Tropical Health Matters

Dr Olumide Ogundahunsi of the of the Unicef-UNDP-World Bank-WHO Tropical Disease Research Program (best known as TDR) helped organize a symposium on the history and future goals of the Multilateral Initiative for Malaria (MIM) at the current MIM Conference. He describes the symposium, efforts to launch a MIM Society, and related issues below.

Dakar is hosting the 7^th Multilateral Initiative for Malaria (MIM) Pan Africa Malaria Conference 21 years after the first such gathering of malaria researchers in the city in 1997. At that time Northern research and development organizations including NIH/Fogarty, WHO/TDR, Wellcome Trust, SIDA and others sought to take measure of the malaria research experience and needs of African scientists and scientific institutions. It was challenging at that time to find strong and representative core of malaria researchers across the continent. Arising from that first conference was the development of MIM and a plan for building the capacity of African researchers through a series of malaria research grants that included both postgraduate training as well as support for applying the acquired skills in undertaking malaria research.

Dr John Reeder, Director of TDR and Prof Fred Binka

Between 1997 and 2007 MIM supported Fifty six (56) research capacity strengthening (RCS) grants through the Special programme for research and training in Tropical diseases (TDR) for an aggregate amount of $12.9 million from 1997 to 2007.  The grants responded to basic gaps in capacity, research tools/commodities/supplies and communication. The latter reflected a major need for researchers to connect with the global malaria research community to learn and share.

These grants under the aegis of the MIM/TDR task force on Malaria RCS addressed the following broad research themes: Pathogenesis and Immunology of Malaria, malaria vector control (including insecticide resistance), Chemotherapy and antimalarial drug resistance, research and development of new tools from natural products, and research to facilitate malaria control interventions. At the Symposium Representatives of the 56 MIM grantees from West, Central, East and Southern Africa shared experiences during and after completion of their MIM grant. These included –

• Professor Francine Ntoumi, Malaria immunology and pathogenesis research capacity in Central Africa, University Marien Ngouabi, Brazzaville, Republic of Congo
• Professor Lizette Koekemoer, Malaria vector research capacity in Africa, University of the Witwatersrand, Johannesburg, South Africa
• Professor Abdoulaye Djimde, Malaria treatment and antimalarial drug resistance in West Africa., Univerity of Bamako, Bamako, Mali
• Professor Wilfred Mbacham, Malaria treatment and antimalarial drug resistance in Central Africa, Univeristy of Younde 1, Younde, Cameroon
• Professor Kwadwo Koram, Malaria epidemiology research capacity for elimination and control in Africa, Noguchi Memorial Institute for Medical Research and University of Ghana,  Accra, Ghana

These speakers demonstrate MIM’s and their own specific achievements in following areas:

• -Capacity built with infrastructure, technology transfer, skill acquisition and graduate students and postdocs trained (including their current status/subsequent contribution to malaria research and (or) control)
• -Resources/other grants leveraged
• -Collaborations established and sustained
• -Contributions to national and regional malaria research capacity, control and elimination.

MIM ‘alumni’ speaking at the Symposium

Since that time those receiving the MIM RCS were able to benefit from further TDR and other malaria research grants and in the process have themselves helped develop new generations of malaria scientists in the universities and institutes where they work. MIM has continued to address the original research gaps. The holding of six subsequent Pan-African conferences.  Grants were also provided for establishing satellite communications systems at three institutions where grantees were based.

Participants in this process who attended the current conference (MIM2018) were able to help achieve on of the objectives of the symposium that is “highlighting the importance of continuous investment in training and monitoring of young African scientists.” The symposium also articulated the unmet and emerging gaps in research capacity of particular relevance to malaria control and elimination.

Visiting the TDR booth to discuss MIM experiences and research opportunities

MIM started and continues as a partnership among Northern and African research organizations with a rotating secretariat. For the past 10 years the MIM secretariat has been based in Africa, and most recently in Cameroon in the Biotechnology Centre of the University of Yaoundé.

Going forward the MIM is evolving into the MIM Society, a broad-based society which will focus among others on organizing regular MIM conferences, promoting research capacity strengthening and foster and unite the different initiative on the continent and worldwide. The MIM society will also invigorate the young African scientist to emerge as outstanding researchers and leaders with ground breaking innovation in science and its applications to development.

The MIM Society will be a global non-profit organization whose mission is to unite all human resources, young and experienced, working on malaria (from researchers over implementers, teachers, producers, funders, policy makers) to strengthen and sustain the capacity of malaria affected countries and to be an umbrella organization for all malaria related initiatives. The MIM Society through its members will guarantee capacity building goals for malaria researchers set by MIM 20 years ago will be carried forward for another 20 years and more.

The 30^th African Union (AU) Heads of State Summit at its headquarters in Addis Ababa, Ethiopia provided an important opportunity to bring the challenges of infectious diseases on the continent to the forefront. Led by the African Leaders Malaria Alliance (ALMA), two major activities occurred, raising greater awareness and commitment to fighting neglected tropical diseases (NTDs) and recognizing the contributions countries have made in the fight against malaria.

For many years ALMA has maintained Scorecard for Accountability and Action by monitoring country progress on key malaria interventions. It later added key maternal and child health indicators.  At the AU Summit ALMA announced that NTD indicators would be added to the scorecards which are reported by country and in summary.

The scorecard will now “report progress for the 47 NTD-affected countries in sub-Saharan Africa in their strategies to treat and prevent the five most common NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma. By adding NTDs to the scorecard, African leaders are making a public commitment to hold themselves accountable for progress on these diseases.”

In the press release Joy Phumaphi, Executive Secretary ofALMA, explained that, “Malaria and NTDs both lay their heaviest burden on the poor, rural and marginalised. They also share solutions, from vector control to community-based treatment. Adding NTDs to our scorecard will help give leaders the information they need to end the cycle of poverty and reach everyone, everywhere with needed health care.” This will be an opportunity to demonstrate, for example, that, “In 2016, 40 million more people were reached with preventive treatment for at least one NTD than the year before.”

The combination is based on the logic that NTDs and malaria are both diseases of poverty. Malaria and several NTDs are also vector-borne. Also community platforms are a foundation for delivering needed drugs and supplies to tackle these diseases. Ultimately the decision shows that Heads of State are holding themselves accountable for progress in eliminating these diseases.

At a malaria-focused side meeting of the AU Summit Dr. Kebede Worku (Ethiopia’s State Minister of Health) shared that his government has been mobilizing large amount of resources to the fight against malaria which has led to the shrinking of morbidity and mortality since 2005. He also stressed that Africans should be committed to eliminate malaria by the year 2030. “Failing to do so is to repeat the great failure of 1960s faced at the global malaria fighting.”

The highlight for the malaria community at the Summit was the recognition of six countries that have made exemplary progress in the past year. The 6 countries that are leading the way to a Malaria-Free Africa by 2030 are Algeria, Comoros, Madagascar, the Gambia, Senegal, and Zimbabwe, recognized by ALMA for their sharp decline in malaria cases. Madagascar, the Gambia, Senegal and Zimbabwe Reduced malaria cases by more than 20 percent from 2015 to 2016. Algeria and Comoros are on track to achieve a more than 40 percent drop in cases by 2020.

H.E . Dr. Barnabas Sibusiso Dlamini, the Prime Minister of the Kingdom of Swaziland, whose King and Head of State is the current chair of ALMA, warned all endemic countries that, “When we take our eyes off malaria, the cost for our countries is huge. Yet if we increase our efforts to control and eventually eliminate malaria, the yield we get from it is tremendous. It is time that we dig deep into our pockets and provide malaria programmes with the needed resources.”

Mentioning the need for resources raises a flag that calls on us to be a bit more circumspect about progress. IRINNews notes that this is a critical time in the fight against malaria, when threatened funding cuts could tip the balance in an already precarious struggle. IRIN takes the example of Zambia to raise caution. They report that the results of malaria control and the government efforts have been uneven. While parasite prevalence among small children is down almost by half in some areas, many parts of the country have seen increases in prevalence

IRIN concludes that, “For now, the biggest challenge for Zambia will be closing the gap in its malaria elimination strategy, which will cost around $160 million a year and is currently only about 50 percent funded – two thirds from international donors and one third from the Zambian government. Privately, international donors say the government must spend more money on its malaria programme if it is to succeed.” Cross-border transmission adds to the problem.

Internal strife is another challenge to malaria success. “The recent nurses’ strike which lasted for five months may have cost Kenya a continental award in reducing the prevalence of malaria during the 30th African Union Summit in Ethiopia on Sunday.” John Muchangi in the Star also noted that, “However, Kenya lost momentum last year and a major malaria outbreak during the prolonged nurses’ strike killed more than 30 people within two weeks in October.”

Finally changes in epidemiology threaten efforts to eliminate malaria in Africa. Nkumana, et al. explain that, “Although the burden of Plasmodium falciparum malaria is gradually declining in many parts of Africa, it is characterized by spatial and temporal variability that presents new and evolving challenges for malaria control programs. Reductions in the malaria burden need to be sustained in the face of changing epidemiology whilst simultaneously tackling significant pockets of sustained or increasing transmission. Many countries like Zambia thus face both a financial and an epidemiological challenge.

Fortunately ALMA is equipped with the monitoring and advocacy tools to ensure that its members recognize and respond to such challenges. The Scorecards will keep the fight against the infectious diseases of poverty on track.

Understanding the tasks that health workers perform in real life can improve their basic Training. Marion Subah of MCSP and Jhpiego shares experiences in using Task Analysis to improve pre-service training of midwives and lab technicians in Liberia. Her findings summarized below, are presented at the American Society of Tropical Medicine’s 66th Annual Meeting.

Health worker task analysis helps human resource planners and managers update pre-service education (PSE) curricula and plan needed in-service training. In Liberia, a task analysis was conducted focusing on Liberia’s midwives’ and Medical Laboratory Technicians’ (MLT) work practices.

Task lists were developed using curricula, job descriptions and professional scope of practice, and validated by key stakeholders for each cadre. Responses from 25 MLTs and 26 midwives were examined that addressed the following questions:

1. How often do you do the task (frequency)?
2. Where did you learn to do the task (location)?
3. How well do you think you are able to perform the task (performance)?
4. How critical is the task in terms of patient and/or public health outcomes (criticality).

Eligibility criteria included those currently practicing between 6 months and 5.5 years following graduation. Midwives were assessed for five tasks relating to malaria service provision, including provision of preventive treatment for malaria in pregnancy, management of vector borne diseases, diagnosis and management uncomplicated malaria in adults and children (respectively), and provision of malaria preventive services.

Lab technicians were assessed for one malaria task, performance of parasitological tests. On average 61% of midwives learned these malaria tasks in PSE, 74% said they performed these tasks daily, 80% felt proficient in performing the tasks, and 82% rated the tasks moderate to high in criticality. For MLTs, 88% learned malaria testing in pre-service education, 100 % performed this task daily, 77% felt they were proficient and 93% said the task was of moderate to high criticality.

Task Analysis Flow Chart

The results from this rapid task analysis are being applied to the current curricula review. Courses that could be updated or strengthened have been identified. Malaria Case Management Technical Update and Effective Teaching Skills Training are being organized for tutors at the training schools. Finally, integrated supportive supervision tools are being strengthened to improve performance of these malaria tasks by midwives and lab technicians.

The time is ripe for a revitalization of the primary health care (PHC) movement. “Health for All through Primary Health Care” (HFA) was first envisioned at the 1978 International Conference on Primary Health Care (World Health Organization and UNICEF), and was enshrined in the Declaration of Alma-Ata. The HFA goal of bringing essential, affordable, scientifically sound, socially acceptable  health care provided by health workers who are trained to work as a health team and who are responsive to the health needs of the community, guided by strong community engagement by the year 2000 but has not been fully met. Fortunately the vision of Alma-Ata has taken root, sprouted and flourished in a number of locations.

Thanks to the vision and intellectual and political leadership of Dr. Tedros Adhanom Ghebreyesus, the then Minister of Health of Ethiopia and recently elected Director General of the World Health Organization, Ethiopia is an outstanding example of the Alma-Ata legacy. Access to PHC services was greatly expanded through the training of 40,000 Health Extension Workers (women from the local area with one year of training, each of whom serve 2,500 people and receive a government salary), recruitment of 3 million community female health volunteers (called the Health Development Army), and engagement with communities to enable them to take responsibility for improving their health.

This expansion of PHC enabled Ethiopia to achieve its health-related MDGs. Child mortality (those younger than 5 years of age) declined from 166 deaths per 1,000 live births in 1990 to 67 in 2016 (MDG 4). Significant progress was achieved in reducing levels of childhood malnutrition (MDG 1). MDG 5 was almost reached, with a decline in maternal morality of 72%, versus the goal of 75%, and the percentage of mothers obtaining a delivery by a skilled provider increased 6-fold between 1995 and 2016. The prevalence rate of modern contraceptive use increased from 6% in 2000 to 35% in 2016. MDG 6 (for HIV, malaria and tuberculosis) was also reached. The number of new HIV infections declined by 90%, and the number of AIDS-related deaths by 53%. Between 1990 and 2015, the tuberculosis incidence and mortality rate declined by 48% and 72%, respectively. The malaria incidence rate declined by 50% and malaria mortality by 60%. Ethiopia’s PHC system is acknowledged as the major factor leading to these impressive health gains.

Representatives from more than half of sub-Saharan Africa countries have come to Ethiopia to see its PHC system in action. Because of this interest, in 2016 the Federal Ministry of Health of Ethiopia established the International Institute for Primary Health Care – Ethiopia, with seed funding from the Bill & Melinda Gates Foundation and technical support from the Johns Hopkins Bloomberg School of Public Health. Our goal is for the Institute to become a global center of excellence for training, knowledge dissemination and research in primary health care, supported by multiple donors.

The Institute has begun to provide formalized short-term training to high-level policy makers and officials, program planners and managers, as well as to those engaged in service delivery, to see first-hand how an effective national PHC system functions. Trainees come from within Ethiopia and around the world. Trainees also visit communities, meet their leaders, and observe primary health care providers at work. Trainees will return to their home country with renewed energy and new vision and skills to revitalize their own primary health care system.

The Institute will also conduct and support research that yields evidence to guide ongoing strengthening of the Health Extension Program, and will rapidly disseminate open access information about recent advances in PHC. The Institute marks a significant step forward on the road to achieving the Alma-Ata vision of Health for All.

A website for IIfPHC-E is being built to provide further information about these programs and will be available at: www.iifphc.org.

This posting was prepared by: Kesetebirhan Admasu¹, Michael J. Klag², Yifru Berhan Mitke³, Amir Aman⁴, Mengesha Admassu⁵, Solomon Zewdu⁶, Jose Rimon⁷, Henry B. Perry⁸

¹Chief Executive Officer, Rollback Malaria Partnership, Geneva, Switzerland and Chair, Advisory Board, International Institute for Primary Health Care — Ethiopia

²Dean, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

³Minister, Federal Ministry of Health, Government of Ethiopia, Addis Ababa, Ethiopia

⁴State Minister, Federal Ministry of Health, Government of Ethiopia, Addis Ababa, Ethiopia and Co-Chair, Advisory Board, International Institute for Primary Health Care – Ethiopia

⁵Executive Director, International Institute for Primary Health Care – Ethiopia, Addis Ababa, Ethiopia

⁶Health and Nutrition Development Lead – Ethiopia, Integrated Programs, Global Policy & Advocacy – Global Development, Bill& Melinda Gates Foundation, Addis Ababa, Ethiopia

⁷Director, Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

⁸Coordinator for Johns Hopkins University Support of the International Institute for Primary  Health Care – Ethiopia, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

The Frontline Health Worker Alliance reminds us that, “Frontline health workers are the backbone of effective health systems – and are those directly providing services where they are most needed, especially in remote and rural areas.” These are the people who make delivery of essential malaria prevention and case management services possible. They further note that April 3-9, 2016 is World Health Worker Week and “is an opportunity to mobilize communities, partners, and policy makers in support of health workers in your community and around the world.”

Unfortunately the very areas of the world that have the most malaria also have the greatest shortage of health workers as seen in Africa, South and Southeast Asia. In this situation skills and dedication of every single available frontline health worker are crucial for defeating malaria. This can only be achieved if they are up-to-date in the latest malaria programs.

For example, most malaria endemic countries in Africa have updated their malaria in pregnancy guidance to reflect the need to provide intermittent preventive treatment (IPTp) at every antenatal care visit after the 13th week of pregnancy with doses at a month interval. This means a pregnant woman may now receive 3 or more doses. What is still needed in many countries is full dissemination of this guidance to all frontline health staff so that they can implement this service correctly and fully.

As we move toward malaria elimination, more people will live in areas with unstable or epidemic transmission. The chances of developing severe malaria will increase. Updated skills on managing severe malaria that results in convulsions, chronic anemia and death are needed for these frontline staff.

Enhanced skills in surveillance are now needed as we move toward malaria elimination. Good diagnostic, record keeping and reporting skills are needed by frontline staff to help identify malaria transmission hotspots. Skills are also needed on treatment regimens that include transmission blocking medicines.

Vector control will remain an essential part of defeating malaria, but health workers will need to learn about new technologies as these become available. They will need skills for better targeting of complimentary interventions like larviciding. Continual efforts to manage routing distribution of long lasting insecticide-treated nets must ensure that health workers have the skills and resources to follow-up and promote actual use of the nets for their intended purpose.

Vaccines and other new technologies will become available for controlling malaria. Health worker capacity building will be needed to ensure each of these new additions to the malaria arsenal are implemented in the most effective manner.

From the foregoing we can see that there are many reasons why the malaria community should observe World Health Worker Week now and continue to build health worker capacity to defeat malaria throughout the year.

Colleagues[1] from Jhpiego’s Burkina Faso Improving Malaria Care USAID-supported project and the Johns Hopkins Bloomberg School of public Health are presenting a poster at the 64^th ASTMH Annual Meeting in Philadelphia at noon on Tuesday 27^th October 2015. Please stop by Poster 969 and discuss the results as presented in the Abstract below.

In 2013, malaria was the main reason for consultation (53.90%), hospitalization (63.20%) and death (49.60%) in health facilities; children under 5 and pregnant women are most affected. Recent revisions to the World Health Organization’s (WHO) guidance to maintain effective approaches to defeating malaria, include monthly dosing of intermittent preventive treatment for pregnant women (IPTp), starting from the 13th week of gestation.

To align with the latest WHO guidance, the Burkina Faso Ministry of Health, with support from the USAID-funded Improving Malaria Care (IMC) project, revised national malaria guidelines in March 2014. 68 trainers from 9 health regions were trained on the revised national malaria guidelines.

From June to September 2014, 744 providers from 524 health facilities in 21 districts (33%) were trained on the prevention and management of malaria cases. To ensure updated guidance reaches all health workers, the training included a module on how to update colleagues in their respective facilities.

During supervision visits, most trained providers were using the new guidelines and pregnant women are increasingly receiving the third and higher doses of SP before delivery. In the first six months after the training sessions, pregnant women, who received the third dose of SP (IPTp3) increased from 0% to 12%. Three months later, that proportion rose to 30%. Comparatively, in the remaining 42 districts who received only the copies of the new guideline without training, IPTp3 was 5% nine months after receiving the guidelines.

The training sessions contributed to improving the implementation of revised IPTp guidelines and uptake of IPTp 3 and higher better than distribution of the new guidelines alone. As a result the IMC project will scale-up the training in Year 2 to 600 more providers from 464 health facilities, and other partners have also agreed to support the National Malaria Control Program to reach remaining facilities. Challenges in increasing IPTp uptake include commodity distribution and inadequate engagement of private health facilities to update their practices and reporting of SP distribution.

[1] Ousman Badolo, Stanislas Nebie, Moumouni Bonkoungou, Mathurin Dodo, Thierry Ouedraogo, Rachel Waxman, William R. Brieger

Monday at noon (3 October 2014) at the American Society for Tropical Medicine and Hygiene Annual Meeting in New Orleans, Jhpiego will be presenting two posters. Grace Qorro of Jhpiego’s Tanzania office has one entitled: #Quality Inspired Project – A Key to Achieving Results with Malaria Interventions.” Her abstract is shared below.

With an aim to accelerate malaria case management, Tanzania Ministry of Health and Social Welfare (MoHSW) is strengthening its pre-service education program to ensure graduates have the right knowledge and skills to diagnose and treat malaria. Investment in pre-service education lessens the burden on in-service training since those entering the workforce will have the knowledge and skills they need to provide.

Jhpiego, through MAISHA (Mothers And Infants Safe, Healthy and Alive) program, provided technical assistance to the MoHSW to help develop a pre-service malaria case management-updates Learning Resource Package (LRP), which includes: Facilitator’s Manual, Participant’s Manual, Activity Worksheets and Training Modules addenda.

The LRP was developed based on national malaria policy, guidelines and in-service training materials; it is taught using job aids, power point presentations, video demonstration and numerous case scenarios which reflect what actually happens in real life situations at service delivery points. The LRP aims at reinforcing appropriate practices for care of malaria patients and management of commodities with emphasis on parasite-based diagnosis and compliance to results, proper recording and reporting; and management of malaria in special situations and groups.

The training package is well organized with laboratory and medical supplies which gives each participant an opportunity for hands-on activity to acquire and strengthen their skills. Checklists to guide Quality Assurance/Quality Improvement (QA/QI) processes have been included in these training materials.

The project successfully provided competence-based orientation on malaria case management updates to 210 medical instructors. Annually, it reaches more than 4,000 students from eight Zonal Health Resource Centers and 480 students from Medical Universities.

There is a need to incorporate the addenda developed into these training modules for easy use. In the near future, clinical skills-mentorship will be conducted in selected schools using the nationally approved QA/QI checklists.

Monday afternoon (3 October 2014) at the American Society for Tropical Medicine and Hygiene Annual Meeting in New Orleans, Jhpiego and USAID/PMI are sponsoring a panel on “Integrating and Innovating: Strengthening Care for Mothers and Children with Infectious Diseases.” If you are at the meeting please attend to learn more about our Malaria activities in Kenya.

One of the panel presentations is “Performance Quality Improvement Lending to Corrected Documented Outcomes for Intermittent Preventive Treatment in Kenya,” by Jhpiego staff Muthoni Kariuki, Augustine Ngindu Isaac Malonza, and Sanyu Kigondu, who are working with USAID’s Maternal & Child Health Integrated Project (MCHIP).

According to Malaria policy in Kenya all pregnant women in malaria endemic areas receive free intermittent preventive treatment with SP have access to free malaria diagnosis and treatment when presenting with fever have access to LLINs (National Malaria Strategy (NMS) 2009–2017).

By 2013 80% of people living in malaria risk areas should be using appropriate malaria preventive interventions. Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine Pyrimethamine (IPTp-SP) intervention is recommended for use in malaria endemic region.

MCHIP broadly implemented Capacity Development and service delivery and improvement interventions that also had impact on the delivery of malaria in pregnancy services through collaboration with the Ministry of Health divisions/units at national level: (malaria, reproductive health, community health).

At county level scale up provision of IPTp at facility level took place in 14 malaria endemic counties. This included 8 counties in the lake endemic region including Bondo sub-county (the MCHIP model sub-county) and 6 in the coastal endemic region.

Quality Improvement through Performance Quality Improvement (PQI) process was instituted to enhance service delivery. The MCHIP era in Bondo Strengthened ANC Services using the following:

• Development of MIP Standards-Based Management and Recognition (SBM-R) standards
• Orientation of facility in-charges, supervisors and service providers on the standards
• Monitoring of IPTp uptake using DHIS2 data
• Feedback to facility in-charges and supervisors on DHIS2 findings
• Collection of ANC data from ANC registers (2011-2013)
• Feedback to facility in-charges and supervisors on ANC data

Quality improvement in the malaria in pregnancy component was undertaken with the objective to improve quality of MIP services including IPTp data management at facility level using PQI approach. An Example of a MIP SBM-R standard is seen below.

In-service training focused on orientation of facility in-charges on PQI who then continued orientation at Facility Level. Overall we oriented 1200 facility in-charges and 100 supervisors on the standards. Facility in-charges cascaded orientation to 2,441 service providers.

We then analysed ANC data from DHIS (2011-2013) indicated proportion of pregnant women receiving IPTp2 was higher than IPTp1 (IPTp2+ doses reported as IPTp2 dose). We helped improve reporting by  service providers not oriented on use of the ANC register in order to reduce data errors.

In conclusion, PQI is a best practice in provision of MIP services. Standardization of knowledge among service providers is essential in provision of quality MIP services. Development of facility in-charges as mentors in the facility to ensure continued orientation of new service providers.

Use of appropriate monitoring tools is necessary to assist in assessment of quality of services provided including data management. Feedback to service providers is one of the performance rewards and encourages participation in knowledge acquisition

Monday afternoon (3 October 2014) at the American Society for Tropical Medicine and Hygiene Annual Meeting in New Orleans, Jhpiego and USAID/PMI are sponsoring a panel on “Integrating and Innovating: Strengthening Care for Mothers and Children with Infectious Diseases.” If you are at the meeting please attend to learn more about our Malaria activities in Malawi.

One of the panel presentations is “Improving Malaria Outcomes in Malawi: Focusing on Integration of Services at all Levels” presented by John Munthali, Senior Technical Advisor, Jhpiego/Malawi. John works with Support for Service Delivering Integration-Services (SSDI-S), a USAID bilateral program (2011-2016) with Partnerships in 15 Districts involving the Ministry of Health, Jhpiego, Save the Children International, Care Malawi and Plan International.

SSDI-Services focuses on Malawi’s Essential Health Package (EHP) Focal Areas with particular emphasis on Maternal Health, Newborn and Child Health, Family Planning and Reproductive Health, HIV/AIDS and TB, Nutrition and Malaria. Aspects of the Malaria Component include Intermittent Preventive Treatment and Insecticide Treated Bed Nets

SSDI-S is based on Promotion of the continuum of care from household to hospital. Health Facility Approaches address Improved Technical Capacity of Health Workers, Functional Health Facility, and Data-informed Decision Making. Community Approaches involve Improved Technical Capacity of CHWs, Functional Village Clinics, and Community Mobilization. Integration is a major concern such that there are no missed opportunities of EHP services at all levels.

Positive Trends since have been seen since Inception. Malaria in Pregnancy interventions supported the National Malaria Control program to review the Malaria in Pregnancy guidelines and training manuals to adopt the new WHO policy recommendations. 74 Trainers were trained in all 15 districts. MNCH services were established in selected districts. 344 HSAs were trained. 70 community-based Core Groups oriented on MNCH. SSDI supported ongoing MNCH activities through review meetings and distribution of reporting forms.

As a result of these integrated high impact interventions there has been a remarkable increase in the uptake of IPTp 2 (16% in June 2012 to 64% in Sept. 2013) by pregnant women in the SSDI-services focus districts. Central to this increase is the integration of services at the facility level where malaria has been highly integrated into maternal, newborn and child health. The project has also seen IPTp 1 uptake maintained at above 91% in all the 15 districts

Malaria Care capacity building has resulted in improved iCCM services delivered by Health Surveillance Assistants (HSAs) at village clinics. iCCM is serving as the foundation for community-based treatment of malaria by HSAs while at facility level IMCI provides an integrated approach to manage childhood illnesses including malaria.

In conclusion, it is feasible to integrate MNCH programs at all levels using SBCC and Systems Strengthening. Having an integrated project looking at the whole spectrum of health services (system strengthening, service delivery and behavior change) can help improve programming & service delivery.

During his talk in the final sessions of the MIM2013 6th Pan African Malaria Conference Dr. Olumide Ogundahunsi of WHO/TDR Geneva, highlighted four people who have demonstrated the multiplier effects of MIM research grants. Below are Dr. Ogundahunsi’s remarks.

In 1999, Lizette Koekemoer obtained her PhD from Witts.  Her first independent research grant was in 2003 and between 2004 and 2007 she was supported by MIM to study insecticide resistance in Anopheles arabiensis in southern Africa. She subsequently receieved funding from the national and international agencies to support her work on insecticide resistance mechanisms and novel control interventions.  She now heads the  Vector Control Reference Laboratory (VERL), National Institute For Communicable Diseases (NIED) of the National Health Laboratory Service (NHLS), Johannesburg, South Africa

Sam Awolola obtained his PhD from the University of Ibadan in 1997 and received a grant to support his research on insecticide resistance of the malaria vector mosquitoes in Nigeria from MIM/TDR in 2003 after his post doc in South Africa. He subsequently received research grants from the welcome trust, European Commission and several other agencies.  He is currently the Deputy Director (research), Coordinator Malaria Research Program at the Nigerian Institute for Medical Research and chairs the indoor residual spraying subcommittee of the National Malaria Elimination Program In Nigeria.

Eric Achidi obtained his PhD in 1994 at Ibadan, Nigeria.  He was supported by MIM & TDR from 1998 to 2009 and over time has successfully competed for and received grants from WT, EU, FNIH.  He is presently the Vice Dean Faculty of Science at the University of Buea Cameroon … an institution that did not feature in the 3 publications per year list of the 1999 WT report.

Jane Chuma is one of the more recent recipients of capacity building support from MIM.  She obtained her PhD in 2006 from the University of Cape Town and received MIM support about the same time to study access to effective malaria treatment and prevention among the poorest groups in Kenya. She is now a researcher at the KEMRI-Wellcome Trust Research Programme where she is working on health financing for universal health coverage with funding from the Wellcome Trust and DfID. She supports the health financing task group in her country, helped initiate the establishment of a masters in health economics and policy at University of Nairobi and supports researchers in various countries in their work on health systems and health financing.

These are among the 90 plus MIM alumni, the vast majority of whom have remained in Africa and resisted the pressures of brain drain.  Our congratulations go to MIM-TDR with hopes that other agencies can step up and match this track record.