Category Archives: Monitoring

Malawi Makes Progress and Plans to Defeat Malaria: Directions from the 2017 Malaria Indicator Survey

Children, Equity, IPTp, ITNs, Monitoring

Malawi has conducted four Malaria Indicator Surveys (MIS), with the most recent being in 2017. Such surveys are crucial tools for [planning and evaluating efforts by national control programs and their partners. Dr. Dan Namarika, Secretary for Health, Ministry of Health in the preface to the 2017 Report sums up the context and progress best, and so first, we have reproduced his narrative below.

Then we look at the example of the insecticide treated net (ITN) data as a way to guide future planning. The MIS format itself has seen improvements with much better color graphics in addition to the traditional tables. Some of these are also shared herein.

According to Dr Namarika, “Malaria is a major public health problem in Malawi where an estimated 4 million cases occur each year. Children under age 5 and pregnant women are most likely to have severe illness. The Ministry of Health, in collaboration with partners, has developed the Malawi Health Sector Strategic Plan 2017-2022, which articulates the priorities for health sector development in the next 6 years and prioritizes malaria. In line with that emphasis, the National Malaria Control Program has just finished the development of the National Malaria Strategic Plan 2017–2022 with the goal of scaling up malaria interventions to reduce morbidity and mortality by 50% in 2022.

“We strive for progress in achieving prompt, effective malaria treatment. We hope to improve access to early intervention and treatment by expanding village clinic services, using insecticide-treated nets, spraying inside residences, managing the environment, encouraging changes in social behaviour and communication, and preventing malaria in pregnancy. We have set for ourselves high targets for these interventions, and we are confident that we will achieve our strategic goals of halving the incidence of malaria and deaths, as well as reducing the prevalence of malaria and malaria-related anaemia.

“Surveys such as the current Malaria Indicator Survey (MIS) are essential measures of progress towards these goals. Without measurement, we can only guess about progress. The 2017 Malawi Malaria Indicator Survey (MMIS) is the country’s fourth nationally representative assessment of the coverage attained by key malaria interventions. Interventions are reported in combination with measures of malaria-related burden and anaemia prevalence testing among children under age 5.

“Overall, there has been considerable progress in scaling up interventions and controlling malaria. We noted a decline in malaria prevalence from 33% in 2014 to 24% in 2017. Insecticide-treated net (ITN) ownership has increased from 70% in 2014 to 82% in 2017.

“Results of the 2017 MIS also show improvement on use of intermittent preventive treatment during pregnancy (IPTp) by pregnant women age 15-49. Coverage has increased from 64% for two or more doses in 2014 to 77% in 2017. The percentage of women who took three or more doses of SP/Fansidar for prevention of malaria in pregnancy increased from 13% in 2014 to 43% in 2017.

“In addition, numbers of children receiving a parasitological test and artemisinin-based combination therapy continue to increase.

“These results represent the combined work of numerous partners contributing to the overall scale-up of malaria interventions. I would like to request that all partners make use of the information presented in this report as they implement projects to surmount the challenges depicted here.”

According to PMI, “The 2017-2022 National Malaria Strategic Plan (MSP) builds on the successes achieved and lessons learned during implementation of previous strategic plans.” The example of ITN targets is illustrative and is included in the target, “At least 90% pf the population use one or more malaria preventative interventions.”

So in addition to showing progress with ITNs, the MIS 2017 report also points to gaps that require strengthened intervention. While there has been an increase of household net ownership we can see in the graph that the target for universal coverage of 1 net for 2 people still needs work. We can also see in the graphs that equity remains a challenge with a lower proportion of poorer households owning a net. In addition net ownership is lower in the Central Region of the Country.

We learn from the graphs that having access to a net in the household does not guarantee that people will actually use or sleep under them. The tables show us that the traditionally defined ‘vulnerable groups’ like pregnant women (62.5%) and children below the age of 5 years (67.5%) were more likely to sleep under nets than household members in general (55.4%). The push towards universal coverage stresses that all household members contribute to the health, welfare and wealth of the family and should be protected from malaria.

Now we should Return the comments by Dr Namarika on the value of having MIS data. All endemic countries need to ensure their malaria data are up-to-date to ensure they use this information to keep their strategic plans on track to defeat malaria.

African Leaders Malaria Alliance Recognizes Country Achievements, Adds NTDs to its Scorecard

Advocacy, Borders, Children, Conflict, Costs, Epidemiology, Funding, Human Resources, Leadership, Monitoring, Mortality, NTDs, Partnership, Surveillance

The 30th African Union (AU) Heads of State Summit at its headquarters in Addis Ababa, Ethiopia provided an important opportunity to bring the challenges of infectious diseases on the continent to the forefront. Led by the African Leaders Malaria Alliance (ALMA), two major activities occurred, raising greater awareness and commitment to fighting neglected tropical diseases (NTDs) and recognizing the contributions countries have made in the fight against malaria.

For many years ALMA has maintained Scorecard for Accountability and Action by monitoring country progress on key malaria interventions. It later added key maternal and child health indicators.  At the AU Summit ALMA announced that NTD indicators would be added to the scorecards which are reported by country and in summary.

The scorecard will now “report progress for the 47 NTD-affected countries in sub-Saharan Africa in their strategies to treat and prevent the five most common NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma. By adding NTDs to the scorecard, African leaders are making a public commitment to hold themselves accountable for progress on these diseases.”

In the press release Joy Phumaphi, Executive Secretary ofALMA, explained that, “Malaria and NTDs both lay their heaviest burden on the poor, rural and marginalised. They also share solutions, from vector control to community-based treatment. Adding NTDs to our scorecard will help give leaders the information they need to end the cycle of poverty and reach everyone, everywhere with needed health care.” This will be an opportunity to demonstrate, for example, that, “In 2016, 40 million more people were reached with preventive treatment for at least one NTD than the year before.”

The combination is based on the logic that NTDs and malaria are both diseases of poverty. Malaria and several NTDs are also vector-borne. Also community platforms are a foundation for delivering needed drugs and supplies to tackle these diseases. Ultimately the decision shows that Heads of State are holding themselves accountable for progress in eliminating these diseases.

At a malaria-focused side meeting of the AU Summit Dr. Kebede Worku (Ethiopia’s State Minister of Health) shared that his government has been mobilizing large amount of resources to the fight against malaria which has led to the shrinking of morbidity and mortality since 2005. He also stressed that Africans should be committed to eliminate malaria by the year 2030. “Failing to do so is to repeat the great failure of 1960s faced at the global malaria fighting.”

The highlight for the malaria community at the Summit was the recognition of six countries that have made exemplary progress in the past year. The 6 countries that are leading the way to a Malaria-Free Africa by 2030 are Algeria, Comoros, Madagascar, the Gambia, Senegal, and Zimbabwe, recognized by ALMA for their sharp decline in malaria cases. Madagascar, the Gambia, Senegal and Zimbabwe Reduced malaria cases by more than 20 percent from 2015 to 2016. Algeria and Comoros are on track to achieve a more than 40 percent drop in cases by 2020.

H.E . Dr. Barnabas Sibusiso Dlamini, the Prime Minister of the Kingdom of Swaziland, whose King and Head of State is the current chair of ALMA, warned all endemic countries that, “When we take our eyes off malaria, the cost for our countries is huge. Yet if we increase our efforts to control and eventually eliminate malaria, the yield we get from it is tremendous. It is time that we dig deep into our pockets and provide malaria programmes with the needed resources.”

Mentioning the need for resources raises a flag that calls on us to be a bit more circumspect about progress. IRINNews notes that this is a critical time in the fight against malaria, when threatened funding cuts could tip the balance in an already precarious struggle. IRIN takes the example of Zambia to raise caution. They report that the results of malaria control and the government efforts have been uneven. While parasite prevalence among small children is down almost by half in some areas, many parts of the country have seen increases in prevalence

IRIN concludes that, “For now, the biggest challenge for Zambia will be closing the gap in its malaria elimination strategy, which will cost around $160 million a year and is currently only about 50 percent funded – two thirds from international donors and one third from the Zambian government. Privately, international donors say the government must spend more money on its malaria programme if it is to succeed.” Cross-border transmission adds to the problem.

Internal strife is another challenge to malaria success. “The recent nurses’ strike which lasted for five months may have cost Kenya a continental award in reducing the prevalence of malaria during the 30th African Union Summit in Ethiopia on Sunday.” John Muchangi in the Star also noted that, “However, Kenya lost momentum last year and a major malaria outbreak during the prolonged nurses’ strike killed more than 30 people within two weeks in October.”

Finally changes in epidemiology threaten efforts to eliminate malaria in Africa. Nkumana, et al. explain that, “Although the burden of Plasmodium falciparum malaria is gradually declining in many parts of Africa, it is characterized by spatial and temporal variability that presents new and evolving challenges for malaria control programs. Reductions in the malaria burden need to be sustained in the face of changing epidemiology whilst simultaneously tackling significant pockets of sustained or increasing transmission. Many countries like Zambia thus face both a financial and an epidemiological challenge.

Fortunately ALMA is equipped with the monitoring and advocacy tools to ensure that its members recognize and respond to such challenges. The Scorecards will keep the fight against the infectious diseases of poverty on track.

The quantitative impact assessment of community health projects in selected African countries by using Lives Saved Tool

Monitoring, Mortality, water

Park 1Chulwoo (Charles) Park who has been undertaking the Masters of Science in Public Health at the Johns Hopkins Bloomberg School of Public Health is sharing herein his experiences with the LiST tool in African countries.

The Lives Saved Tool (LiST) is a computer-based tool that estimates the impact of scaled up health intervention packages in a quantitative manner. By modeling complex mathematical relationship of coverage difference among interventions for maternal, neonatal and child health (MNCH), LiST shows us quantitative results, such as mortality rates, incidence rates, number of cases averted, percentage of stunting and wasting, number of cause-specific death and lives saved.

Especially, LiST can project and run multiple scenarios for subnational target population in the country not only to evaluate existing MNCH project but also prioritize investments for the future based on the quantitative results. World Vision International (WVI) has implemented LiST analysis to strengthen its evaluation and strategic planning methods for MNCH projects since 2013.

Recently, the mid-term evaluations for Access to Infant and Maternal (AIM)-Health project in Kenya, Mauritania, Sierra Leone, Tanzania, and Uganda were conducted through mixed methods analysis, both qualitative research (in-depth interview and focused group discussion) and quantitative research (LiST) from June to September of 2014.

Park 2Subsequently, LiST was solely utilized to quantify the retrospective impact of Water, Sanitation, and Hygiene (WASH) project in Southern Africa Region (SAR), Malawi, Mozambique and Zambia between 2010 and 2014. The significant impact indicates that the combined effect of all five WVI WASH interventions (improved water source, home water connection, improved sanitation, hand washing with soap, and hygienic disposal of children’s stools) have prevented 989,745 diarrhoeal cases among the under-five target population of 506,019 children.

In other words, every single young child prevented 1.96 cases of diarrhea, and prevention rate for diarrhoea was 13% throughout the implementation period. Another results indicate that WVI’s WASH project contributed a 209% mean increase in percentage of under-five lives saved and 15.5% mean decrease in under-five mortality rates across SAR.

  • Chulwoo (Charles) Park, MSPH ’15
  • Johns Hopkins Bloomberg School of Public Health, Department of International Health, Division of Global Disease Epidemiology and Control
  • For more information write to e-mail: park@jhmi.edu

Data for Decision Making Series: The Importance of CHW Data Collection

Community, Monitoring

This posting appeared originally on website of 1 Million Community Health Workers.

This week marks our final installment in the Data for Decision Making series! For our final interview weDSCN1535 talked with Dr. William (Bill) Brieger, Senior Malaria Specialist at Jhpiego and a Professor in the Health Systems Program of the International Health Department at John Hopkins Bloomberg School of Public Health. For over two decades Dr. Brieger taught at the African Regional Health Education Center at the University of Ibadan, Nigeria. He also previously served as a public health and health education consultant to various international organizations including the World Bank, the African Program for Onchocerciasis Control, UNICEF, the World Health Organization, US Peace Corps, and various USAID implementing partners. Dr. Brieger is internationally known for his expertise in social and behavioral aspects of disease control and prevention.

What are the most pressing challenges in the development of scaled-up CHW programs today?

 I think part of the challenge is that it is difficult to obtain a clear commitment and approach regarding the implementation of CHW programs. A good contrast is seen in the difference between integrated community case management (iCCM) and community directed intervention (CDI). With iCCM, organizations focus on getting treatments to people, whereas with CDI, organizations are interested in building up capacity within communities to support distribution of key health services. Philosophically, iCCM and CDI programs are two different approaches, with CDI aiming to help communities make a conscious decision about participating in the process and making a comDSCN5479mitment to support any volunteers within the community.

The other challenge is that NGOs provide different programs and interventions, which is difficult for countries – mainly Ministries of Health – to manage. I think Rwanda has been the most successful with harmonization and represents a good example of overcoming NGO program fragmentation. Rwanda has systematized the implementation of NGO programs, by requiring NGOs to go through the Ministry of Health to ensure that their programs adhere to the national standards. Burkina Faso has also tried to tackle this problem, and the Ministry of Health has created a “Community Health Promotion Directorate” to assist in harmonizing service provision amongst NGOs. There are certain structural approaches to management that can help scale-up programs while maintaining community commitment; but CHW scale-up will not work unless the community is strongly involved in the selection of health volunteers and is holding those volunteers accountable to community norms and expectations.

Why is data on frontline health workers, particularly CHWs, important?

Data on CHWs and data from CHWs are equally important. Organizations need to know who is providing services in the community so they can plan for training and continuing education. Having a good record of community volunteers and keeping that record updated is important, especially at the health center level. Data collection starts with the health center keeping data on the villages where they operate – the geographical coverage, counts on the volunteers within that village, demographic information about the volunteers, and where they work. Monthly records should be submitted by CHWs to ensure proper service delivery and patient tracking. If all of this is being done, then the data needed for making programmatic decisions can be sent forward to the district, state, or regional province.

In your opinion, what are the largest gaps in data on frontline health workers, particularly CHWs, right now?

 One of the largest gaps in CHW datDSCN1485aa is data showing whether CHW deployment mirrors community needs. For example, based on experiences in Rwanda and Nigeria, we know it is very important to have older female CHWs provide maternal health services, particularly woman who have been pregnant before. It is critical for an older woman to provide these services because she will be able to gain the trust of her community, which will allow pregnant women in the community to see the volunteer to discuss their pregnancy and receive treatment without any stigma. Situations like this demonstrate how important it is to keep track of the demographics of CHWs, along with the service needs of communities, especially services involving confidentiality like home-based care for HIV. With this information in hand, it can be quickly determined if an organization has CHWs with the appropriate characteristics to serve a community.

How can we begin to close these gaps?

DSCN1595 volunteer brings his village register to clinic for checking Currently, most health centers do not keep a good record of community volunteers. This is where we can start to close the gaps in CHW data. If organizations and governments start streamlining data at the health center level, this data can then be reported to other levels of the health system. It is important to at least have an annual or semiannual assessment to determine changes, such as exits and promotions, within the CHW population. I have always envisioned it as a partnership between the health center and the community, so that the health center really knows the catchment area. For example, in most of the health centers and small clinics in Nigeria, the staff draws a hand-drawn map of their catchment area so that they know where their clients will come from. While imperfect, this allows the health center staff to have a good understanding of the community demographics. However, before this can happen it is critical that we start to actually keep track of community volunteers and health workers.

Equity, Inequities and Malaria

Equity, Monitoring

The World Health Organization has just released a new report entitled, State of inequality: Reproductive, maternal, newborn and child health. Because of its effort to look across the board at low and middle income countries generally, it does not include more region specific indicators like malaria services. This led us to look at a few recent DHS/MIS  (Demographic & Health and Malaria Indicator Surveys) to see what we can learn about equity or its opposite for malaria.

For RNMCH malaria indicators and equity we can examine coverage of long lasting insecticide-treated nets for both pregnant women (abbreviated as “preg < LLIN” in the attached charts) and children below five years of age (child < LLIN), taking of at least two doses of intermittent preventive treatment by recently pregnant women (IPTp2), and finally receipt of artemisinin-based combination therapy for febrile children below five years of age (ACT child, or where ACT not specified AMD child for antimalarial drug).

Slide4The equity variables presented in these surveys include residence in a rural or urban area, education of the woman, and wealth quintile. Recent reports from Nigeria (DHS 2013), Malawi (MIS 2014), and Angola (MIS 2011) were examined.

The first issue one notices is that these countries have not achieved the Roll Back Malaria coverage target of 80% that was set for 2010, let along sustained it. One could argue that it is not important to talk about equity until a country Slide10demonstrates the health systems capacity to seriously scale up these interventions. On the other hand one could also argue that efforts toward achieving equity at any stage of a program are important as these point to future sustainability and achievement.

The three countries in question each present a very different picture when it comes to equity. Starting with women’s education it is important to note that in two of the countries the proportion women with  post secondary is too negligible to analyze separately. The underlying last of access to post-secondary education is an important equity issue in itself.

Slide7For Nigeria access to both IPTp and ACTs for children is skewed toward those with higher levels of education. Angola’s coverage is also better for more highly educated women. Malawian women with lower education have better IPTp2 coverage, but the other indicators are mixed.

Rural disparity compared to better urban access to malaria commodities is evident in Angola and Nigeria for all Slide2indicators, while Malawi is again mixed. Interestingly in Malawi children in rural areas (41%) show better use of ACTs than those in urban settings (23%).

Angola exhibits the starkest contrast among wealth quintiles with all indicators showing increased coverage as wealth increases. In Nigeria this is true for IPTp and ACTs, but for LLINs, there is a peak in the middle quintile. It is often said in Nigeria that wealthier people prefer screening their homes than sleeping under nets.

Slide9Many factors enter into the picture. Malawi which is poorer in terms of GDP that oil-rich Angola and Nigeria has achieved better overall coverage with less pronounced disparities. One should also consider the differences in physical size with implications for program logistics among the countries.

In its own report, WHO says, “Health inequality monitoring is an essential step towards achieving health equity. It has broad applications and can be conducted across diverse health topics. Applying the best practices in health inequality monitoring presents an opportunity to share the state of inequality with stakeholders, indicate areas in need of improvement and track progress over time.” With tools like DHS, MIS and even national health information systems, endemic countries should also monitor their malaria intervention coverage and bring stakeholders together to address equity gaps.

Moving toward Malaria Elimination in Botswana

Borders, Elimination, Indoor Residual Spraying, Monitoring, Surveillance, Vector Control

elimination countriesThe just concluded 2015 Global Health Conference in Botswana, hosted by Boitekanelo College at Gaborone International Convention Centre on 11-12 June provided us a good opportunity to examine how Botswana is moving toward malaria elimination. Botswana is one of the four front line malaria elimination countries in the Southern African Development Community and offers lessons for other countries in the region. Combined with the 4 neighboring countries to the north, they are known collectively as the “Elimination Eight”.

The malaria elimination countries are characterised by low leves of transmission in focal areas of the country, often in seasonal or epidemic form. The pathway to malaria elimination requires that a country or defined areas in a country reach a slide positivity rates during peak malaria season of < 5%.

pathwayChihanga Simon et al. provide us a good outline of 60+ years of Botswana’s movements along the pathway beginning with indoor residual spraying (IRS) in the 1950s. Since then the country has expanded vector control to strengthened case management and surveillance. Particular recent milestones include –

  • 2009: Malaria elimination policy required all cases to be tested before treatment malaria elimination target set for 2015
  • 2010: Malaria Strategic Plan 2010–15 using recommendations from programme review of 2009; free LLINs
  • 2012: Case-based surveillance introduced

The national malaria elimination strategy includes the following:Map

  • Focus distribution LLIN & IRS in all transmission foci/high risk districts
  • Detect all malaria infections through appropriate diagnostic methods and provide effective treatment
  • Develop a robust information system for tracking of progress and decision making
  • Build capacity at all levels for malaria elimination

Botswana like other malaria endemic countries works with the Roll Back Malaria Partnership to compile an annual road map that identifies progress made and areas for improvement. The 2015 Road Map shows that –

  • 116,229 LLINs distributed during campaigns in order to maintain universal coverage in the 6 high risk districts
  • 200,721 IRS Operational Target structures sprayed
  • 2,183,238 RDTs distributed and 9,876 microscopes distributed
  • While M&E, Behavior Change, and Program Management Capacity activities are underway

Score cardFinally the African Leaders Malaria Alliance (ALMA) provides quarterly scorecards on each member. Botswana is making a major financial commitment to its malaria elimination commodity and policy needs. There is still need to sustain high levels of IRS coverage in designated areas.

Monitoring and evaluation is crucial to malaria elimination. Botswana has a detailed M&E plan that includes a geo-referenced surveillance system, GIS and malaria database training for 60 health care workers, traininf for at least 80% of health workers on Case Based Surveillance in 29 districts, and regular data analysis and feedback.

M&E activities also involve supervision visits for mapping of cases, foci and interventions, bi-annual malaria case management audits, enhanced diagnostics through PCR and LAMP as well as Knowledge, Attitudes, Behaviour, and Practice surveys.

Malaria elimination activities are not simple. Just because cases drop, our job is easier. Botswana, like its neighbors in the ‘Elimination Eight’ is putting in place the interventions and resources needed to see malaria really come to an end in the country. Keep up the good work!

Invest in Using Preventive Services: an Update from the 2014-15 Uganda Malaria Information Survey

IPTp, ITNs, Monitoring

MIS Uganda 2014-15The Demographic and Health Survey people have just released the preliminary MIS results for Uganda. From the viewpoint to the Millennium Development Goals (MDGs), there are cautiously positive signs.

Insecticide treated bednet ownership by households has reached 90%. Equity appears to have been achieved with the households in the lowest, second and third wealth quintiles registering 92%, 94% and 93% ownership. The highest and next highest quintiles had 85% and 88% ownership respectively. Those in the higher wealth quintiles often have better quality housing that of itself offers preventive benefits.

An interesting number is that over 86% of households obtained their nets through campaigns. It appears that the catch up phase of net distribution is repeating itself and the more sustainable keep up phase where nets are provided through routine services has not taken effect.

Household ownership of at least one net translates into use by only 69% of residents generally, and still only 74% in homes that actually own a net. Net use by ‘vulnerable groups’ was a bit better: 74% for children below five years of age and 75& for pregnant women. Thus we can see that household ownership does not guarantee that we meet the 2010 target of 80% coverage/use.

We have moved from recommending two doses of sulfadoxine-pyrimethamine as intermittent preventive treatment for malaria in pregnancy to three or more. The MIS does not report on increased doses but even for two contacts, only 25% of recently pregnant women in Uganda were covered.

The results show that malaria prevention is still an elusive goal. Thirty per cent of children given malaria rapid diagnostic tests during the survey had malaria parasite antigens. We must invest more in ensuring that preventive interventions are routinely available and are actually used before our attention is diverted from the MDGs to the SDGs.

Highlights from Malawi’s 2014 Malaria Information Survey

IPTp, ITNs, Monitoring, Treatment

Two major forms of malaria data collection help inform national malaria control programs and their supporters about progress and help focus continued resources and interventions. Routine national health information tells us about program implementation on a regular basis. National surveys give us a point-in-time picture of coverage.  For the latter, Malawi has been fortunate in recent times to have conducted Malaria Information Surveys every two years.

Pf_mean_2010_MWIMalawi continues to have endemic malaria as documented by the MAP project in the attached graphic. While some of its neighbors in southern Africa are moving toward elimination, Malawi still experiences prevalence (as measured by rapid diagnostic test) in children below five years of age of 43%, 28% and 33% in 2010, 2012 and 2014 respectively.

In the chart below we can see that malaria preventive measures have varied in coverage over the three survey periods and may be said to be on a very slightly upward trend.  The Roll Back Malaria target of 80% coverage by 2010 and the US President’s Malaria Initiative target of 85% are still illusive.

In fact, simply having an ITN in the home is no guarantee that people will use it. Overall in 2014 72% of people living in a house with a net slept under one the night before the survey. The rate of use was better for children below five years of age (87%) and pregnant women (85%), but a gap remains.

Malawi MIS 2014 HighlightsOverall coverage for two doses of sulphadoxine-pyrimethamine (SP) for intermittent preventive treatment in pregnancy (IPTp) remains low. Now that WHO is recommending IPTp with SP during each antenatal care visit after 13 weeks, we are aiming for 3, 4 or more doses. In 2014 89% pregnant women in Malawi received one dose, 63% received two and 12% received three.

Malaria treatment for febrile children was the indicator with the best performance (not counting the fact that treatment was not always preceded by a diagnostic test).  Most (93%) of children took an artemisinin-based combination therapy (ACT) drug, and 74% took it within a day of fever onset.

The 2014 MIS provides more detailed breakdown by region and socio-economic group, which should be helpful for planning.  The major take home message though is that five years after the RBM target dates, many countries, Malawi included, have not been able to scale up and sustain the high intervention coverage needed to bring down mortality and guide us on the pathway to malaria elimination.

As the 2015 Millennium Development Goals are being replaced with a broader development agenda, we hope that malaria will not become a neglected tropical disease again. Actually using data from the MIS to take timely decisions by national programs and donors is essential to keep us on the path.

Jhpiego at ASTMH: Performance Quality Improvement for IPTp in Kenya

Health Systems, Human Resources, IPTp, Malaria in Pregnancy, Monitoring

Monday 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 Kenya.

Endemic areasOne of the panel presentations is “Performance Quality Improvement Lending to Corrected Documented Outcomes for Intermittent Preventive Treatment in Kenya,” by Jhpiego staff Muthoni Kariuki, Augustine Ngindu Isaac Malonza, and Sanyu Kigondu, who are working with USAID’s Maternal & Child Health Integrated Project (MCHIP).

According to Malaria policy in Kenya all pregnant women in malaria endemic areas receive free intermittent preventive treatment with SP have access to free malaria diagnosis and treatment when presenting with fever have access to LLINs (National Malaria Strategy (NMS) 2009–2017).

By 2013 80% of people living in malaria risk areas should be using appropriate malaria preventive interventions. Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine Pyrimethamine (IPTp-SP) intervention is recommended for use in malaria endemic region.

PQI approachMCHIP broadly implemented Capacity Development and service delivery and improvement interventions that also had impact on the delivery of malaria in pregnancy services through collaboration with the Ministry of Health divisions/units at national level: (malaria, reproductive health, community health).

At county level scale up provision of IPTp at facility level took place in 14 malaria endemic counties. This included 8 counties in the lake endemic region including Bondo sub-county (the MCHIP model sub-county) and 6 in the coastal endemic region.

Quality Improvement through Performance Quality Improvement (PQI) process was instituted to enhance service delivery. The MCHIP era in Bondo Strengthened ANC Services using the following:

  • Development of MIP Standards-Based Management and Recognition (SBM-R) standards
  • Orientation of facility in-charges, supervisors and service providers on the standards
  • Monitoring of IPTp uptake using DHIS2 data
  • Feedback to facility in-charges and supervisors on DHIS2 findings
  • Collection of ANC data from ANC registers (2011-2013)
  • Feedback to facility in-charges and supervisors on ANC data

Quality improvement in the malaria in pregnancy component was undertaken with the objective to improve quality of MIP services including IPTp data management at facility level using PQI approach. An Example of a MIP SBM-R standard is seen below.

Sample StandardIn-service training focused on orientation of facility in-charges on PQI who then continued orientation at Facility Level. Overall we oriented 1200 facility in-charges and 100 supervisors on the standards. Facility in-charges cascaded orientation to 2,441 service providers.

ANC DataWe then analysed ANC data from DHIS (2011-2013) indicated proportion of pregnant women receiving IPTp2 was higher than IPTp1 (IPTp2+ doses reported as IPTp2 dose). We helped improve reporting by  service providers not oriented on use of the ANC register in order to reduce data errors.

In conclusion, PQI is a best practice in provision of MIP services. Standardization of knowledge among service providers is essential in provision of quality MIP services. Development of facility in-charges as mentors in the facility to ensure continued orientation of new service providers.

Use of appropriate monitoring tools is necessary to assist in assessment of quality of services provided including data management. Feedback to service providers is one of the performance rewards and encourages participation in knowledge acquisition

 

 

Improving the Quality of Malaria Data in Burkina Faso

Monitoring

Jhpiego and partners have been implementing USAID’s Improving Malaria Care (IMC) project in Burkina Faso for the past 9 months. In the paragraphs below, the team in Ouagadougou has reported their experiences in improving the quality of malaria data reported from the district level. Good quality data are needed to identify challenges and successes and make decisions for future malaria programming

DSCN5436 reviewing malaria treatment recordsIMC involves data collectors (Healthcare providers) directly in the data validation process. Previously, the malaria data validation was supported by the Global Funds and was done at the Regional level. The new approach proposed by IMC is to organize malaria data validation at district level where the healthcare providers who continuously collect data, can participate in the data validation meetings.

The pilot phase was conducted in the first 20 supported Health Districts in April (14th – 18th). In total, 520 healthcare providers attended the data validation meetings across 20 Health Districts. The most important lessons learnt are following:

  1. The involvement of the primary data collectors (Healthcare providers) in this activity reinforced their capacity to improve data quality;
  2. The correction of the mistakes made during these meeting have been integrated in the national database (BD_Malaria);
  3. This was another opportunity to explain the key indicators of malaria and how to control the data quality inside of the Health Facility;
  4. Based on the quantity of the mistakes noted during these data validation meetings in only 20 Health Districts (20 of 63 HD), we can affirm that these are some important data quality issues.

Dr Kam Semon, District Medical Officer of Banfora Health DistrictDr Kam Semon, District Medical Officer of Banfora Health District, after the Data validation workshop shared his views of the experience.

“Firstly, allow me to thank Jhpiego for his permanent assistance and innovation regarding healthcare management. I have appreciated the new approach developed by Jhpiego to ensure data quality. During this meeting I have noted that they are lot of mistakes in the data we used to plan and to make decision.

“I have noted that the Data manager at District level and healthcare providers (who collect routine data) have to work very closely to improve and ensure data quality. That means we have to more involve the Data Manager of District in the regular supervision visits. […] I promised you to use the new approach for all health data validation.

“I will discuss with my team, to include the data validation using that new approach in our quarterly health management meeting. I would like to thank Jhpiego once again. I also thank USAID for his financial support to the IMC project. “