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Monthly Archive for "November 2011"

Communication &Community &Migration Bill Brieger | 26 Nov 2011

Thailand shares challenges of reaching migrant and conflict-affected populations

thai-1-sm.jpgThailand, who hosted the Asia Pacific Malaria Elimination Network community engagement workshop, shared with participants the special challenges their health programs face in developing, implementing and monitoring of behavior change communication strategy for migrants, mobile populations, refugees in camps and people spending nights in the forest.  This requires creating messages on treatment strategies and appropriate use of LLINs as well as designing a relevant migrant household health survey.

The challenges were well described in a recent publication –

Most highly mobile migrants along the Thai-Cambodia border are not accessing health messages or health treatment in Thailand, increasing their risk of malaria and facilitating the spread of potentially resistant Plasmodium falciparum as they return to Cambodia to seek treatment. Reaching out to highly mobile migrants with health messaging they can understand and malaria diagnosis and treatment services they can access is imperative in the effort to contain the spread of artemisinin-resistant P. falciparum.

thai-3-sm.jpgTo respond to these needs, the staff of the Bureau of Vector Borne Disease, Thailand have developed specific BCC materials, tools and method for the target group in two languages(as seen in posters here). They have produced radio broadcast messages in migrant languages on community radio channels.  They have also built capacity of migrant health workers and migrant health volunteers on the malaria program.

As with any vulnerable population advocacy is needed too generate support for migrant health. The Bureau of Vector Borne Disease, Thailand has organized meetings of migrant health committees and undertaken advocacy with the business owner, stakeholders and migrant health networks for thai-6-sm.jpgmalaria control and prevention. Collaboration with employers is essential to locate the migrant population.

Because of the cross-cultural nature of this work the Bureau of Vector Borne Disease is working to strengthen the capacity of health staff and health volunteers in communication skills needed for effective health education.

Malaria does not respect borders and boundaries. Thailand is offering other countries valuable lessons on first how to recognize the needs of migrant and refugee populations and secondly on how to involvement in the disease control process.

Advocacy &Community &Funding Bill Brieger | 25 Nov 2011

Despite Global Fund Round 11 Cancellation, APMEN Community Engagement Workshop Closes on Optimistic Note

Just as the Asia Pacific Malaria Eradication Network’s community engagement workshop was ending in Chiang Mai Thailand, word reached the group that the Global Fund had cancelled its call for Round 11 funding. During the workshop participants and facilitators had discussed the community systems strengthening potential of Global Fund grants and how this could benefit APMEN counties’ community engagement strategies.

The Global Fund euphemistically phrased this cancellation at the just completed Global Fund Board meeting in Accra with a key decision point that notes the Board “Agrees to establish a Transitional Funding Mechanism … in order to provide this continuation funding (and) Decides to convert Round 11 into a new funding opportunity …”   Jeffrey Sachs clearly laid a large portion of the blame on the U.S. Government, which is responsible for about a quarter of the Global Fund project money when he observed that the U.S. …

had pledged $4 billion during 2011-13 to the Global Fund, or $1.33 billion per year. Now it is reneging on this pledge. For a government that spends $1.9 billion every single day on the military ($700 billion each year), Washington’s unwillingness to follow through on $1.33 billion for a whole year to save millions of lives is a new depth of cynicism and recklessness.

dscn5842-sm.jpgThe APMEN meeting therefore closed with a call on donors to honor their commitments to the Global Fund and the community programs it makes possible.  The final session was also devoted to action planning that included brainstorming by country teams of alternative funding sources to support community engagement.

Gawrie Galappaththy from Sri Lanka expressed clearly the workshop participants’ surprise and disappointment over the Global Fund announcement.  “Many of our countries have been receiving Global Fund support since 2003, and we are collectively dependent on the Global Fund from its different rounds. The reality is that with Global Fund support being so regular, governments have shifted some of their financial support for health to other areas. An abrupt stop to Global Fund support will hit us hard.  It will be necessary to regenerate the political will all over again for malaria and health.”

Gawrie also worried that, “Malaria is a dynamic disease. If we let the pressure off, it will re-grow as happened after the first eradication effort.  If we can’t get this elimination done now, we may never have a chance to do it again.”

The Globe and Mail summarizes the problem succinctly. “The global economic crisis has claimed a new victim: a $22-billion (U.S.) health fund that has saved millions of lives in Africa and other low-income regions during the past decade… The cuts by donor governments are not just because of the economic slowdown and the financial crisis in Europe, but also because of concerns over corruption in several recipient countries.”

The BBC interviewed the HIV/AIDS Alliance on this issue, and not surprisingly learned that this is the worst of all possible times to see cutbacks in funding for disease control.  The Alliance’s Director mentioned issues that could equally apply to malaria when he said that, “These should be exciting times – the latest scientific developments …”  New vaccines, new medicines and strengthened community participation strategies are just a few of the latest malaria developments that could be threatened.

Community engagement does take time and effort, even if it does not cost anywhere near the price of nets and drugs. Communities bring valuable resources to the table, but at the same time we do not want to foist malaria control and elimination responsibilities off on vulnerable poor people in developing countries.  APMEN workshop participants are going to be engaged in advocacy themselves, and are optimistic that donors old and new will not let communities down.

Community &Elimination Bill Brieger | 23 Nov 2011

Solomon Islands: 3 Pillars of Community Participation in Ysabel Province against Malaria

Albino Bobogare and Makiva Tuni shared their community participation experiences at the APMEN Community Engagement meeting in Chiang Mai, Thailand. Care Smith-Guyeye helped prepare this summary of their presentation

solomon-3-sm.jpgSolomon Islands is a country in the West Pacific, neighboring Papua New Guinea and Vanuatu. The country is known for its rugged environment and remote populations, where boats are used as the main transportation across many islands. Farming and fishing are the main means of subsistence. Healthy Island Settings approach is the main priority in the Ministry of Health and Medical Services 2011 to 2015 strategic plan.

Ysabel Province has approximately 200 villages with slightly more than 20,000 total inhabitants. This province has a malaria elimination goal. The community engagement in Ysabel is supported by three pillars: First, a history of tradition and community participation at the local level, whereby populations respect the “chiefly culture.” Second, the Anglican Church through their women’s groups (Mother’s Union) plays a strong role – 95% of the population follows this religion. Last, the provincial government through the provincial health services, the VDCP, health promotion division, Rotarians Against Malaria (RAM), and the Pacific Malaria Initiative Support Center (PacMISC) support community engagement efforts. In addition, engagement of youths is important.

solomon-2-sm.jpgThe main activities of the community engagement strategy are school and health facility supervisory visits, village and community visits, Church groups (Mother’s Unions), RAM tool program, and the ‘Tidy Village’ competition. Provincial health school visits are conducted by a provincial public health team lead by a Health Promotion officer with close support from the VBDCP to travel and provide education, and a teacher training booklet and other relevant materials were developed and used.

Health village visits are also conducted and have a syllabus and IEC materials, integrated health committees, ownership of community is considered strong in this province. The Tidy Village competition is based on criteria of health and sanitation. Awards are given for the winners of the competition.

solomon-8-sm.jpgFunding has primarily originated from RAM, Ministry of Health and Global Fund funding with some support from PacMISC, AusAID.

These activities have led to a sustained implementation of source reduction for malaria control and other public health related diseases, and in building political advocacy and expectations of leaders. Challenges to these methods include the lack of supervisory visits because of lack of staff. Plans for the future are to adopt these activities in other provinces and continue and expand the educational component beyond school settings.

Borders &Community &Research Bill Brieger | 23 Nov 2011

Training and Research needs to support community engagement in malaria elimination

gawrie.jpgGawrie Galappaththy guided a session at the Asia Pacific Malaria Elimination Network’s Community Engagement for Malaria Elimination Workshop that helped participants summarize their group work on training and research to support community participation in malaria elimination.  Her report follows:

All the participants were agreed and thought that following training areas are necessary for effective community engagement for malaria elimination.  Thoughts about training included key topics and target groups as seen below.

  • Advocacy – Advocacy  is needed for all level including central, district, village level for all the category of staff
  • Partnership with other sectors- specially with the public sector as more than 50% of patients in most of the countries seek treatment from the public sector
  • Skills on communication methods – As most of the health personnel is not very much familiar with communication, methods it is important to train all the trainers on communication methods eg -COMBI, materials, participatory approach)
  • Resource mobilization- funds as well as personals
  • Integration with other diseases – community engagement as an integral part of the health (health package)
  • Training for community – training of community on every aspects of malaria
  • Strategy developments – most of the malaria programmes in their strategic plans not mentions the involvement of community in malaria elimination. It is important to include this aspect along with key activities
  • Skills on Monitoring & Evaluation – most of the countries engaged community for malaria control but lack M&E component. It is important to include M&E as an integral part of the elimination statergy
  • Empowerment of community for sustainability of community engagement in malaria elimination

Many research areas were identified by the participants, but need to priority areas depending on funds availability.  Examples of priority research issues included …

  • Cost effectiveness of engagement of community in malaria elimination
  • Improvement of drug compliance specially among migrant workers
  • Case studies or documentation of success stories
  • Promote treatment seeking behaviour specially in   malaria elimination countries
  • KAP studies on malaria especially since perceptions may change as we progress toward elimination
  • Role of community in malaria elimination
  • Effectiveness of village malaria posts/brigade in malaria elimination
  • Role of NGOs/FBOs in malaria using community engagement
  • Development and testing of Training modules
  • Research on new mechanisms of community  engagement for mobile population
  • Understand community structure and to identify the mechanism to sustain motivationAchieving synchronous cross boarder community engagement for malaria elimination

thai-cambodia-border.jpgOf particular interest in the region are the training and research needs to identify and test strategies for community engagement between countries – cross-border areas present a special challenge in terms of mobile populations and malaria medicine resistance. APMEN therefore, has to play a major role in advocacy as it is important to increase awareness among politicians, decision makers regarding cross border problems between countries. APMEN can raise a voice in international bodies such as SAARC, ASEAN, BIMSTEC etc.

Regular meetings in cross-border areas are essential at district/state level between countries eg  Bhutan and ASSAM, Bhutan and West Bengal.  There is need to address the issue of communication methods between countries taking into consideration ethnicity, language, cultural background etc

Priority Research and training needs for cross-border areas include descriptive studies to understand the migrant pattern, behavior, and risk groups. We also require needs assessment studies including assessments of existing facilities among border populations.

On the final day of the workshop, participants refined and prioritized these research and training topics for follow-up action back home.

Community &Integration Bill Brieger | 23 Nov 2011

Bhutan: Community Action Groups – Building local participation for improvement in public health

Participants at the Asia Pacific Malaria Elimination Network’s Community Engagement for Malaria Elimination Workshop shared their country experiences on community participation.  Below is a summary of experiences shared by participants from Bhutan, which shows how we can integrate malaria activities into broader community development efforts.

dscn5601-sm2.jpgBhutan is a small country of 39,000 km2 with a population of 634,982. It is bordered by large countries – China to the north and India to the south. The northern reaches of the country are in the Himalayas and have high elevation and cooler climates thus there is no malaria transmission in this region (4 districts). The middle section of the country is considered at risk for seasonal transmission (9 districts) and the southern zone bordering India is considered endemic (7 districts).

One of the main community participation methods in public health, including malaria control and elimination, is the formation of Community Action Groups (CAGs). In the rural communities, these groups have been formed at the village level in four southern districts in Bhutan from 2009 to 2011. The CAG initiative aims to create community ownership of health activities, stimulate decentralization of health work to the grassroots level, and to motivate and build capacity for local leadership. CAG members receive a three-day training which covers sanitation, community motivation, nutrition and child care. The training, meeting costs and monitoring of the CAGs are funded by Global Fund.

Members of the CAG are elected by the community:

  • Chairperson (Tshogpa): this representative is paid by the Government for a five year term
  • Secretary: this is a Village Health Worker, who provides the message delivery on preventive and curative services and are involved in LLIN distribution. These workers attend training on communication methods and receive refresher training.
  • Allied sector representative
  • Water caretaker: this person has strong community ties
  • Female representative
  • Religious group member: this is typically a monk

The CAGs discuss priorities and develop a community action plan. The groups meet quarterly with monitoring every six months and reports are sent to block level with feedback going up to the national level.

One CAG has been successful in achieving sanitation improvements. CAGs are also seen as a platform for multi-sector involvement. A challenge of this strategy is the high turnover of village health workers because they are no incentives. In the future, Bhutan hopes to increase the number of districts with CAG groups, but the source of funding is not yet available.

[Thanks to Yeshi Nidup, Tshewang Phuntsho and Cara Smith-Gueye for the presentation and this summary.]

Community &Elimination Bill Brieger | 22 Nov 2011

APMEN workshop reviews community engagement frameworks and tools

Do we take the community seriously – not just as recipients of information? Susanna Hausmann-Muela of the Swiuss Tropical institute raised this important question at the start of her talk to participants at the Asia Pacific Malaria Elimination Network’s Community Engagement for Malaria Elimination Workshop on Tuesday. She stressed the importance of dialogue and mutual learning so that we may learn from the community how they perceive malaria and understand their response to it.  Their response likely reflects the many troubles in people’s lives – trying to access food, jobs, education – and malaria may be the straw that breaks the camel’s back.

dscn5639-sm.jpgWe need to learn from people what kind of bednets are ‘right’ for them and not assume that synthetic fiber long lasting insecticide treated net that has survived scientific efficacy trials is the one size that fits all.  At the same time we should not abandon scientific rigor, because randomized control trials of community participation have shown the effectiveness of community participation in reducing neonatal mortality and dengue serological indices in communities. We need similar evidence for malaria interventions. Such interventions though, need to be designed with and by the community bearing in mind APMEN’s community participation framework.

Jeffery Smith of the World-Wide Antimalarial Resistance Network based in the Mekong Region encouraged workshop attendees to learn from the long history of participation by communities and people living with AIDS who took charge of their situation when science alone was not enough to solve the problems of the epidemic.

He encouraged the group to think more broadly about the term community, especially in today’s climate of high mobility, migration and air travel.  Communities everywhere, not just those that physically border endemic countries, need to be vigilant and incorporate malaria surveillance activities into other primary health care programs.

health-systems-community-systems.jpgChoosing an appropriate mix of community intervention tools was the theme of the talk by Bill Brieger of the Johns Hopkins University.  He provided examples of how local settlements in partnership with front-line health facilities use a community directed interventions (CDI) approach to increase access and coverage of malaria interventions and other basic health services. Community systems and health systems must collaborate.

A major challenge of CDI is not the willingness and ability for communities to plan and deliver nets, IPTp, RDTs and ACTs at the local level, but in helping health workers and program managers overcome their biases against lay people and ensure that they maintain the supply chain so the community has the commodities needed to provide life saving services at the grassroots.

Community &Elimination Bill Brieger | 22 Nov 2011

APMEN Meeting provides opportunities to exchange community engagement experiences

dscn5608-sm.jpgThe APMEN Community Engagement for Malaria Elimination Workshop today provided the ten participating countries opportunities to share and learn from each other. One approach was a round table session or World Café where visitors to each country table could learn about innovative strategies for community engagement and offer suggestions and ideas.  The second format was an exhibition where countries presented materials they had developed for BCC, training and program management.

dscn5633-sm.jpgBelow are some of the lessons learned which were posted, discussed and sorted after the roundtable session. Some of these lessons are general for community engagement while others are especially relevant to the malaria elimination phase.

Countries found that interest malaria may wane in the community as experience fewer and fewer cases.  Therefore it was suggested that malaria activities be fully integrated into other community level disease control activities so the community will not ‘forget’ malaria.  Funding may also wane, and community engagement can be the basis for advocacy efforts to also keep health systems engaged in malaria work. Another aspect of integration is the need for community case management capacity for treating other febrile illnesses since the community will perceive and still be concerned about ‘fever’ even in the absence of malaria.

dscn5642-sm.jpgA lesson of general value include the need to build on community achievements. Communities have their own participation ‘culture’. Therefore communities have their own mechanisms for solving problems, and these can be used as a foundation to address new issues like malaria elimination. Ultimately we need to look toward the community for innovative ways to tackle the problem of malaria elimination on their own terms.  Another aspect of the participatory culture in a community may be seasonality based on the variying demands on community members’ time at different times of the year.

We will present some of the individual country experiences in subsequent postings.

Community &Elimination Bill Brieger | 21 Nov 2011

APMEN – building malaria elimination on a history of community engagement

apmen_banner.gifThe APMEN Community Engagement for Malaria Elimination Workshop started by establishing the broader context of community participation in disease control efforts.  Dr. Wichal Satimal, Director of Vector-borne Disease Control in the Thailand Ministry of Health first welcomed the Asia Pacific Malaria Elimination Network members  to Chiang Mai and Thailand, host country of the Workshop.

dscn5589-sm.jpgDr Charles Delacollette of WHO reminded participants that community engagement is not new to the World Health Organization and member states, and in fact was the foundation of the 1978 Alma Ata Declaration on Primary Health Care.  Reaching back farther, Dr Delacollette recalled that the malaria eradication effort begun in the 1950s was possibly the first international disease control program to reach out to the remotest communities.  He explained that these foundations today manifest in hundreds of thousands of community health workers and volunteers based in villages throughout the Asia Pacific Region.  Other trends in health system reform include decentralization that can give more power to consideration of local priorities.

Dr. Maxine Whittaker of the University of Queensland, and one of the workshop organizers, stressed that a key theme of this meeting is “bringing the human back into malaria control and intervention.” She drew attention to the fact that at the heart of the six WHO key health systems elements should be a seventh, the ‘people’ who must be partners in strengthening health systems.

dscn5594-sm.jpgJo-An Atkinson, also of the University of Queensland reviewed the 60-year history of community participation in disease control and elimination.  An important lesson was the need for better documentation of evidence of what works in terms of community engagement strategies, especially in terms of impact on diseases. Jo-An outlined a variety of factors that influence a community’s ability and willingness to engage in disease control activities ranging from gender and power relationships to lack of congruence between community perceived priorities and agency targets.

Ultimately the challenge to participants posed during this first session was the need to begin the process of establishing best practice guidelines for community engagement in malaria elimination before the end of the meeting.

Community &Eradication Bill Brieger | 21 Nov 2011

Closing in on Malaria Elimination in the Asia Pacific Region

malaria-distribution-in-asia-pacific-region-sm.jpgThe Asia Pacific Malaria Elimination Network (APMEN) is starting a workshop entitled ‘Building Competence in Connnunity Engagement for Malaria Elimination,’ tomorrow (22 November) in Chiang Mai, Thailand. APMEN includes 11 countries that are making clear progress to malaria elimination in the region.

The meeting will feature discussions on topics such as …

  • Lessons from 60 years of community participation in communicable disease control and elimination
  • Going to scale with community engagement for malaria elimination (models for equitable access and sustainability)
  • Experiences and challenges in achieving synchronous cross‐border community engagement for malaria elimination
  • Embedding community engagement for malaria elimination in comprehensive Primary Health Care delivery: A systems strengthening approach

Country case studies will be shared by Bhutan, China, Indonesia, Malaysia, Philippines, Republic of Korea, Solomon Islands, Sri Lanka, Thailand and Vanuatu. Discussions will focus on identifying intervention, training and research strategies to support elimination efforts.  Reports on the meeting will begin tomorrow.

Community &Malaria in Pregnancy &Treatment Bill Brieger | 09 Nov 2011

Malaria Communities – making progress in Uganda

The Malaria Communities Program (MCP) of the US President’s Malaria Initiative gives non-governmental organizations a chance to make an impact at the local level in 15 endemic countries. Ronald Apunyo of Medical Teams International provides us an update on MCP activities in Uganda.

mcp-uganda-mti-3.jpgThe Malaria Communities Project in Uganda is currently being implemented (With funding from USAID) in Lira, Otuke, Alebtong and Dokolo Districts, part of the Lango sub-region of northern Uganda, with a population of approximately 765,458 and 166,190 households. Primary beneficiaries include 159,895 children under five years of age and 39,578 pregnant women.

According to a recent report from the World Health Organization, Uganda has the world’s highest malaria incidence, with a rate of 478 cases per 1000 population per year. Malaria is the leading cause of morbidity and mortality in Uganda and is responsible for up to 40% of all outpatient visits. Malaria is the leading cause of morbidity and mortality nation-wide, and is particularly high in the northern region, where Dokolo and Lira Districts account for 54% of the sub region’s malaria cases and only 46% of the population.

Northern Uganda is a transitional environment, and communities are in the process of resettling in their ancestral lands after 20 years of insecurity and internal displacement due to attacks from the “Lord’s Resistance Army.” The project has endevoured to fill gaps identified in Uganda Malaria Control Strategic Plan by meeting training, support and supervision needs for VHTs who have been trained by MOH and by strengthening community-level behavior change and health promotion efforts to complement PMI and National Malaria Control Program (NMCP) broader malaria prevention interventions.

mcp-uganda-mti-1.jpgThe project has had two years of uninterrupted implementation in all the Sub-counties of Dokolo district, in the past two years (Since 2009/10). The project focuses on reducing malaria-related morbidity and mortality among pregnant women and children under 5 years of age in the project areas by

  1. Increasing the percentage of pregnant women and children under 5 years of age sleeping under an LLIN each night.
  2. Increasing the percentage of pregnant women who receive 2 or more doses of IPTp during their pregnancy
  3. Increasing the percentage of children under 5 years of age with suspected malaria who receive treatment with ACT within 24 hours of onset of symptoms

A review of Dokolo district Health Management Information System between 2006/7 and 2010/11 indicates an improvement in some of the key projects target indicators pertaining to ANC attendance by pregnant women, new malaria cases in OPD IPTp uptake and stockouts of key medicines.


  • There is a steady increase in ANC fourth visit in Dokolo district since project start in 2009/2010.
  • Proportion of Pregnant women receiving IPTp2 increased from 60% to 69% between 2009/10 and 2010/11


The successful use of Social and behaviour Change communications interventions in malaria control should be coupled with reliable supply of malaria commodities at the health facilities inorder to attain satisfactory results.

Use of community volunteers like female VHTs at the ANC to mobilize and conduct less technical work like providing clean water to pregnant women,observing Directly observed treatment (DOT), carrying out health education sessions and providing other support to pregnant mothers at the health units greatly reduces workload of health workers as well as waiting time of pregnant
women during ANC (a key reason why pregnant mothers do not attend ANC).

The role of community structures like the village health teams (VHTs) has made significantly positive contributions towards the fight against malaria within the communities.

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