COVID-19 has caused many health projects in Nigeria to reconsider how they function. The TiPToP malaria in pregnancy project of Jhpiego and Unitaid has been adjusting to the COVID-19 pandemic by training health workers to be more conscious of infection prevention skills. The abstract below is being presented at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting explains what is being done. See Author List below.

Given the importance of infection prevention and control (IPC) measures for reducing the transmission of COVID-19, a cross-sectional, mixed-methods study was conducted to assess IPC knowledge and practices of frontline health workers – both facility- and community-based health workers (CHWs) – in three local government areas (LGA) in Nigeria: Akure South, Bosso and Ohaukwu. In November 2020, a structured survey was administered to 622 health workers – 294 facility-based (47%) and 328 CHWs (53%) – at 174 primary health care centers.

In each LGA, key informant interviews (KII) were conducted with health department management teams; 5 members from LGA and 3 from State health teams. Of all health workers surveyed, 58% had been trained in IPC during COVID and 5 of 11 questions were correctly answered by >94% of providers; however, 3 questions were correctly answered by 65% or fewer.

More health workers reported that they practiced recommended IPC behaviors during than before the COVID 19. Significant differences were seen for reported washing hands before glove use (70.5% vs 95.2% during COVID), washing hands after glove use (70.5% vs 95.2%), and using a surgical mask in the workplace (61.7% vs 97.6%).

There was no change in reported washing and disinfecting of hands after contact with each patient (69.0% vs 68.6%) or use of an N95 mask in the workplace (8.2% vs 9.1%). Incorrect use of hand sanitizer when hands are visibly soiled however increased (35.8% vs 95.7%). The KIIs confirmed these findings.

As one CHW in Ohaukwu said, “We increased our use of face masks, hand sanitizer and gloves,” while a facility-based health worker from Bosso said, “. . . now we take more precaution than then . . . unlike before we palpate with our hands but now we use gloves.”

KII showed that fear of contracting the disease was the reason for change in behaviors. Despite reports of improved IPC measures, use of N-95 masks and hand sanitizer practices remain sub-optimal. There is need for continued support for correct hand hygiene, and to reinforce the relative importance of different IPC practices to ensure adherence to COVID-19 preventive measures

AUTHOR LIST

Bright Orji 1, Elizabeth Oliveras 2, Emmanuel Ugwa 3, Bartholomew Odio 1, Herbert Onuoha 1, Christina Maly 2, Ibrahim Idris 4, Festus Okoh 5, Emmanuel Dipo Otolorin 1, Elaine Roman 2 — 1Jhpiego, Abuja, Nigeria, 2Jhpiego, Baltimore, MD, United States, 3Federal Medical Center, Birnin kudu, Jigawa state, Nigeria, 4Niger State Ministry of Health, Minna, Nigeria, 5National Malaria Elimination Program, Federal MOH, Abuja, Nigeria

 

Aung K. Zaw et al. share in a poster their experiences with malaria and COVID-19 in Myanmar through the Defeat Malaria USAID/PMI Project. This can be found at the website of the 69^th Annual Meeting of American Society of Tropical Medicine and Hygiene Which is virtual. Their presentation is see below.

The President’s Malaria Initiative-supported Defeat Malaria Project aims to enhance the technical and operational capacity of the NMCP and health care providers in four States/Regions of Myanmar between 2016-2021. The project designed a capacity development strategy for staff and the NMCP using cascade training.

Master mentors (MM) from new Regions of the project were trained November/December 2019 who will train a cadre of general trainers (GT) at district and township level. Then GT will conduct onsite courses for integrated community malaria volunteers (ICMV).

However, due to the current COVID-19 situation travel and movement restrictions are in place. The project shifted from classroom-based to virtual training via Zoom for a 5-day training of GT and to develop 11 GT on malaria and other ICMV-managed diseases and training skills.

Participatory classroom training methodology was used for virtual training, including knowledge update and skills and attitudes development. Pre and post-training knowledge assessments and skills assessments were carried out to measure knowledge improvement. Daily and end course evaluations were done to gauge participants’ perception of virtual training. 64% of participants passed (score ?80%) the pre-training knowledge assessment, and 100% achieved ?80% on the post-training assessment.

Training skills (facilitation and demonstration of skills) were assessed using checklists during practice with RDTs and all participants passed. Coaching skills could not be assessed in this virtual training. Daily evaluation results showed that participants’ expectations and objectives were met. 75% stated that they felt more confident in planning and conducting a training course.

According to the final evaluation, 83% of participants felt positive about the virtual training methodology. On the other hand, 17% noted occasional difficulty hearing due to unstable internet connections. From a logistics and cost standpoint, it is feasible to continue the use of the virtual training platform for technical and training skills courses at the township level.

Authors and Affiliations

Aung K. Zaw(1), May Khin(1), Thiha Soe(1), Khin Zin(1), Ni Ni Aye(1), May Aung Lin(2), Thin Chit(2), Naung Naung(2), Paing Lin(2), Soe Tun(2), Wai Paing(2), Arkar Thant(2) – 1.Jhpiego, Myanmar/PMI Defeat Malaria, Yangon, Myanmar, 2.University Research Co., Myanmar/PMI Defeat Malaria, Yangon, Myanmar

Mildred Komey Akosua,* James Sarkodie, Kezia Malm1 Raphael Ntumy, and Gladys Tetteh presented a poster entitled “Systematic Approach to the Review of Malaria Management Guidelines Ghana, 2019” at the 68th Annual Meeting of the American Society for Tropical Medicine and Hygiene.

The primary objective of the Ghana NMCP is to reduce morbidity & mortality due to malaria through effective strategies. Implementation of these effective malaria control strategies depends largely on the availability of up-to-date, evidence-based, and standardized reference materials to guide and improve practice. Guidelines for the management of malaria in Ghana, including the anti-malaria drug policy (ADP), guidelines for case management of malaria (CM) and guidelines for malaria in pregnancy (MiP) were last updated in 2014. The 2014 review took over six months and left behind no documented methodology to guide subsequent reviews.

The World Health Organization recommends a comprehensive review everyfive years. In order to make the 2019 review process concise, efficient and reproducible, the NMCP with support from the PMI Impact Malaria project outlined a methodical approach to the review.

The process established an oversight review committee; identified all stakeholders relevant to update the ADP and guidelines; prepared a reference package of technical resources and research findings; nominated experts and allocated them to topic-specific technical working groups (TWGs). (Fig 1)

Then, a series of TWG consultative meetings were held with clearly defined processes and outputs, and independent external experts and potential end users of the guidelines ratified the draft guidelines. (Fig 2 and Fig 3)

A final phase included development of training content, training manuals, and development of key job-aids. (Fig 4 and Fig 5) Costs for the review process were identified and funding obtained.

All components of the 2019 process were enhancements to the unrecorded 2014 review. The process resulted in a documented and costed methodological approach, an up-to-date ADP, MiP and CM guidelines, training curriculum, training manuals, and job aids; all developed in a timely and efficient manner over a three-month period.

It also resulted in an approach for achieving minor policy and guideline updates between comprehensive five-year reviews. Using a systematic well-defined comprehensive approach with clear expectations for inputs, process, outputs, roles, timelines, costs, and sequelae actions, results in up-to-date widely accepted policies and guidelines whose implementation can be easily operationalized, with mechanisms for minor guideline updates between comprehensive five-year reviews.

*Author affiliations: Ghana National Malaria Control Programme, PMI Impact Malaria Project, Jhpiego

TWITTER.COM/IMPACT_MALARIA; IMPACTMALARIA.ORG

Anjoli Anand,* Favero Rachel, Catherine Dentinger, A. Ralaivaomisa, S. Ramamonjisoa, Elaine Razafimandimby, Jocelyn Razafindrakoto, Katherine Wolf, Laura C. Steinhardt, Julie Thwing, Bryan K. Kapella, M. Rabary, Sedera Mioramalala, Jean Pierre Rakotovao presented a poster on “Malaria Case Management Practice and Elimination Readiness in Five Elimination Districts of Madagascar, 2018” at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings are shared below.

Madagascar’s Malaria National Strategic Plan 2018-2022 calls for progressive malaria elimination beginning in low-incidence districts (< 1 case/1000). Although an elimination plan has not yet been developed, optimizing access to prompt diagnosis and quality treatment will be its foundation, along with improving outbreak detection and response, and developing an elimination plan.

There was need to understand current practices in preparation for elimination such as estimating current implementation readiness, documenting current diagnosis and treatment practices (case management), Assessing the use of data to inform decision-making and determining the availability of commodities, training and supervision. To assess this readiness and inform planning, we surveyed health facilities (HFs) and communities.

In September 2018, we randomly selected 35 HFs in 5 of the 8 districts identified for elimination, surveyed 41 HWs and 34 community health volunteers (CHVs), and observed 300 clinical encounters between HWs and patients of all ages. Quantitative and qualitative tools were used to collect data. There were a health facility checklist, an interview guide for health facility providers, a clinical observation guide, a community health volunteer CHV) interview guide, and a stakeholder interview guide.

To evaluate elimination readiness, a composite score was assigned to each HF catchment area that incorporates all survey responses based on commodity availability, malaria CM practices, data management, and supervision practices.

In preliminary results, 8 of 34 (24%) CHVs reported that they do not manage children under 5 years (CU5) with fever at the community level. Of 26 CHVs who care for CU5, 18 (69%) identified history of fever as a criterion for suspected malaria, 20 (77%) reported using a malaria rapid diagnostic test (RDT) when evaluating patients reporting fever, and 15 (58%) reported giving antimalarials for a positive RDT. Among treating CHVs, 13 (30%) reported having RDTs, and 11 (42%) reported having antimalarials currently available. A

Among facility-based HWs, 83% identified history of fever as a criterion for a suspected case. Of 120 patients with reported or recorded fever, 56 (47%) were tested with an RDT. Five RDTs were positive; a first-line antimalarial was prescribed to 4 of those patients. This evaluation is a baseline for CM performance as Madagascar establishes elimination targets. In the evaluated districts, CM could be improved by strategies to increase testing at CHV and HF levels and address availability of commodity stocks in the community.

*Affiliations: Epidemic Intelligence Service, Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States; Maternal Child Survival Program, Washington, DC, United States; US President’s Malaria Initiative; US Centers for Disease Control and Prevention, Antananarivo, Madagascar; Maternal Child Survival Program, Madagascar, Antananarivo, Madagascar; Maternal Child Survival Program, Antananarivo, Madagascar; US President’s Malaria Initiative, Antananarivo, Madagascar; Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States; National Malaria Control Program, Antananarivo, Madagascar

Moumouni Bonkoungou,* Ousmane Badolo, Youssouf Sawadogo, Stanislas Nebie, Thierry Ouedraogo, Yacouba Sawadogo, William Brieger, Gladys Tetteh, and Blami Dao presented their work on “mMentoring, a New Approach to Improve Malaria Care in Burkina Faso” at the 68th Annual Meeting of the American Society of Tropical Medicine and Hygiene as seen below.

Malaria is the leading cause of consultation (43.3%), hospitalization (44.1%) and death (16.1 %) in Burkina Faso. In the Sahel Region, the case fatality proportion due to malaria is 2% compared to 0.8% for the national average. This region is most affected by malaria than others. Also, the Sahel Region is currently experiencing high levels of insecurity making movement of health teams difficult and unsafe.

mMentoring is the use of mobile technology to ensure capacity building and continuing education among health staff. The process started by a workshop to develop messages, and briefing of the main actors.

Each week, messages and quizzes (An automatic answer is sent to each quiz) are sent to 753 providers (nurses, midwives, medical doctors) of the 115 health centers in the Sahel Region. Each month, messages are revised by a team at national level before being sent.

The messages sent were related to several key malaria prevention and control interventions, such as case definition, parasitological diagnosis, clinical case management of simple and severe cases, intermittent preventive treatment in pregnancy (IPTp), pre-referral treatment with rectal artesunate in children under 5 years, insecticide-treated bed nets.

After 10 months of implementation, 64 reinforcement messages on case management and prevention guideline and 63 quizzes were sent. Proportion of correct responses to the quizzes ranged from 43% and 96%. The lowest scores related to topics on management of severe cases while the highest were related to diagnosis of malaria.

The participation rate (number of respondents of the 753 targeted health workers) is on average 22% with 71% of participants from primary health facilities. Also, we notice IPT3 increased from 14.8% in the quarter 3 of 2017 to 45.6% in the same quarter of 2018 (with mMentoring).

The rate of performance of rapid diagnostic tests (RDTs) rose from 67.5% to 77.8%. The case fatality rate during this quarter of 2017 was 3.3% and 1.8% in 2018. As a real platform for continuing training, it would be wise to extend this approach to other regions of the country and also to other health actors like community health workers.

 

 

 

 

 

*Affiliations: PMI Improving Malaria Care Project, Ouagadougou, Burkina Faso, Ministry of Health, National Malaria Control Program, Ouagadougou, Burkina Faso, Johns Hopkins University, Baltimore, MD, United States, Jhpiego Baltimore, Baltimore, MD, United States

After the World’s first attempt at eradicating the complicated disease malaria mainly through a single tool, a period of control set in where the aim was to reduce mortality through prompt and presumptive treatment of fevers with anti-malarials, particularly in young children. During this period in the 1980s and 1990s it was recognized that parasite-based diagnostic capabilities in the form of microscopy were limited, so in malaria endemic areas, it was worth providing inexpensive medicines like chloroquine (CQ) and sulfadoxine-pyrimethamine (SP) to febrile children in order to save lives. When the fevers did not resolve, other illnesses explored.

The difficulty arose in identifying cases that did not offer clinical clues that they might be malaria. Today countries approaching malaria elimination face challenges, such as seen in Zanzibar where, “outdoor transmission, a large asymptomatic parasite reservoir and imported infections, require novel tools and reoriented strategies to prevent a rebound effect and achieve elimination.”[i] Here we examine the challenge of asymptomatic malaria infections.

Background

By 1998 when the Roll Back Malaria partnership formed, there had been enough research done so that the malaria community had a better arsenal of interventions including insecticide-treated bed nets, artemisinin-based combination therapy (ACT) and intermittent preventive treatment with SP during pregnancy. The Abuja Declaration of 2000 set a target of 80% coverage of these interventions by the year 2010.

While ACTs overcame the challenges of parasite resistance that had developed for the single drugs, CQ and SP, it cost several times more than those medicines. The need for easy-to-use, inexpensive, point-of-care diagnostics was recognized so that not only would ACTs be targeted only to parasitologically confirmed malaria cases, but also in the process, overuse and misuse would not contribute to parasite resistance of these new drugs.[ii] Unfortunately, the development and dissemination of antigen-based rapid diagnostic tests (RDTs), lagged behind the availability of ACTs meaning that health workers unfortunately continued their business as usual with presumptive treatment using ACTs. 

The benefits of RDTs were generally two-fold. First, they could be used by front-line, auxiliary and community-based health workers. Secondly, they tended to identify more cases than microscopy. The big challenge was convincing health workers to use them and trust the results, because the era of presumptive treatment had given these staff a false sense of confidence in their own clinical diagnostic abilities.

Although reaching the 2010 coverage targets has remained illusive for most endemic countries, there has been enough progress for major reductions in incidence (despite a recent upsurge).[iii] As the proportion of actual malaria cases among febrile illness patients declines, concern has risen that transmission might continue among people with subclinical or asymptomatic malaria. Here we explore the extent of this problem and new directions in parasitological testing needed to ensure continued progress toward elimination in each endemic country.

Understanding the Risk of Asymptomatic Malaria

Risk can relate to geographical, epidemiological, and socio-demographic factors as well as history of malaria interventions. Kenya has stratified the country by higher and lower malaria transmission areas. Even the higher areas are comparatively low compared to its higher transmission neighbors. Studying the prevalence of asymptomatic malaria in some of these higher transmission areas in the west of the country was seen as a way to better identify people at risk and learn about intervention effectiveness. An examination of apparently healthy children (no symptoms) revealed a Plasmodium falciparum malaria prevalence 36.0% (27.5%, 44.5%) by RDT and 22.3% (16.0%, 28.6%) by thick film microscopy.[iv] Living in a household with electricity was protective but the adjusted odds ratio of prevalence comparing households with and without indoor residual spray showed only borderline benefit. Unfortunately, in Zanzibar, asymptomatic malaria infection was not associated “with use of any vector control.”¹

A major challenge in detecting cases through routine health care systems is care seeking patterns of care seeking for fever. The 2018 World Malaria Report acknowledges that there are major equity challenges in care seeking wherein families with higher incomes, better education and living in urban areas are more likely to seek help for their febrile children that rural, poor and less educated families who would be more at risk. Care seeking without the signs of fever is more challenging. A dual strategy of enabling better service utilization as well as outreach to detect cases will be necessary to detect asymptomatic cases.³

In Burkina Faso, the prevalence of asymptomatic malaria infection in children under 5 years of age was estimated at 38.2% in 24 of its 70 health districts. Those at most risk for asymptomatic malaria infection included the following:[v]

• older children (48–59 vs < 6 months: OR: 6.79 [5.62, 8.22])
• children from very poor households (Richest vs poorest: OR: 0.85 [0.74–0.96])
• households located more than 5 km from a health facility (< 5 km vs ? 5 km: OR: 1.14 [1.04–1.25])
• localities with inadequate number of nurses (< 3 vs ? 3: 0.72 [0.62, 0.82]
• rural areas (OR: 1.67 [1.39–2.01])

Nine districts reported significantly higher risks (Batié, Boromo, Dano, Diébougou, Gaoua, Ouahigouya, Ouargaye, Sapouy and Toma. The researchers concluded that, “Such national spatial analysis should help to prioritize areas for increased malaria control activities.”

A study in Ghana found that, “children and pregnant women had higher prevalence of submicroscopic gametocytes (39.5% and 29.7%, respectively) compared to adults
(17.4%).”[vi]

An additional concern is emerging in terms of sharing of malaria parasite species between humans and primates, especially as urbanization and deforestation push these two populations into closer contact. For example Mapua and colleagues working in Central Africa Republic, “found the human malaria parasite P. ovale wallikeri in both asymptomatic humans and western lowland gorillas in Dzanga Sangha Protected Areas. Molecular analysis revealed that the genotype of the P. ovale wallikeri DNA found in a gorilla was genetically identical to that of a human isolate within the mt cytb and mt cox 1 genes, indicating potential human–ape transmission.”[vii] They noted similar sharing of parasites in the region between humans and chimpanzees.

Detecting and Responding to Asymptomatic Cases

WHO’s Framework for Malaria Elimination[viii] recognizes the important role of case detection and subsequent treatment as well as broader community level preventive responses around detected cases. In the context of elimination WHO notes that case detection “requires use of a diagnostic test to identify asymptomatic malaria infections.” WHO stresses that a case is a case, regardless of whether it is symptomatic or asymptomatic, as long as the diagnostic process confirms presence of malaria infection.

It is important to monitor Plasmodium parasitemia in areas where malaria transmission has declined and efforts to achieve malaria elimination are underway, such as Zambia, where 3,863 household members were tested.[ix] Only 2.6% were positive by either microscopy, RDT, or PCR. Of these, 48 (47%) had subpatent parasitemia, and 85% of those with subpatent parasitemia were asymptomatic. “Compared with individuals without parasitemia, individuals with subpatent parasitemia were significantly more likely to be aged 5–25 years.” The authors suggested that their findings pointed to the need for active or reactive case detection to identify asymptomatic individuals and thus better target individuals with subpatent parasitemia with appropriate malaria interventions.

WHO explains that active case detection (ACD) takes place in areas of limited or under-utilization of health care services.⁴ It may start with initial screening for symptoms, followed by appropriate parasitological laboratory confirmation. In low-transmission settings or as part of a focus investigation, “ACD may consist of testing of a defined population group without prior symptom screening (population-wide or mass testing) in order to identify asymptomatic infections.” Elimination cannot be achieved until even asymptomatic infections have stopped. The challenge is the expense of community-wide screening.

Reactive Case Detection (RCD), according to WHO, takes place in settings low transmission intensity where the few “occurring malaria cases are highly aggregated.”⁴ When a case is identified, usually through identification of an actual infected patient at a local clinic, the community where the patient comes from is visited and a “net is cast around the index case” where household members and neighbors within a selected radius are tested. In this process asymptomatic cases are also identified.

Our existing diagnostic tools may be inadequate. McCreesh and colleagues reported on subpatent malaria in Namibia that, “fever history and standard RDTs are not useful to address this burden. Achievement of malaria elimination may require active case detection using more sensitive point-of-care diagnostics or presumptive treatment and targeted to high-risk groups.” This includes loop-mediated isothermal amplification (LAMP) using dried blood spots, which they tested.[x] Likewise from experience in a Zambian study, Kobayashi and co-researchers suggest, “more sensitive diagnostic tests or focal drug administration may be necessary to target individuals with subpatent parasitemia to achieve malaria elimination.”[xi]

Responses to detecting asymptomatic cases start at the individual level with prompt treatment of those found through RCD to be infected. Then focused preventive interventions such as distribution of insecticide treated bednets can be provided to those in the cluster or village. Follow-up would be needed for such ‘hot spots.’ 

On a broader basis we have Seasonal Malaria Chemoprevention (SMC) as practiced in Sahelian countries where during the peak transmission (rainy) season intermittent preventive treatment is given to children monthly by community health workers and volunteers. Of course, many of these children would be asymptomatic carriers and SMC could benefit the reduction of parasites in circulation. At present SMC focuses on pre-school aged children, but Thera and co-researchers stress the importance of reaching school aged children who are also often asymptomatic carriers.[xii]

Another intervention being tested for mass drug administration (MDA) use providing the community with ivermectin, a drug that has been highly effective in controlling filarial diseases and also found to kill mosquitoes who take a blood meal from a person who has recently taken it.[xiii] This strategy is still being tested, but again MDA means all community members, especially those with asymptomatic infection, would be reached.

A major question requires further research. To what extent do asymptomatic, submicroscopic and subpatent parasitemia contribute to continued malaria transmission? Another question is how can we address malaria infection in other primates? We know that scientists recommend targeting of malaria elimination interventions based on mapping of these infections.⁵ We therefore need to study the actual transmission potential of this phenomenon.

---

[i] Björkman A, Shakely D, Ali AS, Morris U, Mkali H, Abbas AK, Al-Mafazy A-W, Haji KA, Mcha J, Omar R, Cook J, Elfving K, Petzold M, Sachs MC, Aydin-Schmidt B, Drakeley V, Msellem M and Mårtensson A. From high to low malaria transmission in Zanzibar—challenges and opportunities to achieve elimination. BMC Medicine (2019) 17:14, https://doi.org/10.1186/s12916-018-1243-z

[ii] Global Malaria Programme. Universal access to malaria diagnostic testing – An operational manual. World Health Organization. November 2011 (rev. February 2013). https://www.who.int/malaria/publications/atoz/9789241502092/en/

[iii] Global Malaria Programme. World malaria report 2018. World Health Organization. 19 November 2018. https://www.who.int/malaria/publications/world-malaria-report-2018/en/

[iv] Peprah S, Tenge C, Genga IO, Mumia M, Were PA, Kuremu RT, Wekes WN,  Sumba PO, Kinyera T, Otim T, Legason ID, Biddle J, Reynolds SJ, Talisuna AO, Biggar1 RJ, Bhatia K, Goedert JJ, Pfeiffer RM, Mbulaiteye SM. A Cross-Sectional Population Study of Geographic, Age-Specific, and Household Risk Factors for Asymptomatic Plasmodium falciparum Malaria Infection in Western Kenya. The American Journal of Tropical Medicine and Hygiene, Volume 100, Issue 1, Jan 2019, p.54-65. DOI: https://doi.org/10.4269/ajtmh.18-0481.

[v] Ouédraogo M, Samadoulougou S, Rouamba T, Hien H, Sawadogo JEM Tinto H, Alegana VA, Speybroeck N and Kirakoya?Samadoulougou F. Spatial distribution and determinants of asymptomatic malaria risk among children under 5 years in 24 districts in Burkina Faso. Malaria Journal 2018; 17:460 https://doi.org/10.1186/s12936-018-2606-9

[vi] Lamptey H, Ofori MF, Kusi KA, Adu B, Owusu-Yeboa E, Kyei-Baafour E, Arku AT, Bosomprah S, Alifrangis M, Quakyi IA. The prevalence of submicroscopic Plasmodium falciparum gametocyte carriage and multiplicity of infection in children, pregnant women and adults in a low malaria transmission area in Southern Ghana. Malar J. 2018 Sep 17;17(1):331. doi: 10.1186/s12936-018-2479-y.

[vii] Mapua MI, Hans-Peter Fuehrer HP, Petrželková KJ, Todd A, Noedl H, Qablan MA, and Modrý D. Plasmodium ovale wallikeri in Western Lowland Gorillas and Humans Central African Republic. Emerging Infectious Disease journal. Volume 24, Number 8—August 2018. https://wwwnc.cdc.gov/eid/article/24/8/18-0010_article

[viii] Global Malaria Programme. A framework for malaria elimination. ISBN 978-92-4-151198-8. World Health Organization 2017, http://www.who.int/malaria/publications/atoz/9789241511988/en/

[ix] Kobayashi T, Kanyangarara M, Laban NM, Phiri M, Hamapumbu H, Searle KM, Stevenson JC, Thuma PE, Moss WJ and the Southern Africa International Centers of Excellence for Malaria Research. Characteristics of Subpatent Malaria in a Pre-Elimination Setting in Southern Zambia. The American Journal of Tropical Medicine and Hygiene, 10 December 2018, DOI: https://doi.org/10.4269/ajtmh.18-0399

[x] McCreesh P, Mumbengegwi D, Roberts K, Tambo M, Smith J, Whittemore B, Kelly G, Moe C, Murphy M, Chisenga M, Greenhouse B, Ntuku H, Kleinschmidt I, Sturrock H, Uusiku P, Gosling R, Bennett A, Hsiang MS. Subpatent malaria in a low transmission African setting: a cross-sectional study using rapid diagnostic testing (RDT) and loop-mediated isothermal amplification (LAMP) from Zambezi region, Namibia. Malar J. 2018 Dec 19;17(1):480. doi: 10.1186/s12936-018-2626-5.

[xi] Kobayashi T, Kanyangarara M, Laban NM, Phiri M, Hamapumbu H, Searle KM, Stevenson JC, Thuma PE, Moss WJ, For The Southern Africa International Centers Of Excellence For Malaria Research.Characteristics of Subpatent Malaria in a Pre-Elimination Setting in Southern Zambia. Am J Trop Med Hyg. 2018 Dec 10. doi: 10.4269/ajtmh.18-0399. [Epub ahead of print]

[xii] Thera MA, Konea AK, Tangaraa B, Diarraa E, Niarea A, Dembeleb A, Sissokoa MS, Doumboa OK. School-aged children based seasonal malaria chemoprevention using artesunate-amodiaquine in Mali. Parasite Epidemiology and Control 3 (2018) 96–105. https://doi.org/10.1016/j.parepi.2018.02.001

[xiii] Smit MR, Ochomo EO, Aljayyoussi G, Kwambai TK, Abong’o BO, Chen T, Bousema T, Slater HC, Waterhouse D, Bayoh NM, Gimnig JE, Samuels AM, Desai MR, Phillips-Howard PA, Kariuki SK, Wang D, Ward SA, ter Kuile FO. Safety and mosquitocidal efficacy of high-dose ivermectin when co-administered with dihydroartemisinin-piperaquine. www.thelancet.com/infection Published online March 27, 2018 http://dx.doi.org/10.1016/S1473-3099(18)30163-4

Background

Management Sciences for Health notes[1] that, “PBF is a powerful means for increasing the quantity and quality of health services by providing incentives to health providers to improve performance. A PBF program typically includes performance?based grants or contracts. Health clinics and their staff are rewarded for reaching or exceeding health indicators.” MSH cautioned that, “while PBF is expected to reduce unit costs in the long?term by increasing productivity, unit costs may actually increase in the short term when services have previously been underfunded???as salaries rise to appropriate levels, missing equipment and supplies are purchased, and facilities are upgraded.” In the long term they explained that PBF had a, “crucial impact on revenues received at health centers, motivated access to quality services for the people served, and allowed the Government of Rwanda to actively manage its investments in pursing national health goals.”

Between 2001 and the mid-2000s Rwanda introduced and began scaling up PBF. The focus of health care shifted from inputs to outputs to outcomes.  “Performance improvements that have been documented in Rwanda after the introduction of performance incentives for primary health care and HIV/AIDS service products have been impressive.”[2] In two pilot districts health care consultations per capita more than doubled. Institutional deliveries tripled. Child immunization, maternal immunization and contraceptive prevalence rates also increased.

There is national policy and political support for PBF as it fits into government desired for accountability. Financial support comes from government and specific programs within the Ministry of Health such as malaria elimination and TB control who have invested in specific performance indicators. Donors such as USAID, World Bank, and Global Fund, play a major role in providing the technical and financial support that pays for performance.

Community Level

PBF in Rwanda operates at all levels of the health system, but of interest to PHC are the front-line health centers and the local cooperatives and community health workers (CHWs). CHW support came about in 2008 as a strategy to sustain the CHWs system. PBF in Rwanda is based on two kinds of contracts, contracts on the performance of the health unit and contracts on the performance of individual health workers.

The PBF procedures manual[3] explains that, “Community PBF (C-PBF) is implemented at the village level through the trained community health workers (CHW) operational within each community. Health posts are located at the cell level and due to their private or faith-based organizations affiliation they are not integrated into the PBF system. Health Center PBF is implemented at the sector’s level health center while district and provincial hospitals are implementing the district hospital PBF model (recently linked with accreditation).”

Under the USAID MCHIP Project, Jhpiego conducted a malaria program implementation assessment in Rwanda that examined the health systems building blocks including financing. The report noted that, “Cooperatives have been set up for CHW; there are usually about 120 people (depending on the number of CHWs in the catchment area of the health center) per cooperative with a president, vice president, secretary, treasurer, and three advisors.[4] Cooperatives can engage in many different types of income-generating activities, based on the agreement among the members, and the executive committee makes final decisions and determines how income will be disbursed among members.”

The aspect of PBF contracting is undertaken with the CHW Cooperative. “Through the PBF, CHW cooperatives can earn ~250USD per quarter from the government. The total amount is based on the completeness of CHW reports and their performance on 20 set indicators. These indicators include elements such as timeliness and completeness of reports, number of pregnant women receiving consultation in the first trimester, number of women accepting family planning (new and continuing clients), and infant growth monitoring.”

Rwanda has also introduced a quality of services element known as Pay-4-Performance, and entities such as health centers and CHW cooperatives are also given a quality score arising from supervisory processes. The quality component has helped “cooperatives linked to the PBF address issues of attrition and motivation. The division of supervision among cell leaders also reduces the work burden for facility-based supervisors.” Practical service delivery problems such as stock-outs of commodities are less likely to occur at the community level when PBF is in place. The challenge moving forward may be the stress created by adding more responsibilities to the duties of the CHWs.

The MCHIP report concluded that, “PBF has set up a system of accountability so that not only is funding spent appropriately, but results are also expected and rewarded. PBF addresses the challenges of motivation that so often plague health care workers and managers in other countries who do not see rewards for working hard and doing a good job. The fact that the system of emphasis on quality services in sufficient quantities radiates from the national to the district to the community level (i.e., districts reporting to the President’s office, and CHWs reporting on indicators to health center supervisors) ensures that a culture of rewarding good performance is developing.” A systems challenge is dependence on donor support in terms of both continuity and donor focus, as many donors focus on particular interventions (malaria, family planning), leaving gaps among the service indicators.

---

[1] Management Sciences for Health. The Health Impact of Performance-Based Financing in Rwanda. Published: 2010?12?23 http://blog.msh.org/2010/12/23/the-health-impact-of-performance-based-financing-in-rwanda/

[2] Louis Rusa, (National PBF Coordinator-Ministry of Health Rwanda), and Gyuri Fritsche, (Health Care Financing Specialist-Management Sciences for Health). Rwanda: Performance-Based Financing in Health. Sourcebook: Second Edition. http://www.ccoms-imsuerj.org.br/capfts/2011/uploads/4-3RwandaPBF.pdf

[3] Ministry of Health, Rwanda. Performance Based Financing Procedures Manual for Health Facilities (Hospitals and Health Centers). April 2018.

[4] Maternal and Child Health Intergrated Program (USAID, Jhpiego). Analysis of the Status of Prevention and Control of Malaria in Rwanda: Best Practices and Challenges to Program Implementation. November 2013.

In the 1990s the Navrongo research center started the Community-based Health Planning and Services (CHPS) initiative 3 pilot districts. The CHPS Initiative has now become the national strategy for implementing community-based service delivery by reorienting and relocating primary health care from sub-district health centers to convenient community locations.[1] CHPS is even seen as crucial to Ghana’s broader poverty reduction agenda and policy.

The CHPS Operational Policy notes that, CHPS was designed to operate at the third tier of the district health system that encompassed a district hospital, sub-district health centers and community-based services by addressing the needs of zones of 3000-4,500 residents “where primary health care services will be provided to the population by a resident Community Health Officer (CHO) assisted by the Community structures and volunteer systems. The deployment of all elements necessary for the CHO to provide house-to house service shall make that zone a fully functional CHPS zone within the sub-district,” thus creating CHPS compounds. It is the CHO who represents the human resource innovation in the Ghana system

A CHO engages each Community within the zone in micro planning of health activities termed “community decision making systems,” building on the following key elements: Community (as social capital); Households and individuals (as target); Planning with the community (community participation); and Service delivery with the community (client focused).

Community health nurses (CHN) trained in the nation’s various schools of nursing would be designated a CHO once they were posted to a CHPS compound. The CHPS compound, often a building donated by the community or a philanthropist served as a health post and accommodation for the CHO. There could be two CHOs and a trained midwife, since CHNs are not trained to conduct delivery. The CHOs are expected to deliver a package of essential primary health care and promotion services at the community level that revolves around home visiting. The idea is to take services to the clients.

While the curriculum of a CHN addresses some basic issues of the CHPS program, CHNs do not exit school as ready-made CHOs. Those who opt to become CHOs must receive orientation from the regions and districts where they work in a CSPS. Depth and quality of orientation varies. CHOs could be assisted by community health volunteers who are supervised by a community health committee.

Sacks et al. report that CHNs obtain a Certificate in Community Health Nursing as part of pre-service training after completing a 2-year curriculum post-secondary school.[2] After 3-5 years of service, CHNs can enroll for higher education to become a midwife or public health nurse (PHN). Sacks and colleagues found that CHN/CHO satisfaction was often determined by professional isolation and lack of basic resources and materials to perform their jobs.

By 2002, 95 out of 110 districts had launched the CHPS program, though not every potential zone was covered. The rapid national expansion of the CHPS program may have contributed to some of the CHNs’ frustrations, as the time was not taken to recruit and train health workers from the target communities who would have spoken the same language. Facilities were not upgraded prior to the increase of health workers and communities were not prepared to provide free housing to CHNs, as originally planned, say Sacks and co-researchers. Although the original goal was for CHPS to achieve complete national coverage by 2015 through the establishment of 6,000 CHPS zones, challenges led to completion of only 3,000 CHPS zones by then.  Now, more than 20 years after the initial trial, Ghana is re-launching the CHPS policy to elevate PHC as a priority and to expand the CHPS model to parts of the country that are not yet covered.[3]

The three broad areas of work by the CHO include basic primary health care issues such as promotion and prevention, management of minor or common ailment and their referrals and case detection, mobilization and referrals. Ghana Web reports that,[4] CHPS compounds cover all 8 essential PHC services and aim at helping ensure improved access to primary health care in these communities. For proper functioning of the various CHPS compounds, there is very strong community participation in the implementation.

The article reports that, “Where there is strong community participation, traditional leaders and community members provide resources, both financial and non-financial incentives, to support implementation of the program. A CHO is expected to work in partnership with the community, households and district assemblies to ensure that, citizens are able to access services and health information as and when they need them whereas the communities are expected to also exert some levels of answerability to health providers.”

The Upper West Region serves as an example of CHPS and CHOs implementation as reported by the Ghana News Agency.[5] There are 308 functional CPHS zones out of 361 planned which cover 62% of the population. The region had 364 CHOs in the 308 functioning zones and 305 active community committees, with 1,669 volunteers. Unfortunately, only 155 of the functioning CHPS zones were fully equipped to standard. A relaunch of CHPS will focus on performance guidelines, systems strengthening and quality of services

---

[1] Community-Based Health Planning and Services (CHPS): The Operational Policy, Ghana Health Service, Policy Document No.20, May 2005.

[2] Emma Sacks, Soumya Alva, Sophia Magalona and Linda Vesel. Examining domains of community health nurse satisfaction and motivation: results from a mixed-methods baseline evaluation in rural Ghana. Sacks et al. Human Resources for Health (2015) 13:81, DOI 10.1186/s12960-015-0082-7

[3] John Koku Awoonor-Williams, Elisabeth Tadiri, and Hannah Ratcliffe . Translating research into practice to ensure community engagement for successful primary health care service delivery: The case of CHPS in Ghana. https://improvingphc.org/translating-research-practice-ensure-community-engagement-successful-primary-health-care-service-delivery-case-chps-ghana

[4] Gabriel Frimpong. The Community-Based Health Planning and Service (CHPS) concept in Ghana, Ghana Web. Tuesday, 24 April 2018. https://www.ghanaweb.com/GhanaHomePage/features/The-Community-Based-Health-Planning-and-Service-CHPS-concept-in-Ghana-646058

[5] Prosper K. Kuorsoh, Upper West Region has 62 per cent CHPS coverage. Ghana News Agency. Thursday 9th August, 2018. http://www.ghananewsagency.org/health/upper-west-region-has-62-per-cent-chps-coverage-136932

Community-Based Health Insurance (CBHI) is seen as a way to promote universal health coverage and protect vulnerable populations from catastrophic financial effects of illness. Malaria can be such an illness is not treated in a timely manner, and having insurance can help prevent delays.

In countries including Rwanda, Burkina Faso and Senegal a particular CBHI scheme known as mutuelles has taken root. For Rwanda USAID (2018) reports that …

The 2014–2015 DHS showed that insurance coverage has remained stable since the 2010DHS and that 79 percent of the households have at least one family member with health insurance and that among those insured 97 percent have community health insurance (mutuelles). Early ANC attendance is also encouraged by providing targeted SBCC, combined with innovative community- and facility-level performance-based financing and high enrollment in community health insurance schemes (mutuelles). The MoH, with the support of partners, has worked to improve the quality of services for case management at health facilities through training and capacity building efforts at national and district levels.

A study looked at health care seeking for children below 5years of age in Rwanda in 2005 to 2010 and found that, “In both years,under-five children with Mutuelles were more likely to use medical care than uninsured children. Children in 2010 had a higher probability of using medical care … regardless of the children’s poverty or Mutuelles status.” The study provides an example of how pre-payment CBHI can not only increase universal health coverage but also address challenges of equity (Mejía-Guevara et al., 2015).

Below is a chart showing the fee structure in Rwanda (Tashobya, 2017). [The trainer should ask participants about fees for CBHIs or other national health insurance schemes in their countries if such exist and how participation in CHBI helps achieve UHC.]

Fees in Rwanda’s community insurance scheme, Mutuelles
Ubudehe/Social Category	Annual Rwandan Francs per Household Member	Approximate US Dollars
1	0 (Paid by government)	0
2	2,000	2.25
3	3,000	3.35
4	4,000	7.85

Now The East African reports that, “With more than 90 per cent of Rwandans covered under the community-based health insurance scheme locally known as Mutuelle de Santé, Rwanda is one of the few developing countries in the world that have successfully achieved universal healthcare” (Kagire, 2018) This was achieved by addressing enrollment, quality of cane and transferring management of the scheme to the Rwanda Social Security Board (RSSB). Now more than ever, no one needs to die from malaria in Rwanda.

• Kagire, Edmund (2018). Rwanda Has Achieved Universal Healthcare. The East African. 15 December 2018. https://allafrica.com/stories/201812150128.html
• Mejía-Guevara I, Hill K, Subramanian SV, Lu C. (2015). Service availability and association between Mutuelles and medical care usage for under-five children in rural Rwanda: a statistical analysis with repeated cross-sectional data. BMJ Open. 2015 Sep 8;5(9):e008814. doi: 10.1136/bmjopen-2015-008814.
• Tashobya, Athan (2017). Mutuelle Month: Govt targets 100% subscription. The New Times. Published : April 03, 2017. https://www.newtimes.co.rw/section/read/210035
• USAID/President’s Malaria Initiative (2018) Rwanda Malaria Operational Plan FY19. https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy19/fy-2019-rwanda-malaria-operational-plan.pdf?sfvrsn=3