Tropical Health Matters

Essential Medicines, Commodities and Supplies Needed for Community Level Primary Health Care Interventions is our 2-credit online course offered from 5-9 June 2023 as part of the Global Health Systems Summer Institute. Please check the syllabus and share with colleagues.

Course Description” Essential commodities are among the 8 basic primary health care services and the 6 health systems building blocks as defined by the World Health Organization

Primary health care programs in low and middle-income countries require essential health commodities be made available at the community level. Logistic systems need to be developed to ensure that commodities are adequately estimated and delivered. In addition, systems for safely maintaining and monitoring stocks are needed at the community level.

The Summer Institute offers a variety of short-term courses in a variety of global health areas between 5-30 June 2023. The Global Health Systems Summer Institute provides early- and mid-career public health professionals with cutting-edge skills in a variety of global health topics. The Institute is also a great opportunity for part-time MPH and other Hopkins students and fellows to learn a valuable set of skills in an in-demand and rapidly growing field of public health. Below are issues covered in the Essential Medicines course.

• Overview of Essential Medicines for Primary Health Care
• Essential Medicines for Primary Health Care
• Basic Primary Health Care Procurement and Logistics
• Financing for Essential Medicines
• Implementation of Essential Medicines Programs in Primary Health Care
• Preventative Chemotherapy for Neglected Tropical Diseases
• Ensuring Essential Pharmaceuticals Go “Beyond the End of the Road”
• Supply Chains
• The Role of Indigenous Medicine
• Supply Chain Management for CDI: The Malaria Example
• Logistics Management Information System in Community Based PHC
• Community Mass Drug Distribution
• The CDI Process: Expanding Beyond Ivermectin
• Supply Chain Management in Ethiopia
• Community Supply Chain Challenges in Nigeria

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.[1]

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, vaccination, etc.”

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:[2]

• 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 resilience.[3]

A recent Global Fund grant to Burkina Faso was entitled, “Strengthening health systems and scaling-up of integrated community case management interventions.”[4] 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, though.

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.

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[1] Ministere De La Sante. Draft Strategie Nationale De Sante Communautaire Au Burkina Faso 2019-2023. September 2018

[2] McConville 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

[3] Ouedraogo, Celestine (2016). Promoting Community-Led Resilience and Development Solutions in Burkina Faso. World Food Program. https://www.wfp.org/stories/promoting-community-led-resilience-and-development-solutions-in-burkina-faso

[4] Global Fund (2017). Burkina Faso BFA-S-PADS Grand Performance Report. https://www.theglobalfund.org/en/portfolio/country/grant/?k=d8f34742-0d57-410c-b5ba-39615edc5785&grant=BFA-S-PADS

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 and nutrition.

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[1]. 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 Rwanda-HMIS[2], 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.[3]

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 including –

• Report Quality:  Timeliness, Accuracy and Completeness of Report
• Cooperative   Quality: Legal status, Presence of President, Bank account, etc.

Secondly, Pay-for-indicators 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.

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[1] 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

[2] 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

[3] Rwanda Integrated Health Management Information System. https://hmis.moh.gov.rw/

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

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

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

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

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

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

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

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

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

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• Request information for fully online Master of Applied Science in Community-based Primary Health Care Programs in Global Health
• Also get information for fully online Master of Applied Science in Master of Applied Science in  Global Health Planning and Management
• Learn more about fully online Certificate in Global Health Practice, a stand alone or first year for our 2 Global Health Masters of Applied Science
• Master of Applied Science in Humanitarian Health