A new review by Conroy, Datta, and John highlights the connection between the kidneys and malaria on this World Kidney Day. They explain that “15 years ago, renal failure was considered a rare complication in children with Severe Malaria, yet it is now recognized as one of the strongest predictors of mortality in severe malaria.”
While severe malaria is related to reduced kidney perfusion, Conroy et al. note that, “additional studies are needed to evaluate the spectrum of AKI over hospitalization to define the etiology and pathophysiology of acute kidney injury in pediatric severe malaria.” In the diagram to the right, they show that kidney involvement is among the most deadly forms of severe malaria.
These problems are not limited to Africa. Dayanand and colleagues describe “single or multi-organ dysfunction involving liver, kidney, and brain” occurring in Mangaluru, India.
Brown et al.warn travelers including people returning to endemic areas after a long absence to be aware of severe malaria dangers once they return to non-endemic countries. “Severe malaria can cause significant multiorgan dysfunction including acute kidney injury (AKI). The pathogenesis is not clearly understood but proposed mechanisms include acute tubular necrosis (ATN) due to impediments in renal microcirculation, infection-triggered proinflammatory reactions within the kidney, and metabolic disturbances.”
The World Health Organization’s Third Edition on its guidelines on managing severe malaria addresses acute kidney injury with attention to reversing dehydration, addressing reduced urine output and even the need for dialysis. Clearly the best response is prompt diagnosis and treatment when malaria is in its very early stages, and better yet, using insecticide treated bednets to prevent the problem in the first place.
The Global Fund sixth Replenishment Conference will take place in October 2019 to raise new funds and mobilize partners toward ending AIDS, TB and malaria by 2030 in alignment with the Sustainable Development Goals. The target is to raise at least US$14 billion “to help save 16 million lives, avert 234 million infections and help the world get back on track to end these diseases.”
It is not exactly clear how much of this US$14 billion would be pegged for malaria, especially since there are cross-cutting health systems strengthening components to many grants. That said, the total seems to pale in light of the 2018 World Malaria Report estimated investment needs of US$6.6 billion alone for malaria from 2020 onward.
Of course the Global Fund is calling on the private sector to “mobilize at least US$1 billion to step up the fight.” It is not clear whether this should be included in the US14 billion or in addition.
The RBM Partnership notes that “Accounting for more than half of all external resources and 44% of total malaria funds available, the Global Fund represents the leading source of funding for malaria prevention and treatment.” Such non-Global Fund external resources have come from partners like the World Bank, the US President’s Malaria Initiative, DfID and a host of other bilateral, NGO and corporate sources. The implication is that at most 15-20% of current financial investment in malaria has been borne endemic countries.
RBM also highlights that at the recent African Union meeting, “African Heads of State and Government adopted the 2018 African Union Malaria Progress Report which was prepared by malaria experts from countries in Africa…” This means that the leaders acknowledged that malaria investments and significant achievements already made “are under threat and accelerated action is needed now to get countries back on track.” This led the current chair of the Africa Malaria Leaders Alliance, His Majesty King Mswati III of the Kingdom of Eswatini, to say, “It will take significant resources to achieve malaria elimination. Now, more than ever, we must boost our domestic resources from both the public and private sectors.”
Analysis in the ALMA Scorecard shows in the fourth quarter of 2018 most countries have acquired the needed funds to finance malaria commodities. The analysis does not point out the source of these funds. The 2030 target is only 11 years away. Serious national planning, political will and advocacy are needed not only to prevent resurgence of malaria to pre-RBM days, but also to reduce and eliminate a disease responsible for so much economic loss and loss of life.
The WHO defines Equity as “the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other means of stratification. ‘Health equity’ or ‘equity in health’ implies that ideally everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential.”
WHO goes on to say that, “Countries and programs need to disaggregate selected health indicators by key stratifiers including demographic characteristics (gender, age), place of residence (urban/rural, subnational), socioeconomic status (wealth, education), as well as other characteristics (migrant/minority status etc.).”
“What must now be clear is our conviction that any review of factors for world-wide malaria control must give specific attention to issues of socio-economic inequity and disease epidemiology.” Malaria is not an equal opportunity killer, but disproportionately affects certain segments of the population. Heggenhougen et al. continue that, “while we argue for a focused attack on malaria, we cannot avoid noting that without attention to these larger matters – inequity and marginalization – any improvement in health, including malaria, may be short-lived.”
The Demographic and Health Survey (DHS) and its Malaria Indicator Survey (MIS) provide an important snapshot on equity issues in the rollout and coverage of major malaria. In particular, we look at the issue of long lasting insecticide-treated nets in two countries, Ghana (2016 MIS) and Liberia (2016 MIS), to demonstrate how equity issues can be seen. Two three measures are considered, wealth quintile, location (urban/rural) and gender/sex.
In Ghana we see that having at least one net for the household is more common in lower income groups. These groups are more vulnerable. Although not specifically shown in the MIS, one might assume that people in the higher income groups have better quality housing that provides less opportunity for mosquito entry. Likewise households in rural areas, where anopheles are more likely to breed, have a higher proportion of nets. So while nets are not ‘equally distributed by these characteristics, they are more favorably available in those households that may be more vulnerable to malaria.
When we look at the indicator of universal coverage where it is expected that there should be one net for every two household members, the proportion meeting that goal is much lower than simply having a net in the household for all groups. That said the pattern of higher proportions among rural and lower income groups remains. Within households, the Ghana MIS a nearly equal proportion of female (43%) and male (41%) had slept under a net the night prior to the survey.
Overall, Liberia has much lower LLIN coverage than Ghana. The pattern for location is similar to that of Ghana, but for wealth, the poorest group (Q1) have lower coverage that wealth quintile groups 2-4. Also as in Ghana the Female (40%) and male (38%) are very similar.
We encourage readers to review the recent MIS and/or DHS reports from the countries where they work and look for differences in net availability as well as uptake of other malaria control interventions to determine the level of equity in intervention access and use, but also as one sees in Liberia, take action to ensure that strategies are in place to reach the poorest and most vulnerable segment of society.
The preliminary 2018 Demographic and Health Survey (DHS) data have been released for Guinea (Conakry). Since the last DHS in 2012, Guinea and its neighbors experienced the largest Ebola outbreak in history, an event that damaged already weak health systems.
The previous DHS showed very weak malaria indicators. Only 47% of households had at least one ITN, which averages to 0.8 ITNs per person (compared to the universal coverage of 2.0). Among vulnerable groups only 26% of children below the age of 5 years slept under an ITN, as did 28% of pregnant women. Very few, 18%, pregnant women got two doses of IPTp, and only 5% of febrile children received ACTs (testing was not reported then).
Not much has changed concerning ITN coverage as reported in 2018. Slight improvements are seen in IPTp (which now requires 3 or more doses) and malaria testing and treatment for children. Ironically none of the indicators has passed the original 2006 Roll Back Malaria target of 60%, let alone 80% for 2010 and not of course the drive for universal coverage.
DHS has released a preliminary report for 2018 and the malaria component is summarized in the charts posted here. The national coverage for ITNs is 44%, slightly lower than 2012, but the average per household member is slightly higher at 1.1. Again, these numbers do not mark significant progress. Looking at wealth and ITN ownership there is a slight benefit in terms of equity in net possession among those with lower income, but this must be seen in the overall context of very low basic coverage.
Having a net in the household and using it are different challenges as seen in the reports of sleeping under the net on the night prior to the survey among children under 5 years of age and pregnant women. The sad finding is that even in households that own a net, the coverage of these two groups remains very low. This is reflected in the low net per person ratio nationally (1.1).
One would almost wonder if malaria is a neglected disease in Guinea. The reality is that since 2003, Guinea has received around $172 million US dollars in malaria project funding from the Global Fund. Its most recent annual funding from the US President’s Malaria Initiative (PMI) is around $14 million. Of that PMI funding 24% was designated for nets and related activities, while 52% was to be spent on medicines, diagnostics and pharmaceutical management. These investments include systems strengthening and capacity building in addition to commodities.
PMI provides the needed context: “Since the country was declared Ebola-free in in June of 2016, Guinea continues to make positive advances towards building a strong health system in line with the health recovery plan. The government continues to mobilize internal and external resources for rolling out the health system recovery plan, but much remains to be done if this plan is to yield the intended results.” Areas in particular need of strengthening within the National Malaria Control Program include coordination, health information systems, leadership, supervision and logistics.
Three years have passed since the last Ebola case in Guinea. Hopefully the country can stave off another outbreak and at the same time strengthen its health system. Guinea may not yet be targeted for malaria elimination, but until systems are strengthened, the resources going into malaria control will not be able to push malaria indicators toward saving more lives.
Gbenga Jokodola tells his story of growing up to fight malaria in Nigeria. Gbenga has a MPH in Field Epidemiology from the University of Ibadan, and a BPharm from Ahmadu Bello University. He is currently working with Malaria Consortium as a Zonal Project Manager on the Seasonal Malaria Chemoprevention (SMC) Project, delivering preventive care to over 400,000 children between the ages of 3 – 59 months in Jigawa and Katsina States of Nigeria. He has worked on several malaria projects over the years sponsored by Unicef, the Global Fund, Catholic Relief Services and the Bill & Melinda Gates Foundation. As he narrates below, his early experiences with malaria were formative of his present focus in life.
At 3 months of age Gbenga was probably still protected from malaria by maternal antibodies and did not realize what malaria held in store for his future
Growing up in Zaria, northern Nigeria in the 70s and 80s was one of the best experience any child could ask for. I lived with my parents in two rented rooms in a compound on one of the streets in Sabon Gari Zaria – a community that had virtually all the tribes in Nigeria and of course, with all the love and communal living you can ever get from a true Nigerian community.
In such loving setting we enjoyed as children, I imagined that mosquito communities also lived around our pit latrine and backyard. I imagined that parent-mosquitoes trained their off-springs very well on how to bite and fly away tactfully, how to dodge the usual clap-like manner we use in killing mosquitoes, which homes to avoid visiting, and so on.
I was reputed to be a strong boy then, one of the few kids who were “strong”; I was a “tough” boy who rarely fell ill to malaria. Then, it was common to hear, “Gbenga is a strong boy”. I ate and slept in any room in our compound – with or without covering from mosquito and was hailed for doing so by my friends who often fall ill to malaria.
Life lesson as a Primary School pupil: There is no immunity against malaria
One day, the “malaria forces” (mosquitoes) taught me a life lesson: Indeed, there is no immunity against malaria.
My local Government primary school rotated school attendance between morning and afternoon every week. As an 8-year-old, while preparing for my afternoon school I suddenly felt very cold and sleepy at the same time and decided to lie down briefly on my senior brother’s 6-spring bed in our sitting room. Shortly after, I was shivering and sweating profusely under 3 of my mother’s wrappers.
Help was not immediately near as most people were out. My head was pounding like I was a piece of yam being pounded with a pestle in my mother’s mortar. My stomach was churning. All the while, I kept saying “I am a strong boy, I will not be sick”! I was in that state for over an hour. I began to wonder if I was strong after all and will not end up dying. I could no longer talk but my teeth were chattering.
Gbenga second from left at about 7 years old in company of Sisters and friends in the compound
Sweating profusely, yet I was cold! I was helpless. It was in this state that one of our neighbor’s daughters walked into our sitting room, wondering if there was any food to eat. Immediately she saw the “strong man” shivering under 3 wrappers, she raised an alarm. Her shout saved me as neighbors immediately rushed into our sitting room. Among them was a relation of the landlord, a beautiful “Aunty” Esther, who was visiting from the Ahmadu Bello University school of Nursing. As soon as she came over, she said: “this is malaria!”.
Aunty Esther immediately organized and rescued me that day; she saved the life of the “strong man”! She quickly sought iced-cold water and toweled my body with my father’s “untouchable” towel hanging on the door of the inner room. Ah, what a good feel it was! She then gave me a sweet syrup which I later found out to be Paracetamol syrup. After about 30 minutes, she returned with a plate of hot rice and stew, encouraging me to eat before treatment with anti-malarial medication. I struggled to eat the rice, angry that I had lost my ever-available appetite! I only took few spoons, amidst the encouragement I received from all present.
I was then given an injection by Aunty Nurse Esther, tucked back into the bed and told to prepare to sleep. She then said, “Gbenga, no school for you today, okay? You even need to get well before you resume school”. Everyone knew I loved school. I had to lose a precious school day (and three more days) to malaria! So, I simply focused on staying alive, wondering which “wicked” mosquito bit me. That was the day I dramatically lost my title of “strong man” to malaria, painfully realizing that I was not immune to malaria at all!
My treatment against malaria was continued with further jabs of the needle (twice a day) over the course of the next 3 days at the Dispensary/Primary Health Unit “Aunty” Esther directed my parents to. I got well and resumed school after the third day. Later, I researched and found out I was treated with a sedative, Chloroquine and Paracetamol.
Gbenga with classmates at First Baptist Church, Benin Street, Sabon Gari Zaria
My parents later introduced “Sunday-Sunday Medicine” (one Sweetened pyrimethamine tablet weekly) against Malaria to our diet on Sundays. With this painful encounter with Malaria, I resolved to fight mosquitoes; I was determined to regain my “strong man” title. I made up my mind to be a community health worker, saving communities from diseases like malaria.
Fast-forward to Year 2007: My new twist in combating Malaria
By the year 2007, my personal malaria episodes had lessened with greater knowledge of the disease. In addition, the application of the preventive, diagnostic and treatment procedures reduced my malaria episodes to about 1 in 3 years. With each episode, I normally use laboratory test (microscopy) to confirm if severity is +, ++, or even +++. Thereafter, I get a prescription from a Physician on appropriate medication to use.
However, while practicing in Abuja, I encountered a tearful case of death from malaria, of an 8-year old beautiful daughter of a colleague. Three days prior to her death, a Community Pharmacist had dispensed anti-malarial medication to her, based on prescription tendered by the father from a Government hospital he had earlier taken her to. The news of her death brought back memories of how I would have died as
an 8-year old from this same Malaria. Yes, this same Malaria! That death of the 8-year old triggered a fresh resolve in me to step up my fight with mosquitoes and combat malaria squarely at community, state, National and global levels.
Still at War with Malaria in 2018
Now armed with post-graduate training in Public Health/Epidemiology and field-based experience, my Malaria diagnosis strategy has now changed. I now use Rapid Diagnostic Test Kits (RDT). If confirmed positive, I receive prescription on the most applicable Artemisinin-based combination Therapy (ACT) to use.
My malaria story continues and will only end when mosquitoes are defeated – when children and adults no longer fall ill nor die from mosquito bites that cause malaria.
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
Here we examine the challenge of asymptomatic malaria infections.
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
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
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
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
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Management Sciences for Health notes
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.” 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
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
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.
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
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
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/
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.
Ministry of Health, Rwanda. Performance Based Financing Procedures Manual for
Health Facilities (Hospitals and Health Centers). April 2018.
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.
The history of community intervention in Burkina Faso dates back to immediately after the declaration of Alma Ata in 1978. The first community health experiments were carried out in 1979 with the support various development partners with an aim of reducing maternal and infant morbidity and mortality difficult to access health districts where village birth attendants where been trained, equipped and supervised. Today as a matter of policy, Burkina Faso aims at improving the quality of health services and increasing access to health services through community-based health workers (CBOs), civil society organizations (CSOs), non-governmental organizations (NGOs) and associations implements community intervention strategies. with the full participation of communities.
Burkina Faso’s draft strategic plan for community health states
that, “Community Health is a
multi-sectoral and multi-disciplinary collaborative enterprise that uses public
health science and some social science approaches to engage and work with
communities. Its purpose is to optimize the health and quality of life of all
people who live, work in a given community. It is based on community needs,
understanding and community priorities for health.”1 Community
participation is seen as central to achieving universal health care.
The Ministry of
Health1 notes that there has been community participation as part of
cost recovery (Bamako Initiative). Communities are part of the management
committees set up at the level of the first-level health facilities so that the
populations thus participate in the management of health facilities, through
these committees. “In recent years, there has been renewed interest in
community health with a strong mobilization of civil society through NGOs and
associations. Community components are integrated into many health programs.
This new dynamic has led to significant progress and positive results in the
areas of the fight against HIV, tuberculosis, reproductive health (family
planning, health of young people and adolescents), malaria, malnutrition,
The Ministry reports that, “Indeed, the community actors
have contributed to the achievement of the results obtained through the
implementation of community-based health services, which however remain to be
rethought not only in its vision but also to be in phase with that of the
universal health coverage. For a better involvement of these actors in the
achievement of the health objectives, the main challenges remain their
motivation, the reinforcement of their capacities and the collaboration with
the agents of health.”1 Systematic evaluation of such results
remains to be done.
While there have not been systematic assessments of these
participatory processes in community health, researchers did take a close look
at the levels and types of community participation attained in water and
sanitation projects in Burkina Faso. The following lessons have implications
for involving Burkina Faso communities on PHC:
Users and Neighborhood groups have a lower level
of participation than city and government stakeholders
It is possible that the social structures and
traditions in Burkina Faso do not encourage a more participative approach
Further study of power structures in Burkina
Faso may determine why participation is lower than expected
There is a significant decrease in participation
levels during the design and selection steps of planning as opposed to the
earlier stages of problem identification and definiing objectives, and the
later stages of option selection and action planning – a question of planning
styles dominated by experts
These issues raise questions about the social and cultural
aspects of the planning process and about leadership and governance. It would
seem that ‘experts’ also need education about how to work with
communities. There are also concerns
about the level of community education employed to help community members and
CBOs make informed choices. The authors raise another important question
concerning expectations that communities will take ownership in the running of
projects when in fact these Users have only been asked about their problems and
then been informed about a solution.
In another sector the World Food Program developed a
diagnostic and planning approach based using community participation and
conducted training and practical exercises on “Community-Based
Participatory Planning.” The exercise brought many community actors
together to identify food security issues such as land degradation, lack of
economic activities for residents in the non-agricultural season and floods
that block access to health and other services. participators discussions
identified community resources to address these issues and demonstrate
A recent Global Fund grant to Burkina Faso was entitled,
“Strengthening health systems and scaling-up of integrated community case
Community-based organizations (CBOs) involved in control of the three diseases
commonly addressed through integrated Community Case Management (iCCM) –
malaria, diarrhea and pneumonia. The program was also expected to strengthen
the community workforce be ensuring adequate numbers of functional CHWs. The
project received a high level of regular reporting by CBOs (100%), but less
than ideal from individual CHWs (83%). This was in spite of the fact that they
achieved recruitment targets for ‘functional’ CHWs. Interestingly the biggest
problem for the CHWs was the extremely low availability of essential supplies
with which they could work (13%). The grant demonstrated the challenges of
involving CHWs in more focused activities as opposed to a broader community
agenda. Reorganization of the CHW program in the last few years has created a
standardized curriculum so that there are two CHWs per village who respond to a
variety of community needs ranging from reproductive health to disease control.
The problem of adequate supplies and materials to do their work continues,
While Burkina Faso has established the basic participatory structures in the form of committees and community agents, the Ministry of Health is concerned that Community participation is low.1 Lessons from other sectors show possible reasons and solutions and inter-sectoral collaboration, one of the hallmarks of PHC should be used to address the challenges. the MOH of course has its own ideas (listed below) about the root causes of this problem and having identified the following, it should be encouraged to continue efforts to strengthen the roll of the community in PHC:
lack of social capital (capacities of communities to work together effectively, to identify problems, to prioritize and take charge of them)
weak involvement of communities in the whole process of implementation.
greater focus on community diagnosis of needs, assets, and priorities, to develop appropriate intervention strategies, planning, implementation, evaluation
lack of capacity (skills, human resources, material and time) of community implementation actors,
lack of accountability of the stakeholders responsible for the implementation of community-based initiatives (CBIs)
lack of a multi-sectoral approach in the resolution of health problems
Insufficient strategies to combat social exclusion and to take into account specific groups also constitute a barrier to community participation
Partners worry that there is difficulty sustaining CBIs and demotivation of actors (CHWs, facilitators), which can allow morbidity and mortality to remain high in the community. Clearly, investment in strengthening community participation will go a long way in saving lives and promoting health.
De La Sante. Draft Strategie Nationale De Sante Communautaire Au Burkina Faso
2019-2023. September 2018
J, Kain J, Kvarnstrom E, et al. (2014) “Participation in sanitation
planning in Burkina Faso: theory and practice”. Journal of Water
Sanitation and Hygiene for Development, vol. 4(2), pp. 304-312. http://dx.doi.org/10.2166/washdev.2014.125
Celestine (2016). Promoting Community-Led Resilience and Development Solutions
in Burkina Faso. World Food Program.
Fund (2017). Burkina Faso BFA-S-PADS Grand Performance Report.
In Rwanda CHWs are male and female resident volunteers
elected by members of the village and are accountable of the village they
serve. They should have a Primary 6 education minimum. The system guarantees
that CHWs are more accessible, acceptable by clients in their communities and
less expensive. Each village has a team of three CHWs. Technical supervision is
done by the Health Center staff and administrative supervision by the in-charge
of social affairs (cell, sector, district). CHWs receive financial compensation
through Performance Based Financing (PBF) based on a set of performance
indicators from monthly reports. It is this reporting process from village
onwards that is explored in this case study. Services include HIV support,
integrated community case management of childhood illnesses, family planning
The structure of the health system is based on 4 Provincial
hospitals that receive referrals from 35 district hospitals. Within these
districts are 465 health centers whose catchment areas contain 2,148 cells and
14,837 villages. With a goal of 3 CHWs per village (1 female & 1 male pair
in charge of iCCM and 1 Female in charge of Maternal Health), Rwanda has
trained 44,511 CHWs. All CHWs are organized into cooperatives. Each health
center oversees one CHW cooperative (which is the basis of performance-based
funding as we discuss in Module 6).
The current system has evolved since 1995, when it was
completely paper-based. The Community Health Information Systems, that is the
M&E system for community interventions, is carried out through different
national data collection and reporting tools ultimately managed by web-based
interface. Tools include national
standard paper-based source document (registers), paper-based monthly summary
form, DHIS-2 and the système d’information sanitaire des communautés/CHW
information system (SISCOM), and Rapid SMS
Initially, separate systems existed to gather data on the
country’s 45,000 community health workers, HIV services, human resources, and
other special programs—these data streams were separate and though the systems
were web-based, none of the databases could interact. The Rwandan health system
was collecting immense amounts of data, and spending considerable time and
money doing so, but it was unable to effectively use that information for
strategic planning or immediate action. As reported by staff of the maternal
and Child Survival Program (MCSP), since the successful launch of the
many new reporting modules have been integrated into the DHIS 2 platform which
include weekly and monthly reporting of community-based health insurance
indicators and the CHW information system.
The following community services are tracked: Treatment of
sick children (iCCM), Community Based Nutrition Program (CBNP), Malaria
Treatment Adults (HBM), RDTs carried out, Family Planning, Home based Follow up
of pregnant women, mothers and newborns, Nutritional monitoring, Under-5
vaccination, Maternal and Newborn Death Surveillance, Drugs and supplies, IEC
activities, and user payments. These are summarized into a CHW monthly report
form and ultimately into the web-based SISCOM monthly summary form. The
web-based R-HMIS data tools are accessible to health staff with passwords.
The data flow system moves as follows:
— Electronic – MOH
^ Electronic – District Hospital
^ Electronic – Health Center
^ Paper-based – Cell Coordinator
^ Paper-based – CHW
The coordinator of CHW cooperative submits the monthly
summary form to Health Center data manager who enters aggregated data into
DHIS- 2/SISCOM. The data entry screen of DHIS-2-HMIS/SISCOM can be accessed at
the health center.
According to MCSP, Rapid SMS text-messaging tool is used by
the CHW assigned to maternal health to track pregnant women and track the first
1000 days of life up to 5 years. Examples of information submitted include 1)
Woman’s pregnancy and delivery, 2) Children under five identified with danger
sign, 3) Tracking referrals (track alert sent and responses) and 4) Maternal
and under five deaths. Rapid SMS data are accessed at District Hospital and
used at the primary level health facilities to respond to maternal and child
health emergencies. Rapid SMS sends automated, actionable responses to CHWs
when reported events indicate risk, or when antenatal care visits or deliveries
are due. Health facilities are notified to prepare for an anticipated delivery
and/or to provide ambulance transport.
DHIS/SISCOM from the CHW also report on drug and supply
management. Primary level health facilities support community health workers
within the catchment area to ensure they have timely and adequate supplies.
At the local administration level (village, cell, sector,
district) CHWs data are used for planning, setting and monitoring health
related performance contracts. At the Central level (RBC/MOH and development
partners), these data inform policies, establish strategies, manage the supply
chain management, aid in research, and perform PBF
MSCP explains that feedback mechanisms and data quality are
promoted through quarterly community sub-technical working group meeting,
Quarterly and annual analysis of community data, and biannual integrated
supervision including community Data Quality Assurance (DQA). Quarterly
analysis of Community Health data informs decisions by the Management Team. The
biannual DQA of community data compares paper vs. electronic sources. Monthly
meetings at Health Center level review reported data and link data to quality
of service provision. Mentorship included community DQA
There are monthly CHWs meetings with cell coordinator to
review reported data. This also aids in Community Performance-Based Financing.
Incentives are given to CHW cooperatives in exchange of their performance based
on two categories of indicators. First,
quarterly payment for reporting is
based on the timely submission of quality data reports related to 29 indicators
Timeliness, Accuracy and Completeness of Report
Quality: Legal status, Presence of President, Bank account, etc.
are additional payment for improvement in five targeted areas (Nutrition, ANC,
SBA, FP referrals and FP new users, LTPM). The average quarterly payment is
$900 per cooperative for a 100% quality score.
MCSP notes as an example of success that all CHWs are using
standard data collection tools (registers, flipcharts and summary forms). All
CHWs are equipped with a mobile phone regularly loaded with airtime for Rapid
SMS, communication with HC and other CHWs. The DHIS-2/SISCOM functional countrywide.
A strong feedback and coordination mechanism is in place and functional. The
PBF includes the CHW reporting rate.
MCSP reports that the
remaining challenges include turnover of trained CHWs, High workload for CHWs,
inadequate response rate on alerts sent through Rapid SMS, disaggregation of
data (e.g. FP not disaggregated by method), disparities in CHWs activity as per
instructions for Rapid SMS, and sub-optimal use of data. Continued mentoring
through CHW meetings addresses community level gaps.
Jean de Dieu Gatete, Jovite Sinzahera,
USAID Maternal and Child Survival Program (MCSP),
Rwanda. Integrating community data into the health information system in
Rwanda. Institutionalizing Community Health Conference, Johannesburg. 27-20
March 2017. www.mcsprogram.org
US Agency for International Development (USAID). THE RWANDAN HEALTH MANAGEMENT
INFORMATION SYSTEM: Improving Collection and Management of Health Service Data
to Support Informed Decision Making. the Integrated Health Systems
Strengthening Project. https://www.msh.org/sites/msh.org/files/ihssp_techbr2_final_webv.pdf
Rwanda Integrated Health Management Information System.
When examining the service delivery building block of a health system we much ask what, how and where? “What” addresses the package of services, “How” describes the mechanisms and personnel who do the delivery, and “Where” considers making services accessible in or very near the community. These are the issues explored in this case study on Nigeria. As USAID notes, “An Essential Package of Health Services (EPHS) can be defined as the package of services that the government is providing or is aspiring to provide to its citizens in an equitable manner. Essential packages are often expected to achieve multiple goals: improved efficiency, equity, political empowerment, accountability, and altogether more effective care.”[i]
Although Nigeria has held Primary
Health Care as the official foundation of its national health policy since
1986, it took nearly 30 years to give legal backing to a standard service
package with the legislative passage and presidential signing of the National
Health Bill in 2014. The law says that “all citizens shall be entitled to a
basic minimum package of health services…” defined as “the set of health
services as may be prescribed from time to time by the Minister after
consultation with the National Council on Health” (National Health Bill, 2014
Up until that time one could infer the existence of an
essential medicines list for primary care through the “Standing Orders” service
These algorithms guide front line health staff known as community health
extension workers (CHEWs) in providing quality and accurate treatment and
prevention for common illnesses. The Standing Orders also form the basis for
training for CHEWs. For each area, “there is a set of actions including health
education, further investigation, treatment, and follow-up necessary
for good client’s care.”
As an example of essential medicines, the section of an
algorithm for fever management below indicates that Artemisinin-Based
Combination Treatment (ACT) malaria medicines and Long-Lasting
Insecticide-Treated Nets (LLINS) for malaria prevention should be part of the
basic package found at the front line.
USAID describes the official service delivery system in
Nigeria as organized in three tiers. Tertiary facilities operated by the Federal
Ministry of Health are the highest level of health care and serve as referral
centers for patients. State Ministries of Health manage secondary facilities,
which provide some specialized health services. Local Government Area (LGA) PHC
Departments manage primary facilities, which provide the most basic entry point
to the health care system-health centers, clinics, and dispensaries. It is at
the LGA level in frontline PHC clinics where the CHEWs mentioned above function
and deliver the basic package. Volunteer CHW programs exist and are often run
by NGOs and are poorly coordinated, although efforts in recent years have aimed
at standardizing their training and activities.
In reality, Nigerians at the community level face a mosaic
of health service delivery mechanisms ranging from LGA clinics and
dispensaries, patent medicine shops, private clinics often run by nurses and
licensed to physicians living in the city, and a range of indigenous
practitioners (herbalists, bone setters) and faith healers (based in all major
The USAID report on Nigeria’s essential services shows major
challenges in health equity.1
Coverage is low for reproductive health,
maternal health, and immunization varies widely and is strongly associated with
wealth, education level, and rural versus urban place of residence.
On some measures, health services coverage among
populations with urban residence is more than double the coverage among
populations with rural residence.
Only about 30% of women in the poorest
households receive at least one antenatal care visit, compared to over 90
percent of woman in the wealthiest households, with service coverage steeply
increasing along with wealth.
Coverage of most key preventive and curative
health services is relatively low with large disparities in geopolitical zones,
between rural and urban zones, and with regard to socioeconomic status; the
poorest fifth of the population are much less likely to receive medical
services than their counterparts in the wealthiest 20 percent of the population.
USAID’s Health Financing and Governance Project,1
helped group the Essential Package of Care into three “service delivery
family-oriented, community-based services that
can be delivered on a daily basis by trained community health, nutrition or
sanitation promoters with periodic supervision from skilled health staff;
population- oriented, schedulable services that
require health workers with basic skills (e.g. auxiliary nurses/midwives and
other paramedical staff) and that can be delivered either by outreach or in
health facilities in a scheduled way; and
individually oriented clinical services that
require health workers with advanced skills (such as registered nurses,
midwives or physicians) available on a permanent basis.
These modes come along with recommended actions which could
be interventions like safe water for the family or drugs like antibiotics for
child pneumonia. Therefore, at present the package focuses more on essential
interventions (than essential medicines) for groups such as adolescents,
pregnant women, women in childbirth, and infants and children among other
populations to be reached with of RMNCH services (reproductive, maternal,
neonatal, and child health).
In conclusion, Nigeria has articulated its PHC
service delivery in terms of what, how and where, but has some ways to go in
articulating a clear essential package across the life span and ensuring
equitable access to and provision of these services across the country and
among all income groups.
Jenna (2016), ESSENTIAL PACKAGE OF HEALTH SERVICES COUNTRY SNAPSHOT: NIGERIA.
United States Agency for International Development (USAID), Health Finance and
Governance Project (Abt Associates). https://www.hfgproject.org/essential-package-of-health-services-country-snapshot-nigeria/
[ii] National Primary Health Care Development Agency (2015) NATIONAL STANDING ORDERS FOR COMMUNITY HEALTH OFFICERS/COMMUNITY HEALTH EXTENSION WORKERS, Revised By CHPRBN IN COLLABORATION WITH NPHCDA. Nigeria Federal Ministry of Health, Abuja.
WR. PHC: in search of a system that works. Africa Health 1987; 10: 30 31,26.