Category Archives: Learning/Training

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

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

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

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

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

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

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

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

Jhpiego at 40 – commitment to malaria prevention and control in Burkina Faso

Jhpiego 40th Anniversary celebration in Ouagadougou with First Lady, US Ambassador, Minister for Health and Jhpiego's President and Vice President

Jhpiego 40th Anniversary celebration in Ouagadougou with First Lady, US Ambassador, Minister for Health and Jhpiego’s President and Vice President

Jhpiego was founded in 1973 to provide technical assistance to countries where the risk of maternal mortality and morbidity was quite high.  While focusing on local capacity building from the start, Jhpiego’s model for technical assistance has evolved.  Burkina Faso first benefitted in 1983 by having health staff attend intensive training at Johns Hopkins Hospital.  Subsequently Jhpiego’s work moved to the field, and some of the early trainees became staff on the ground.

Jhpiego established an office in Ouagadougou in 1996, and one of the earliest projects focused on malaria in pregnancy as part of USAID’s flagship program “Maternal and Neonatal Health” (MNH).  It was during that time that Jhpiego collaborated with partners like CDC to do some of the early testing of the intermittent preventive treatment of malaria in pregnancy (IPTp) in West Africa.  The results of this life-saving intervention were published in the American Journal of Tropical Medicine and Hygiene.

Jhpiego continued to provide technical assistance on malaria in pregnancy interventions and capacity building to the Ministry of Health (MOH) in Burkina Faso through the MNH project and into its successor, USAID’s ACCESS project. Jhpiego worked with partners to update malaria guidelines, training materials, supervisory tools and job aids during this period.

Cover Page Directives finalisées du 23 5 2013In 2009 USAID presented the Maternal and Child Health Integrated Project (MCHIP) with the opportunity to carry out an integrated package of malaria care and prevention strengthening with the MOH and particularly the National Malaria Control Program (NMCP). Over a period of three years Jhpiego, the lead organization in MCHIP, working with together with partners from the NMCP and MOH, was able to accomplish among others the following:

  • Updating Malaria policy and guidelines
  • Updating Malaria supervisory tools and training of supervisors
  • Updating In-service training materials on malaria and training of health facility staff
  • Developing a Strategic communications plan and strategy for malaria
  • Forming of curriculum update committee on malaria at national training schools for primary health staff
  • Training of US Peace Corps Volunteers to support malaria activities in their communities
  • Building the capacity and organizational strengthening for the NMCP itself
  • Conducting a situation analysis of rapid diagnostic test acceptance and use
  • Undertaking a health systems analysis of the strengths and bottlenecks of malaria program implementation in Burkina Faso

Jhpiego 40th Malaria BoothLast week, the Burkina Faso office of Jhpiego hosted the organization’s African Malaria Technical Update Workshop with staff from 15 countries participating. Today Jhpiego is taking its 40th Anniversary celebrations to Ouagadougou.  Jhpiego will express appreciation to local partners in the fight against malaria and threats to maternal and child health.

Jhpiego has been committed on the ground in Burkina Faso to building national capacity for controlling malaria specifically for over 15 years. The recent award by USAID of its bilateral program “Improving Malaria Care” to Jhpiego last October cements Jhpiego’s commitment to the country and to reducing malaria for another five years.

Global Fund – timely oversight or trigger happy

In the past year the Global Fund to fight AIDS, TB and Malaria (GFATM) has suspended grants in Mauritania, The Philippines, Zambia, and Mali. In fact one grant to Mali was terminated. Efforts to identify high risk grants are underway.
Some are saying that the Office of the Inspector General (OIG) of GFATM is finally showing some teeth, while others worry that actions to suspend and terminate will harm the very persons that the Global Fund was set up to help. At the recent 22nd GFATM Board Meeting the Executive Director provided the following comments based on OIG work:

  • Based on recent OIG findings in a number of countries, activities involving cash transfers for training events and associated costs, including per diems, travel, meal and expense payments, are in many cases posing a high risk of misuse
  • The OIG has identified five countries where measures to protect Global Fund-financed drug shipments from theft need to be implemented
  • The Secretariat and OIG agree that LFAs have not been sufficiently focused on the identification of fraud risks and actual fraud in Global Fund-financed programs, and may not currently have the capacity to address these risks

Prior to the recent Board meeting, one wonders whether the communication between the Secretariat, the Executive Director and the Office of the Inspector General were clear and efficient. A 6th December 2010 memo entitled “Joint communication on Inspector General matters” mentioned that, “The Inspector General and the Executive Director of the Global Fund have initiated sincere effort towards collaboration to follow up on recent findings by the Inspector General as well as to take steps to permanently strengthen grant oversight.”

The memo concluded that, “The Global Fund, by nature of its mandate, sometimes has to work with entities with weak programmatic and financial capacity, and to operate in environments where there may be a paucity of financial controls and lack of oversight systems. The Global Fund’s risk management systems are constantly improving. Recently discovered fraud has made the Secretariat determined to redouble its efforts to improve these systems.”

In some cases of suspended grants the Global Fund is looking for alternative Principal Recipients to manage the funds or find alternatives to ensure services to those in need do not cease to be served.  The concern about the Local Fund Agents is valid since the Global Fund, unlike other international agencies, does not have country offices or provide technical assistance.

Several years ago I worked with a team in Nigeria to design and deliver adolescent and youth peer education on reproductive health through community based organizations (CBOs). The initial effort focused on how to organize and train peer educators and the technical aspects of reproductive health. Eventually it became obvious when one CBO leader was using her personal bank account to keep project funds that the local CBOs needed as much technical assistance in establishing and maintaining proper financial and accounting procedures as they did in organizing peer based reproductive health education.

The Global Fund operates in a scale thousands of times larger that our small peer education projects, but the basic principle remains. Don’t condemn local organizations for poor financial performance if you did not try to help them develop better financial and accountability procedures in the first place.

Currently 22% of grants are considered to be poor performers. Too much is at stake in reaching 2015 and beyond to simply say to poor performers, “sorry, your funds are suspended.”

eLearning – prepare yourself to count malaria out

In order to count malaria out we need to learn as much as possible about the design and management of malaria control programs, especially setting up a functional monitoring and evaluation (M&E) system from which health workers, program managers and policy makers can learn and then plan improvements.

intro-w-logo-sm.jpgUSAID’s Global Health eLearning Center is a great free online resource for agency staff and health team members to learn about maternal and child health issues, including malaria. Registration is free, and the format does not require much bandwidth, so should be more accessible to learners in developing countries.  As of World Malaria Day – 25 April 2009 – the 29th course will be added to the curriculum, that is a six-module learning activity on malaria in pregnancy (MIP) developed by Jhpiego.  This compliments the existing general malaria course available on the site.

Global Health eLearning was originally designed to help update the knowledge of USAID health, population and nutrition staff. The website now has over 30,000 registered learners, and 80% of those are not directly affiliated with USAID. This means that the courses are filling a continuing education need for a wide variety of people.  Eventually there may be up to 50 courses, which may be organized into focused learning packages.

Another useful free eLearning site is he Open Course Ware (OCW) program of the Johns Hopkins Bloomberg School of Public Health. Lecture materials from approximately 80 of the School’s courses is available consisting of slides, handouts and other resources.  The course on Malariology

Presents issues related to malaria as a major public health problem. Emphasizes the biology of malaria parasites and factors affecting their transmission to humans by anopheline vectors. Topics include host-parasite-vector relationships; diagnostics; parasite biology; vector biology; epidemiology; host immunity; risk factors associated with infection, human behavior, chemotherapy, and drug resistances; anti-vector measures; vaccine development; and management and policy issues.

Jhpiego has a Malaria in Pregnancy Resource Package (MRP) online.  The MRP contains all the materials needed to conduct training on malaria in pregnancy including a facilitator’s guide, sample slides, a brief tutorial, job aids and other reference documents. The training materials emphasize the M&E component of MIP service delivery.

Another key online learning resource is the Roll Back Malaria Toolbox. One can download a number of reference materials for planning and implementing M&E components to all aspects of malaria control services.

There is no excuse not to keep up-to-date on malaria control with all the free eLearning materials available online. Please share with us additional sources and links that foster eLearning on malaria.