Category Archives: Performance

World Health Workers Week, a Time to Recognize Health Worker Contributions to Malaria Care

Since the beginning of the Roll Back malaria Partnership in 1998 there has been strong awareness that malaria control success is inextricably tied to the quality of health systems. Achieving coverage of malaria interventions involves all aspects of the health system but most particularly the human resources who plan, deliver and assess these services. World Health Worker Week is a good opportunity to recognize health worker contributions to ridding the world of malaria.

We can start with community health workers who may be informal but trained volunteers or front line formal health staff.  According to the Frontline Health Workers Coalition, “Frontline health workers provide immunizations and treat common infections. They are on the frontlines of battling deadly diseases like Ebola and HIV/AIDS, and many families rely on them as trusted sources of information for preventing, treating and managing a variety of leading killers including diarrhea, pneumonia, malaria and tuberculosis.”

The presence of CHWs exemplifies the ideal of a partnership between communities and the health system. With appropriate training and supervision CHWs ensure that malaria cases are diagnosed and treated promptly and appropriately, malaria prevention activities like long lasting insecticide-treated nets are implemented and pregnant women are protected from the dangers of the disease. CHWs save lives according to Nkonki and colleagues who “found evidence of cost-effectiveness of community health worker (CHW) interventions in reducing malaria and asthma, decreasing mortality of neonates and children, improving maternal health, increasing exclusive breastfeeding and improving malnutrition, and positively impacting physical health and psychomotor development amongst children.”

CHWs do not act in isolation but depend on health workers at the facility and district levels for training, supervision and maintenance of supplies and inventories. These health staff benefit from capacity building – when they are capable of performing malaria tasks, they can better help others learn and practice.

A good example of this capacity building is the Improving Malaria Care (IMC) project in Burkina Faso, implemented by Jhpiego and supported by USAID and the US President’s malaria Initiative. IMC builds capacity of health workers at facility and district level to improve malaria prevention service delivery and enhance accuracy in malaria diagnosis and treatment. Additionally capacity building is provided to health staff in the National Malaria Control Program to plan, design, manage and coordinate a comprehensive malaria control program. As a result of capacity building there has been a large increase in malaria cases diagnosed using parasitological techniques and in the number of women getting more doses of intermittent preventive treatment to prevent malaria during pregnancy.

Malaria care is much more than drugs, tests and nets. Health worker capacity is required to get the job done and move us forward on the pathway to eliminate malaria.

Health Systems Strengthening: Improving quality of services for prevention of malaria in pregnancy through the Standards-Based Management and Reward approach in Kenya

Colleagues[1] from the USAID-MCSP Project and Jhpiego (an affiliate of the Johns Hopkins Bloomberg School of public Health) are presenting a poster at the 64th ASTMH Annual Meeting in Philadelphia at noon on Monday 26th October 2015. Please stop by Poster 385 and discuss the results as presented in the Abstract below

Performance quality cyclePerformance quality improvement (PQI) is one of Jhpiego’s 9 health systems strengthening components in provision of health services towards improvement of maternal health including better pregnancy outcomes. The Standards-Based Management and Reward (SBM-R) approach has been used in improving as well as assessing the quality of services provided at health facilities.

Kenya developed 15 malaria in pregnancy (MIP) SBM-R standards for use by service providers in provision of MIP services and is also used by supervisors to assess the quality of services provided at service delivery points. Facility incharges were trained on the 15 MIP SBM-R performance standards and they oriented service providers in their facilities on use of the performance standards.

Performance IPTpA baseline on SBM-R practices was done in all facilities before orientation in Kakamega east and Kakamega central subcounties and 1st assessment on practices done after three months of practice. A total of 30 health facility incharges from the two malaria endemic subcounties (Kakamega east 16 Kakamega central 14) were trained on the 15 MIP SBM-R performance standards.

The facility incharges oriented 291 service providers (127 Kakamega east, 164 Kakamega central) on use of SBM-R performance standards in provision of MIP services in health facilities. Baseline assessment had an average score of 57% for Kakamega east and 58% for Kakamega central.

Performance Score1st assessments were conducted after three months of practice and showed an average score of 76% for Kakamega east and 64% for Kakamega central giving an overall increase in score of 19% and 13% between baseline and 1st assessment for Kakamega east in Kakamega central respectively.

Use of MIP SBM-R performance standards ensures services provided at health facility level are in line with WHO recommendations and national guidelines. Establishment of PQI as a health systems strengthening component is feasible and is an approach that would make available quality MIP services at facility level. Provision of quality MIP services ensures protection of pregnant women against the effects of malaria in pregnancy.

[1] Augustine M. Ngindu, Gathari Ndirangu, Sanyu N. Kigondu, Isaac M. Malonza

Malaria in Pregnancy – analyzing processes, involving new partners

Malaria in Pregnancy: A Solvable Problem—Bringing the Maternal Health and Malaria Communities Together – a meeting in Istanbul organized by the Maternal Health Task Force, Harvard University.

Take Away Messages from Day 2 Presentations. Report by James Kisia, Kenya Red Cross.

Jayne Webster of the London School of Hygiene and Tropical Medicine as the Malaria in Pregnancy Consortium shared a tool that helps identify and address barriers to the delivery of malaria in pregnancy services.  She referred to the tool as “An innovative ‘soft’ technology, a decision-making tool to improve the effectiveness of the delivery of IPTp and ITNs.” The tool is still under development, but key components were presented.

dscn1612b.jpgJayne noted that there are still research questions to answer on how to effectively implement interventions, but while we are waiting for these questions to be answered there are improvements in data collection, collation and use to be made and used for decision making.

Jayne said that we must use the wealth of knowledge we already have to start to take action and make improvements! She took us through the work in progress of a decision tool for use by health managers to assess country and/or sub-national barriers and priority actions required for effective scale-up of the IPTp and ITNs. The tool will eventually be available on the Malaria in Pregnancy Consortium website.

Nancy Nachbar of Abt Associates presented her experiences on Malaria in Pregnancy: The role of the private sector. She said we must talk about the complete health system. If we fail to consider the private sector, we are not considering the whole system!

Half of care for fever or Diarrhea is happening in the private sector- and much of this is happening in the informal sector. Those who are poorer are utilizing the informal sector for treatment seeking. Unfortunately we lack similar utilization data for antenatal care.

Nancy discussed challenges to private sector participation from the public sector perspective as well as from the private sector perspective. She also discussed opportunities for improving private sector participation in MiP prevention. Nancy incited and excited us to think about way out ideas. One creative idea: Could tithing be used as a funding source for malaria in pregnancy?

A key factor to tie these presentations together is the need to develop tools to assess and guide not only the public sector, but also private health care providers on malaria services to pregnant women.

Improving Quality Performance among Community Health Volunteers

Improving Quality Performance among Community Health Workers Providing Integrated Community Management of Febrile Illnesses in Nigeria

A Poster Presentation at the 60th ASTMH meeting by Bright C. Orji, William R. Brieger, Emmanuel O. Otolorin, Jones Nwadike, Enobong Ndekhedehe, Olugbenga Ishola, Godfrey Akro, Nancy Ali

dscn6360-sm.jpgEfforts to improve access to quality case management of febrile illness include the engagement of Community Health Workers (CHWs) to use Rapid Diagnostic Tests (RDTs), dispense ACTs and manage pneumonia and diarrhea. Use of CHWs reduces challenges like a weak public sector, human resource constraints, and variable quality of the private sector.

Studies have suggested that CHWs are able to perform case management services in a training setting, but not much has been done to measure quality performance among CHWs in the field. Jhpiego and the Akwa Ibom State, Nigeria health authorities trained CHWs and developed simple quality performance standards (one-page tool) for CHWs providing community services in Akwa Ibom State, Nigeria.

All 131 trained CHWs in two local government areas providing malaria, pneumonia and diarrhea case management were assessed using the standards. The tool has 37 performance criteria (PC) to measure CHW knowledge, skills and competence in 3 sections:

  • History taking and Examination
  • Conducting RDTs for Malaria and
  • Illness Management

Trained assessors observed CHWs providing services. Each correctly performed criterion was scored 1 point. Three rounds of assessments were conducted at an interval of two months from May-November, 2011.

At the end of each round assessors provided feedback and refresher training for CHWs during their monthly meetings. During Round 1 CHWs achieved an average of 19 (52.2%) PC. This rose to 25 (67.5%) PC at Round 2 and 28 (75.6%).
PC that needed most improvement included checking signs and symptoms to distinguish among the illnesses. CHWs also needed reinforcement on checking RDT expiry date, entering results on records, safe disposing of sharps, and counseling on preventive measures.

In conclusion feedback after Rounds 1 and 2 helped CHWs improve their performance. Additional quarterly assessments and feedback sessions are planned. CHW supervisors can use this tool to enhance the quality of services provided by the CHWs and improve CHW training.

Supervising volunteer community health workers

supervision-chw.jpgVolunteer community or village health workers (CHWs) are crucial human resources to increase and sustain coverage of malaria interventions. Small and large scale training programs have abounded over the years stimulated by the philosophy of the Alma Ata Declaration on Primary Health Care. Unfortunately, CHW programs often fade after a few years because a donor supported project closed or funds dried up for a public health program and the health staff who trained the CHWs loose touch with them.

Without supervision and encouragement CHWs loose interest and forget what they learned. The challenge therefore is to design an appropriate supervisory system for limited resource settings.

Experience with village health workers for primary care and community community directed distributors for onchocerciasis control have demonstrated that effective and appropriate supervision of CHWs requires three main components or partners as seen in the attached diagram.

Staff of the health facility nearest to the community should have initially reached out to the community to assess their interest in community health interventions and helped them organize. Included in this organization is selection of trusted community volunteers to serve as CHWs.  These health staff provide technical supervision on the health services being provided (case management, net distribution) and management processes (good service records and reports).

Health staff may not be able to visit each village in their service catchment areas frequently, but they can host monthly or quarterly meetings where CHWs bring their service records, collect new supplies and receive technical updates. Health staff review the records for accuracy and give pointers to improve data and service quality.

The second partner in CHW supervision are the community members who actually selected the volunteers. The CHWs must be held accountable to the people who selected them. CHWs can be asked to report at community meetings about progress and services provided, and community members can give feedback on the quality of these services.

The third partner is the CHWs themselves.  Often CHWs in a locality form an association and meet regularly.  These meetings create a form of peer supervision.  CHWs share their experiences and lessons learned. They advise each other and jointly solve common problems such as community refusal to talke certain medicines or hand up their bednets. CHWs can even take turn reviewing the basic lessons they learned at the start.

Supervision does require that people get together and have a dialogue about their work. This often means some degree of travel. Here is where we need to rely on local knowledge and make supervision convenient for all. for example, health staff can schedule such gatherings on market days when CHWs and other villagers would normally come to town.

Until we move to the local level and find locally appropriate solutions to supervision, we will not be able to achieve universal coverage.

Transparency and Accountability

measles-immu-cote-divoire-who.jpgAlthough we do not have a malaria vaccine ready for widespread use, it is instructive to learn about how the Global Alliance for Vaccines and Immunizations (GAVI) plans for its financial future. The BBC Reports that GAVI “needs more than $4bn (£3bn) by 2015. This would enable it to continue existing programmes and roll out new vaccines against diarrhoea and pneumonia. But there are fears donors may want to cut back in the current climate.”

A new development is greater scrutiny by donors. BBC adds that, “In March, the UK pledged £150m to Gavi over 10 years. £10m has already been paid out, but there are plans to review all funding of international agencies – of which GAVI is one – as part of a drive to direct money at only the most effective organisations, a spokesperson confirmed.”

Specifically Britain’s Department for International Development (DfID) announced on 3rd June 2010 that, Full transparency and new independent watchdog will give UK taxpayers value for money in aid.” International Development Secretary, Andrew Mitchell, explained that, “We can’t escape the fact that today’s fiscal landscape is radically different from what has gone before. There is a massive deficit, which it is our number one priority to tackle. Against this backdrop our protected aid budget imposes a double duty to ensure that for every pound of taxpayers’ money we spend, we demonstrate 100 pence of value.”

Mitchell described further plans to move aid away from middle income countries. “We will spend the money on our priorities such as maternal health, fighting malaria, and extending choice to women over whether and when they have children.” Other budget cutting measures were identified. The Global Fund was not mentioned by name in the speech.

He also expressed agreement with the new approach of USAID and said, “Women can hold the key to development in the world’s poorest countries – in education, enterprise, micro-finance and healthcare. Investing in women pays dividends throughout the entire community.”

GAVI’s concerns ultimately have to do with the stability of funding. In its action agenda for achieving Millennium Development Goals (MDGs) UNDP pointed out that, “Well-targeted and predictable aid is a critical catalyst for meeting the MDGs and has produced significant results in Burkina Faso, Mozambique, Rwanda, Uganda and Vietnam by making more resources available for service delivery.”

UNDP also indirectly warns about dependence on aid: “Evidence, however, also suggests that countries need to expand their own domestic resource mobilization and to adjust their budgets to ensure maximum return on their investment.”

This period of economic uncertainly has produced one certainty – soul (and pocket) searching is needed by governments – both of donor countries as well as disease endemic countries – if programs are going to be sustained to the point of disease elimination.

Freezing in Zambia

zambia-malaria-indicators-2008.jpgZambia was one of the first recipients of Global Fund support and since Round 1, it has received 3 HIV grants, 2 TB grants and 3 Malaria grants. The chart here shows that Zambia has performed fairly well on achieving Roll Back Malaria coverage indicators. In fact, though not yet reaching the 2010 targets of 80%, Zambia has been seen as one of the top performers in its efforts to control malaria as highlighted in a panel presentation at the recent Women Deliver Conference.

Therefore it comes as a surprise to read the press release from the Global Fund stating that, “Global Fund confirms freeze on cash disbursements to Zambia’s ministry of health, grants to be transferred to UNDP.” This decision was made in August 2009, though not announced until June 2010. The press release stated …

The freeze in disbursement came after Zambian authorities last year uncovered fraud within its own Ministry of Health. Further investigations by the Global Fund showed that the Ministry of Health was not able to safely manage grants. The organization has demanded the return of US$8 million in unspent funds from the Ministry of Health. The Global Fund has also demanded that Zambia takes action against individuals found to be involved in the unaccounted expenditures that led to the freezing of grant disbursements.

A news source reported that, “Money is still being paid to civil society organisations (CSOs).” As noted above the government component of the grant will be managed by UNDP for the meantime. Sarah Boseley of the Guardian points out threats to continued funding translates to more deaths from the three diseases. Furthermore, “The Global Fund is Zambia’s main donor to the health sector, and the suspension of aid will likely hinder the nation’s efforts to fight Aids, tuberculosis and malaria.”
performance-rating.jpg

It is interesting to reflect on the Global Fund 2007 Progress Report which showed that 83% of CSOs as principle recipients of grants scored ‘A’ or ‘B1’ on their grant performance progress reports compared to 75% of grants managed by UNDP and 72% by government agencies. There has been overall improvement in performance in recent years, but the 2009 results reported this year still place CSOs ahead at 84% performing at ‘A’ or ‘B1’ level compared to 75% for governments and 79% for UNDP. Transferring Zambia’s support from government to UNDP is certainly not a long term solution to its problems.

There seemed to be some confusion about the suspension in Zambia. “Zambia’s Health Minister Kapembwa Simbao denied the suspension of funds and said there had been no indication from the organisation to halt donations,” even though the GFATM Board apparently made the decision official at an April 2010 Board meeting. Zambia’s efforts to fight corruption have been undermined when a former president was charged, though acquitted of corruption charges and the Netherlands suspended aid also because of alleged corruption.

Radio France International explained that, “The freeze became public when Aidspan, a group which works with the Global Fund, posted the decision on its website on Monday. The fund issued a statement two days later.” The GFATM is usually known for its transparency, and so the delay of the announcement about the Zambian funding freeze is almost as perplexing as the problem in Zambia itself.

Since GFATM money comes from taxpayers around the world, public accountability is expected. Shining a light on corruption can preserve disease control funding and save lives.

————–

PS – see relevant article in Global Fund Observer: http://www.aidspan.org/index.php?issue=127&article=4

Quality Improvement and Malaria

Sheila Leatherman and colleagues have written this month that …

Despite … acknowledgment of the critical role of quality of care in  strengthening health systems, there are few descriptions of how to insure high-quality health care in developing countries. While modern  approaches to improving quality are increasingly used globally, their appropriateness for resource poor settings has received little attention and their adoption remains sporadic.

These authors have put together a reference list of 22 quality improvement research study publications in developing countries in the following areas:

  • Emergency obstetric care
  • Acute child illness care
  • Primary care
  • Health system (microsystem level)
  • Prescribing practices

Unfortunately, “Many if not most QI interventions are never published.”

Though these studies do not address malaria issues directly, all are areas that affect malaria services.

The WHO health systems strengthening action framework (2007) does mention malaria is several instances.  For example, the report recommends “working more directly with other international partners (e.g. The Global Fund to fight AIDS, TB and Malaria) on their support for health systems strengthening.” The report also recognizes that an integrated approach is needed because, “One cannot advise on health systems financing from the perspective of malaria or child health alone.”

There are some recent articles that do address malaria service quality issues. Concerning malaria case management in Angola, Rowe et al. found problems in maintaining drug stocks, clinical supervision, use of malaria tests, and health worker knowledge.

Specifically addressing testing/parasitological diagnosis in Tanzania, Mosha and colleagues were concerned about over-diagnosis of malaria. They concluded that, “The introduction of RDTs is likely to lead to financial savings. However, improving diagnosis to one disease may lead to over diagnosis of another illness. Quality improvement is complex but introducing RDTs for the diagnosis of malaria is a good start.”

In Cambodia, Yasuoka and co-researchers studied village malaria workers and found that, “VMWs were effective in conducting diagnosis with Rapid Diagnostic Tests (RDTs) and prescribing anti-malarials to those who had positive RDT results, skills that they had acquired through their training programmes. However, most other services, such as active detection, explanations about compliance, and follow-up of patients, were carried out by only a small proportion of VMWs.”

100_0517.jpgJhpiego has a system of performance quality improvement known as Standards Based Management and Recognition (SBM-R). Jhpiego’s malaria in pregnancy (MIP) work is based on WHO’s guidance that MIP services should be integrated into antenatal care (ANC).

In each country where Jhpiego works a set of appropriate performance standards are developed – for example, 16 basic standards for ANC in Nigeria and 18 in Angola. Malaria in pregnancy interventions in both countries have linked improvements in ANC standards, which include MIP services, to increased use of these MIP services. [picture shows recognition ceremony for health workers and facilities achieving 80% of the standards.]

Quality improvement for malaria services is crucial at the next stage for highly endemic countries on their pathway to elimination. This year all are scaling up for impact. Moving forward this scale up must be sustained. Sustained effort can only happen if there is high performance quality among malaria service providers.

Can International Institutions Change Government Behavior?

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

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

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

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

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

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

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

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

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

Performance History Haunts

Kenya’s Saturday Nation reports that the country lost out on appeal for its Global Fund Round 9 malaria and HIV application rejection. “Late last year, Kenya’s (original) application for funding from the Global Fund on Aids, TB and malaria for $270 million was rejected on technicalities and the country’s poor record with the organisation.”

Apparently the rejection of the appeal was two pronged – proposal quality and past performance. First the Nation reports that, “On Kenya’s appeal for malaria funding for example, the panel upholds that the decision made initially by the technical team was sound and saw no need to reverse it.” Then the Nation quotes a Ministry official as saying, “Our under-performance has been the main undoing.”

To date Kenya has received only two malaria grants from the Global Fund – Rounds 2 and 4. Only 17% of the Round 2 funds were ever disbursed for the $27 million grant after start-up in 2003, and apparently the grant ground to a halt after about 3 years, never entering Phase 2.

sample-indicators-r4-nov-09sm.jpgSo far 63% of the $162 million Round 4 grant have been disbursed since inception in 2006. Expenditures are only 60% of disbursement. On last review in November 2009 the grant scored a B2, meaning inadequate performance but potential demonstrated.  The difficulties in performance and new grant success seem ironic since Kenya has recently made major strides in updating its malaria strategy and action plans to better reflect the country’s epidemiological and transmission profiles.

On top of these problems were reports from Kenya early last year that “the Government appointed a taskforce to trace the missing Sh13 billion grant from the Global Fund to fight Aids, tuberculosis and malaria.”

oig-cover-page.jpgOnce grants have been made, the Global Fund’s Office of the Inspector General has a role in monitoring implementation and colating lessons learned to improve GFATM functioning. The most recent report notes that of 17 recommendations made to Kenya to improve the functioning of its grants, none were implemented. General problems across several countries included among others …

  • Conflicts of interest with PRs and SRs sitting on CCMs
  • CCMs micromanaging grants instead of overseeing them
  • PRs not complying with grant agreement clauses
  • Procurement not executed in line with best practices
  • Weak financial management and internal control of PRs
  • Unworkable monitoring/evaluation systems because of unattainable targets and poor data collection procedures (feature attributed to countring including Kenya)

None of the foregoing problems are secret, and yet countries like Kenya cannot seem to get out of the viscious cycle of poor performance leading to new grant rejection leading to funding shortages that lead to more poor performance in their malaria control efforts.  Back in 2008 Kenya went through major efforts to democratize and improve the functioning of its Global Fund governance mechanisms.  Maybe the malaria partnership has not help Kenya accountable for the promises it made?

PS – the Global Fund is not Kenya’s only weak area for international assistance. According to the Nation yesterday, “Kenya has failed the eligibility test for (US) Millennium Challenge aid in each of the past five years because it falls short on governance standards.”