delivery of IPTp2, from 60% in 2012 to 70% in 2016.

In conclusion CHVs have increased their communities’ access to health centers through referrals, health education on malaria prevention, IPTp, and treatment for simple and severe cases of malaria. Regular supervision of CHVs by their supervisors (the health zone managers) is essential to maintaining and strengthening CHV performance and motivation. Continuing advocacy efforts with local authorities is necessary to ensure that CHV activities are sustainable. The project team aims to establish a mechanism to improve documentation of its activities to better measure the impact on indicators at the community, facility, and district levels, and provide evidence for advocacy to sustain these efforts.

Universal Health Coverage – Where is Malaria?

Universal Health Coverage (UHC) is the theme of the 2018 World Health Day on April 7th. The concept was applied to malaria in 2009 regarding the provision of long lasting insecticide-treated nets (LLINs aka ITNs) with the definition of universal meaning one net for every two persons in a household. Up until that time coverage targets for malaria interventions set at the 2000 Abuja Declaration had focused on achieving by the year 2010, 80% of people (particularly pregnant women and children below the age of 5 years) sleeping under ITNs, 80% of children receiving appropriate malaria treatment with artemisinin-based combination therapy (ACTs) within 24 hours of onset of illness and 80% of pregnant women receiving two doses of Intermittent Preventive Treatment (IPTp) for malaria as part of antenatal care (ANC).

Definitions have evolved since the Abuja Declaration. The target for ITNs was extended to all household members (thus universal). The ACT target was modified to require treatment based on parasitological testing (microscopy or rapid diagnostic tests). IPTp targets were extended to achieving monthly dosing from the 13th week of pregnancy, which depending on the point in pregnancy when a women entered the ANC system could be 3, 4 or more doses. In addition to these changes, the US President’s malaria Initiative upped the Abuja targets from 80% to 85% in the countries where it supported national malaria programs.

We are eight years past 2010. It had been assumed that if scale up to 80% had been achieved by then and sustained for five or more years, malaria deaths would come close to zero and elimination of the disease would be in sight. National surveys have shown that reaching these targets has not been simple.

The example of ITNs is a good place to start, as is Nigeria with the highest burden of malaria. The attached chart shows findings from the Demographic and Health or Malaria Information Surveys in 2010, 2013 and 2015. Whether one measures universal coverage by the house possessing at least one net per two residents or by the proportion who actually use/sleep under the nets, we can see that UHC for this intervention is difficult to achieve. Even when households possess nets, not everyone sleeps under them either because of adequacy of nets, preferred sleeping arrangements, internal household power structure or other factors.

In 2015 the majority of nets that existed in households were obtained through campaigns (77%), 14% were acquired from the health services, and 7% were purchased. These systems are not keeping up with the need.

Four endemic countries reported a malaria Information Survey in 2016, Liberia, Ghana, Madagascar, and Sierra Leone. The chart shows that they too have had difficulty in achieving universal coverage of malaria interventions. Of note the chart only includes whether appropriate malaria parasitological diagnosis was done on children who had fever in the preceding two weeks. Data on provision of ACTs is based on fever, not test results, so there is no way to know whether it was appropriate. Generally 20-30% more febrile children received ACTs than were tested.

All three malaria interventions, ACTs, Diagnostics and ITNs, require contact with the health system (including community health workers). If malaria services are indicative of other health interventions, then universal coverage including seeking interventions, getting them and ultimately using them is still a distant goal. To achieve universal coverage there also needs to be universal commitment by countries, donors and technical partners.

Improving intermittent preventive treatment for pregnant women (IPTp) coverage in 5 districts in Chad and Cameroon

Kodjo Morgah and Naibei Mbaïbardoum of Jhpiego with support from the ExxonMobil Foundation ave been working to increase interventions that protect pregnant women from malaria. The results below were shared at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Malaria is the leading cause of morbidity and mortality in Cameroon and Chad, where an estimated 500,000 and 1.5 million cases occur every year, respectively. In Cameroon, 55% of hospitalizations and 241 deaths among pregnant women reported in 2010 were due to malaria. In Chad, malaria accounted for 30% of hospital admissions and 41% of deaths among pregnant women in 2013.

To improve uptake of intermittent preventive treatment for pregnant women (IPTp) for malaria in 5 districts in Chad and the Kribi district of Cameroon, Jhpiego adopted strategies targeting the 4 levels of the health system in each country: updating national policies and guidelines, building capacity of providers, building community health workers’ (CHWs) capacity, and engaging in behavior change communication.

Nationally, Jhpiego provided technical guidance to the Ministries of Health to develop tools including: training and malaria in pregnancy (MIP) reference manuals for providers and CHWs, guidelines on IPTp, and key supervision and data collection tools. At the regional/district levels, 38 supervisors were trained, and they conducted 248 supervisory visits in both countries, reaching 137 health facilities.

At the facility level, 234 providers were trained in malaria prevention and management, MIP, data collection and commodity management. At the community level, 146 CHWs in both countries were trained to raise awareness on malaria prevention and control.

In Chad, CHWs referred 6424 pregnant women for antenatal care/IPTp and 11679 pregnant women for malaria treatment in 2014 and 2015. Health facility and CHW data collection tools were revised and monthly validation of district data was implemented to improve data reliability, completeness, and readiness.

As a result of Jhpiego’s activities in Kribi, IPTp rates increased from the start of the project in 2012 to 2015: from 70% to 83% (IPTp1), 61% to 80% (IPTp2), and 12.7% to 28.1% (IPTp3). Similarly, from 2012 to 2015 in Chad, IPTp1 rates increased from 40% to 83% and from 30% to 50% for IPTp2. These gains are a result of training paired with coaching and supervision activities of trained providers and targeted facilities.

 

Results of an evaluation of the Toolkit to Improve Early and Sustained Intermittent Preventive Treatment in Pregnancy (IPTp) Uptake in Mozambique and Madagascar

Lalanirina Ravony, Elana Fiekowsky, Lisa Noguchi, Patricia P. Gomez, Jean Pierre Rakotovao, Eliane Razafimandimby, Armindo Tiago, Kathryn Smock, Arsene Ratsimbarisoa, Kristen Vibbert, and Robert Sellke shared their efforts to apply a toolkit to enable health providers to ensure better uptake of intermittent preventive treatment for malaria during antenatal clinics. As seen below, they presented their findings at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene.

Malaria in pregnancy (MIP) is a leading cause of maternal and newborn morbidity and mortality; however uptake of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP), an effective prevention tool, remains alarmingly low across sub-Saharan Africa, including Mozambique and Madagascar.

The WHO 2012 policy recommendations to prevent MIP include early enrollment into antenatal care (ANC), accurate estimation of gestational age (GA) and administration of IPTp-SP during ANC visits beginning early in the second trimester, spaced at least one month apart. Preventing MIP remains a challenge in settings with inconsistent application of these recommendations and inadequate provider training in estimating GA.

To improve adherence to these recommendations, a toolkit was designed which includes a job aid with an algorithm to guide providers during ANC visits to determine IPTp-SP eligibility. Twenty-four providers from 24 facilities in Madagascar and 29 providers from seven facilities in Mozambique were trained on use of the job aid and interviewed three months later about their experience.

Individual providers were interviewed using a questionnaire to assess the clarity and utility to the job aid, and their opinions of the practicality of the orientation. Interviewers also gathered information on years of experience and clinical certification. All providers reported that the job aid reminded them to estimate GA and measure fundal height, which is particularly helpful since few women remember the date of their last menstrual period (LMP).

Health workers also reported that the job helped them encourage the use of long-lasted insecticide treated nets, and reminded them of the proper timing to start IPTp-SP. We conclude that the toolkit is useful to prompt providers to calculate GA and offer IPTp as early as possible in the second trimester.

Future potential directions include revision of all Toolkit components to reflect input from this evaluation, including development of a wall poster version to enhance readability, and inclusion of a pregnancy wheel to facilitate calculation of GA and estimated date of delivery.

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.

Results from a Formative Evaluation of the Malaria in Pregnancy Case Management Job Aid in Nigeria

Job Aids can provide valuable assistance to health workers, but it is important to evaluate if they serve the intended purpose.  With support from USAID’s Maternal and Child Survival Program, Bright Orji, Enobong Ndekhedehe, Elana Fiekowsky, Patricia Gomez, Aimee Dickerson, Reena Sethi, Bibian Udeh, Kristin Vibbert, and Robert Sellke reported at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene on their evaluation of a Job Aid for Nigeria on the prevention of malaria in pregnancy as seen below.

Annually, nearly 7 million pregnant women in Nigeria are at risk of malaria in pregnancy (MIP). Although antenatal care is the platform for the prevention and treatment of MIP, malaria is also treated at outpatient departments.

It is known that women of reproductive age (WRA) are often treated for malaria without assessing pregnancy status, although artemisinin combination therapies are contraindicated in the first trimester of pregnancy, and many pregnant women do not receive the recommended low cost interventions.

In order to increase access to these MIP interventions, the President’s Malaria Initiative supported the Maternal and Child Survival Program and partners to develop a two-page job aid for case management of uncomplicated malaria among WRA. In collaboration with the Nigeria Malaria Elimination Program, the job aid was evaluated in Ebonyi State, a high malaria burden area, to determine providers’ perceptions of its clarity, acceptability, and utility.

A half-day workshop on use of the job aid was provided to 35 health workers (nurses – 20%; nurse-midwives – 20%; community health extension workers – 48%; and medical doctors – 12%) already trained on MIP case management, selected from 15 facilities where WRA seek care. After 3 months of use, a one-page questionnaire was administered to 34 health workers.

One-hundred percent stated that the job aid helped them to do the following: identify pregnant women among the WCBA presenting with fever; use rapid diagnostic tests to diagnose malaria; and treat uncomplicated MIP. Sixty-eight percent used the job aid to provide correct treatment for severe malaria and 88% used it while providing services all or most of the time.

The results indicated that after a half-day orientation on use of the job aid, health workers were able to use it to help them identify women who may be pregnant and provide appropriate treatment for uncomplicated MIP. They are also able to explain its use to colleagues.

It is suggested that a poster-size version could be printed and disseminated to appropriate cadres of health workers in clinics where WRA seek care for fever, as it is anticipated that providers could benefit from its use.

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.

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.