Category Archives: Primary Health Care

Experiences and Perceptions of Care Seeking for Febrile Illness among Caregivers and Health Providers in Eight Districts of Madagascar

Andrianandraina Ralaivaomisa, Eliane Razafimandimby, Jean Pierre Rakotovao, Lalanirina Ravony Harintsoa, Sedera Aurélien Mioramalala, Rachel Favero, Katherine Wolf, Patricia Gomez, Jocelyn Razafindrakoto, and Laurent Kapesa of MCSP/Jhpiego (Johns Hopkins University Affiliate), the Madagascar Ministry of Public Health and USAID presented their findings about febrile illness care seeking in Madagascar at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene. Details follow below.

Malaria Care and Treatment in Madagascar is hampered by low perception of malaria risk among caregivers. There is use of self-medication and a lack of health provider knowledge about malaria prevention and treatment in pregnant women. Low-quality care in primary health facilities is another concern (Source: WHO. 2015. Guidelines for the treatment of malaria, 3rd ed.).

As seen in the attached, Study Objectives focus on Caregivers and Pregnant Women as well as Health Providers to determine barriers to effective care seeking of febrile illnesses.

Both Qualitative and Quantitative Approaches were used. Among care seekers we conducted 16 focus group discussion sessions with 128 caregivers and pregnant women. There were also in-depth interviews with 32 pregnant women and 16 caregivers of children under 15. For Health Providers we conducted in-depth interview with 32 public and private health providers and administered 16 knowledge tests and case studies to health providers. We also reviewed logistic management information system records with 16 health

Barriers for Caregivers are seen in the attached table. Barriers were faced by both care seekers and those who did not seek care, but were more common among non-seekers.

Three tables follow that show perceptions of public sector providers, private providers and community health workers. There were positive and negative perceptions of each group of providers.

Health Provider Practices were also studied. They had low adherence to national guidelines for fever and malaria case management. Health workers reported high stock-outs rates of critical commodities (artemisinin-based combination therapy, artesunate). There was also lack of respectful care. Fortunately health provider diagnostic practices included 100% compliance with rapid diagnostic testing in cases of fever. They took temperatures and did physical exams appropriate to client’s symptoms and used microscopy at centers with local laboratory

General Bottlenecks to Timely Care Seeking still existed. There was insecurity due to political situation in some regions. Inability to pay for care or medications was common. Alternative health behaviors included seeking care with traditional healers, and self-medication. There was fear by clients of going to health facilities and inaccurate perceptions of care provided by formal health care system

Recommendations start with the need to train providers and CHWs on national treatment guidelines for managing fever in all age groups and in pregnant women. Efforts are needed to strengthen onsite provider mentoring and supportive supervision and improve respectful care of clients, especially in public sector. Since care seeking still based on cultural norms, there is need to strengthen community/family education about febrile illness dangers and advantages of timely care seeking. Communities can also consider forming “mutuelle” community insurance schemes to relieve cost of care burden.

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.

Achieving UHC through PHC Requires an Implementation Plan

The new Astana Declaration says that, “We are convinced that strengthening primary health care (PHC) is the most inclusive, effective and efficient approach to enhance people’s physical and mental health, as well as social well-being, and that PHC is a cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals.” The Declaration outlined a vision, a mission, and a commitment. An opportunity to discuss how to implement this existed at the two-day conference in Astana Kazakhstan celebrating the 40th anniversary of the seminal Alma Ata Declaration.

Ironically the opportunity was not fully grasped. There were many sessions that shared country experiences ranging from finance to information technology.  Youth who will carry PHC forward for the next 40 years gave their opinions and thoughts. Lip-service as well as actual case examples of community involvement were featured. What we did not hear much of was the specifics of how countries, moving forward, will actually implement the commitments spelled out in the document.

One colleague who has worked with the sponsoring agencies was of the view that since much advanced input and work from many partners and countries had gone into the new Declaration, which was already nicely printed, they were reluctant to provide the slightest chance that debate would be reopened.

As they say, fair enough (maybe), but even if one takes the Declaration as a done deal, the matter if implementation needs to be addressed. There was ample criticism that the Alma Ata Declaration was not properly implemented.  This was in part because academics and development agencies jumped the gun and pushed, with focused financial backing, what would be called selective primary health care that was more agency driven, not community directed as envisioned at Alma Ata (now Almaty) in 1978.

In order not to repeat those mistakes and give full voice to the community and key constituents, at minimum the implementation strategies of the pre-agreed Declaration should have been discussed in specific terms. Sure many ideas and examples were aired, but there was no attempt to focus these into workable strategies.

But was the community even there in Astana to take part in strategizing? One community health worker from Liberia received much attention because she was the odd one out. Sure, there were plenty of NGOs, but not the real grassroots of civil society, although the youth involvement aspect of the conference approached that. Some of these NGOs and agencies had themselves been part of the selective PHC agenda.

There was plenty of talk about us involving them, especially when it came to community health workers (CHWs). CHWs should first be integrated into community systems to ensure they are accountable to communities. Then there should be an equal partnership between community systems and health systems. Otherwise CHWs get lost as just front line laborers.

Of course it is never too late. Regional gatherings may be a better forum that can discuss implementation in a more socially,  economically and culturally appropriate way. Let’s hope we don’t look back in another 40 years and with the Astana Declaration had been better and more faithfully implemented.

Malaria and Primary Health Care: 40 Years after Alma Ata

The Concept of Primary Health Care (PHC) was formalized in 1978 when The World Health Organization and UNICEF convened a major conference in the then Alma Ata in Kazakhstan. The resulting Alma Ata Declaration resulted in advocacy for Health for All, which had evolved into Universal Health Coverage. The Declaration outlined important principles such as community participation in health care planning and delivery, promotion of scientifically sound and acceptable health interventions, the use of community-based health workers (CHWs), and addressing the common endemic health problems in each community. One of those endemic problems common to a majority of communities in Africa is malaria. Now in 2018, 40 years after the Alma Ata Declaration we explore how malaria has progressed within the context of PHC.

The Roll Back Malaria Partnership (RBM) began in 1998, 20 years after Alma Ata. When RBM convened a meeting of African Heads of State in 2000 the resulting Abuja Declaration set targets for major malaria interventions of 80% coverage by 2010. The Abuja Declaration reflected principles of Alma Ata when it called on all member states to undertake health systems reforms which will:

  1. Promote community participation in joint ownership and control of Roll Back Malaria actions to enhance their sustainability.
  2. Make diagnosis and treatment of malaria available as far peripherally as possible including home treatment.
  3. Make appropriate treatment available and accessible to the poorest groups in the community.

By 2011 reality intervened. WHO reported that “In the 10 years that has passed since the Abuja Declaration, there has been progress towards increasing the availability of financial resources for health at least in terms of dollar values. However, there has not been appreciable progress in terms of the commitments the Africa Union governments make to health, or in terms of the proportion of GNI the rich countries devote to Overseas Development Assistance.” Since that time funding from international and bilateral donors has leveled, such that there is even greater need for malaria endemic countries to step forward and guarantee access to malaria prevention and treatment services are available through PHC at the grassroots. Such access needs to move beyond removing barriers to making malaria interventions attractive to the community.

Community Health Workers in Nigeria are trained to provide malaria community case management

Christopher and colleagues looked to the community and examined how response to malaria and other childhood illnesses were faring 30 years since Alma Ata. After they reviewed seven studies of community health workers they concluded that “CHWs in national programmes achieved large mortality reductions of 63% and 36% respectively, when insecticide-treated nets and anti-malarial chemoprophylaxis were delivered, in addition to curative interventions.” (They found little evidence of the effectiveness of these community interventions on pneumonia and diarrhoea.) The challenge they saw was the ability of countries to move beyond successful studies to scale up and sustain community malaria control interventions to the national level and thereby reap the full promises and benefits of PHC.

Others continue to advocate for a community role in achieving malaria goals through PHC. Malaria Consortium has looked at the position of malaria control within the context of Community Based PHC (CBPHC) and the use of CHWs as a means for revisiting Health for All.

Community donates a house in Western Region Ghana to serve as CHPS Compound where malaria services are provided to the community

Ghana’s community-based health planning and services (CHPS) program aims to make primary care accessible at the grass roots. CHPS compounds are small clinics in space usually donated by the community, staffed by community health officers who oversee community based agents (CBAs) and other community volunteers who treat and prevent malaria through integrated community case management. Countries have also build on the community directed intervention approach pioneered by the African Program for Onchocerciasis Control to ensure malaria interventions are delivered through community community planning and action.

Controlling and eventually eliminating malaria will certainly go a long way toward helping achieve Health for All. On this 40th Anniversary year of Alma Ata it is time to ensure that all malaria endemic countries and malaria donors revisit the basic philosophy of community action and participation and ensure that these principals guide us to accessible and sustainable malaria programming by the community “Through their Full Participation.”

(This posting has been extracted from a full article appearing in the April 2018 Issue of Africa Health. Also please join the discussion about Alma Ata at 40 on the forum created by colleagues at the Johns Hopkins Bloomberg School of Public Health.)

New Fully Online Global Health Learning Programs at JHU

Continuing professional development has often been a challenge for people in the field. They may not be able to get study leave, but they do need advanced training in order to progress. The Johns Hopkins Bloomberg School of Public Health as started a new Online Programs for Applied Learning (OPAL) that offers completely online Masters and Certificate degrees.

The Department of International Health is Offering three Master of Applied Learning (MAS) and one Certificate covering global health. The Certificate can be completed in one year minimum and the MAS in two years minimum. More information on these programs can be obtained at the links below.