Author Archives: Nikita Patel

ACCESS-SMC: Smoothing the road to the prevention of malaria

ACCESS-SMC is a three-year UNITAID-funded project, led by Malaria Consortium in partnership with Catholic Relief Services, which is supporting National Malaria Control Programs to scale up access to seasonal malaria chemoprevention (SMC) to save children’s lives across seven countries in the Sahel. By demonstrating the feasibility and impact of SMC at scale, ACCESS-SMC will promote the intervention’s wider adoption. This case study highlights the impact SMC has had in the fight against malaria. Malaria can be prevented- in the Sahel, SMC can play a crucial role.

“If we succeed in further reducing malaria we can begin to reallocate the budget for treatment of malaria to other development matters. We need to carry on.” – Dr. Smaïla Ouedraogo, Minister of Health for Burkina Faso at the SMC Implementation Meeting (February 13th, 2017)

At the end of 2016, ACCESS-SMC had successfully administered seasonal malaria chemoprevention (SMC) to approximately 6.4 million children in seven countries. In the Sahel, where malaria incidence increases with the rainy season, there are 25 million children who can benefit from this life-saving treatment. Three years before the project began the World Health Organization (WHO) issued policy recommendations on SMC as an effective tool to prevent malaria in children (3-59 months). However, before the first ACCESS-SMC campaign in 2015 less than 4 percent of eligible children had benefited from this intervention.

Countries in the Sahel have a shortage of skilled health workers, and simply making antimalarial medicines available does not automatically ensure success. This is why ACCESS-SMC has been working closely with National Malaria Control Programs to effectively train community health workers (CHWs) on how to deliver, administer and begin dialogues around SMC. By delivering basic preventative health services to remote populations, CHWs improve access to and coverage of rural communities in low-income countries.

Family out in the fields farming

Agriculture is the primary economic activity in Burkina Faso. During the rainy summer months, when many families are out in the fields cultivating their crops, CHWs play a crucial role in protecting young children from malaria. They have to work extra hard to make sure every eligible child is reached. In the small rural town of Ziniaré, Jules Ouedraogo works long hours going door-to-door during the four distribution cycles, administering SMC to 45-55 different children each day. “Because the rainy season coincides with the period of farming, we are often obliged to join them in the fields when they are absent at home, or sometimes we go back to the homes at night when parents and children have returned from the fields. We will go to homes, fields, churches, markets; wherever there are children.”

Compaore Zenabo, a mother and fruit merchant, has two children under the age of five. Her children used to fall sick regularly, especially during the rainy season, but since her children began receiving SMC they have not had malaria and income once spent on malaria treatment is now saved. As a working mother, CHWs have made it easy so she does not have to choose between earning income for her family or the health

Health worker explaining the benefits of SMC

of her children. “They come to us and give medicines to our children. When they do not find us at home, they make the effort to come back or join us at our workplaces. Really, we are pleased with the work of the community distributors.”

Delivery of SMC is complicated by the inaccessibility of villages, made even more convoluted with heavy rains flooding roads. Undeterred by the weather, when roads are flooded CHWs either attempt to cross them with boats or canoes, or wait for the water level to reduce. Their relentless efforts resulted in a 45 percent decrease in the number of malaria cases in children under five after the first campaign in 2015, and over 1.3 million children were protected by SMC during the 2016 campaign.

Patrice Ouibga is a health worker at Ziniaré Urban Health and Social Promotion Center. Before the project began it was normal to treat 800-1,000 cases of malaria a month during the rainy season. “By 2016, this number has dropped considerably and parents are very happy. We now have fewer than 100 cases per month during the rainy season. We hope in the future Malaria Consortium can sustain SMC and extend it to other areas not yet covered to save the lives of many children.”

This success story was prepared by Malaria Consortium thanks to funding from UNITAID under the ACCESS-SMC project. The views expressed here do not necessarily reflect those of UNITAID.

© Malaria Consortium. Published July 2017

Photo credits: Malaria Consortium/Susan Schulman

For more information visit www.unitaid.org and www.access-smc.org

Chimbonila: A district committed to fighting malaria

View in: English | Portuguese

The district of Chimbonila in Niassa province has a high malaria burden, which can be difficult to manage for a number of reasons.

The district itself is very large. It is located about 30 km from the city of Lichinga and covers an area of ​​8,075 km² with a population of about 87,000 inhabitants. Despite its proximity to the capital city, however, Chimbonila has the typical challenges of the other districts of Niassa: poor roads and high poverty rates, as well as a remote, mostly rural population which relies on an economy based on agriculture (population density of 15.8 inhabitants per km²).

Since 2014, the National Malaria Control Programme of the Ministry of Health and its partners (World Vision and Malaria Consortium) with funding from the Global Fund, has been implementing the Malaria Prevention and Control Project within local communities.

The project in Chimbonila District involves 22 community structures, 428 volunteers, 23 schools, 72 teachers, 14 health facilities and one community radio in a continuous effort coordinated by Health, Women and Social District Services to ensure the prevention and treatment of malaria.

Since 2014, Gabriela Nazaré has been the Malaria Consortium Field Officer assigned to this district. Her role is to coordinate the activities of all project stakeholders, ranging from health facilities to community volunteers.

Every day Gabriela visits the villages by motorcycle, ensuring that all project’s participants have the necessary tools for mobilisation work and that they have a correct understanding about how to prevent malaria and that they know what to do in the occurrence of malaria symptoms.

After three years as Field Officer, Gabriela feels integrated in the community: “I was born and raised in Lichinga. I moved to Chimbonila to work and today I feel at home. Despite the complexity of the job, knowing that I am contributing to the improvement of people’s living conditions is rewarding.”

Rain or shine, her activities don’t stop. Owing to the large number of beneficiaries, her schedule is very busy. “I try to spend as much time as possible in each community. My routine in each village is to visit schools, health facilities and work with community structures.

“Over the years we have been establishing work mechanisms and today it is amazing how communities are engaged in the project in such a way that they now bring in their own initiatives and suggestions for new approaches.”

 

Text and photos: Xavier Machiana

Expert Q&A: No one size fits all in the pursuit of the best pneumonia diagnostic aids

Malaria Consortium Senior Project Officer, Charlotte Ward, speaks about pneumonia as a global priority issue, how we are attempting to tackle the disease and explore the future of diagnostic devices.

Pneumonia is an acute respiratory infection that affects the lungs and is responsible for 16 percent[1] of deaths of all children under five. This proportion is much higher in low-resource countries where access to healthcare is limited, particularly in South Asia and sub-Saharan Africa.

Yet despite being the single largest infectious cause of death in children worldwide, pneumonia can be diagnosed and treated with low-cost and simple interventions and medication.

 

What are the current challenges in diagnosing and treating pneumonia?

Diagnosis of pneumonia by community health workers (CHWs) is commonly based on counting the number of breaths in 60 seconds in children under five to assess whether the respiratory rate (RR) is higher than the normal parameters for a child of that age. However, manually counting RR can be challenging due to the difficulties in observing and counting chest movements for a full minute and keeping the child calm during this period. Therefore, misclassification of observed rate is common, leading to incorrect diagnosis and consequently inappropriate antibiotic treatment, contributing to the spread of antibiotic resistance.

 What different types of devices are currently being used?

Non-automated devices, assisted RR counting devices and pulse oximeters are currently being used. Non-automated devices are the lowest cost and most commonly used tools. They support manual counting of chest movements by indicating when to start and stop counting. Assisted counting RR devices automate the counting process thus negating the need for manual counting. An example is a mobile RR smartphone app that works by counting the number of times the CHW taps the screen for each chest movement. Pulse oximeters work by measuring the blood oxygen saturation levels in the patient. Three types of pulse oximeters exist: handheld, mobile and finger-tip pulse oximeters.

How do we evaluate the best devices?

Formative research to understand the best class of devices is critical before designing and implementing a device field trial. An example of formative research is pile sorting and accompanying focus group discussions with key stakeholders. Pile sorting is when you ask key stakeholders to sort word, item or picture cards into piles that classify a range of opinions or categories of interest and then capture and explore participants’ decision-making rationale for their sorting using a focus group discussion. In this case, stakeholders including representatives of national and regional Ministry of Health (MoH), regional health bureaus, multilateral organisations such as UNICEF, and relevant NGO staff, would be demonstrated device types and asked to place cards with various device names into different piles according to their perceived usability, and again for their perceived scalability. Devices are then scored based on how they are sorted and those with the highest scores may be carried forward for field testing.

 What challenges will there be in designing appropriate diagnostic aids?

A major challenge is designing appropriate diagnostic aids that appeal to a wide range of stakeholders with differing views and priorities. CHWs and national and regional stakeholders prioritise different characteristics when rating the potential scalability of aids. For example, CHWs emphasise the importance of aids being acceptable to CHWs, parents and caregivers more than national stakeholders who prioritise the need for cost-effectiveness and sustainability. Practical usability is also heavily prioritised by CHWs whereas NGO and MoH stakeholders are strongly invested in ensuring the supply and distribution processes are uncomplicated and inexpensive. Further considerations are whether the device can be used in remote areas with unreliable electricity source, how much training is required to use the device and how durable the device is.

 What are future directions?

Device development is a complex process and the challenges in appealing to a wide range of stakeholders mean that a ‘one size fits all’ approach is unfeasible. However, there is global momentum towards developing automated devices that count RR without the need for human intervention. It is hoped that such devices will offer improved accuracy and effectiveness compared to current practice for classifying the symptoms of pneumonia, therefore improving the treatment of patients at community level. Furthermore, automated devices have the potential to increase caregiver and patient confidence in CHWs, thus strengthening programmes of integrated management of new-born and child health at community level in low-resource settings.

Projects that Malaria Consortium has undertaken on pneumonia

 Related resources:

Charlotte Ward is a Senior Project Officer here at Malaria Consortium. She is currently focussed on the ARIDA project, which is working to bring automated respiratory rate counting aids to wide-scale use by frontline health care workers in resource limited community settings.

 

[1] http://www.who.int/mediacentre/factsheets/fs331/en/

Distribution of LLINs in Niassa Province: mission accomplished

After a year of intensive work, Niassa Province in Mozambique, an area with a high malaria incidence rate, has successfully completed its mass long-lasting insecticidal net (LLIN) distribution campaign in its 16 districts.

The Malaria Prevention and Control Project is part of the Universal Coverage Campaign (UCC),  a national initiative led by the Ministry of Health.  It is funded by the Global Fund, and implemented by World Vision as the recipient partner, with Malaria Consortium, Food for the Hungry and Community Development Foundation as secondary recipients.

The UCC aims to ensure that every Mozambican has access to a LLIN to protect themselves from malaria. In Niassa Province, the campaign has reached approximately 415,000 households in the 16 target districts, amounting to a total of 1,058,750 LLINs. Niassa Province covers an extensive area of ​​approximately 123,000 km², with around nine inhabitants per km² in some of the more remote areas.  Access roads are lacking and most are not tarred, which renders the UCC implementation a complex process.

To overcome these challenges and to meet the high demand, the campaign was cascaded down from the central level, on to the provincial level, and finally expanded to the districts, towns and villages. In a combined effort of thousands of people involved.  The local government, the Provincial Health Directorate, District Directorates, support teams, trainers, distributors, registrators and different service providers were all critical to the success of the mass distribution.

According to Dr. Inês Juleca, focal point of the National Malaria Control Programme of the Ministry of Health of Mozambique for the province of Niassa, “The distribution of LLINs is an activity that includes several steps and high-quality coordination, from the consultation of guiding documents, planning, procurement, transportation and packaging, to communication, engagement, mobilisation, training, population registration and distribution itself.”

In this process, the National Malaria Control Programme is responsible for the acquisition of LLINs and led overall planning and implementation through the decentralised structures of the health system. Malaria Consortium is responsible for operational support, which includes financial management, transport, logistics, training, management of service providers, efficient use of resources and effective coordination at provincial, district and field levels.

On the challenges encountered on the ground, Joaquim Chau, Interim Coordinator of the Malaria Consortium in Niassa province, says: “The challenge of coordinating processes is largely to achieve the commitment of all those involved, even with different procedures or practices, sensitivities and institutional hierarchies, to bring together an understanding of the common vision of what is to be achieved. This makes a difference in the process, and in the professional and individual expectations of all the actors involved.”

With the successful completion of the distribution, the team is planning a post-distribution campaign that will focus on effective messaging about the correct use of LLINs. Highlighting the importance of the post-distribution campaign, Dr. Juleca stated: “Malaria prevention does not end with distribution of mosquito nets. We are ensuring that, after the distribution phase, our beneficiaries are knowledgeable about the use of nets and that this process is effectively translated into behaviour change.”

By Xavier Machiana

Good health for all: a crucial road to gender equality

By 2030, we will ‘achieve gender equality and empower all women and girls’: these are the words used by global leaders to coin Goal 5 of the Global Goals for Sustainable Development.  Today, 8th March 2017, Malaria Consortium is celebrating International Women’s Day together with the global community to show our support for a gender equal world.
Empowering women on a global scale requires a cross-cutting approach, tackling areas that we may not always consider as exerting a direct influence on gender inequality. One issue that has been frequently overlooked as an empowerment mechanism is improvement in global health systems.

The inadequacies of health infrastructure in the world’s most underdeveloped regions has an overwhelmingly and disproportionately high impact on women [1],[2]. Poor or lacking health services lie at the beginning of a long chain of problems contributing to gender inequality.

Tania

Tania Morais, Monitoring and Evaluation Officer at Malaria Consortium, Mozambique, with women members of a community-based organisation

The absence of health infrastructure reinforces poor health; poor health reinforces poverty; poverty reinforces gender inequality. For example, poor health often causes additional economic pressure on a family which can result in girls being taken out of school, or to women staying home to care for sick children rather than work. It can also lead to lasting disability due to pregnancy and childbirth.  These are just some of the ways in which poor health among the poorest and most vulnerable impacts on women in particular, resulting in women being less educated, less economically independent and less empowered than their male counterparts.

And this develops into a cycle, with gender inequality also reinforcing poor health.  Women are, in many regions, not permitted responsibility for decision-making and must seek permission to receive healthcare for their children and themselves from their male counterparts.  In many regions, where men only allow their female family members to seek treatment from women health workers who may be few and far between, this has serious consequences on women’s health and empowerment.

So how has Malaria Consortium worked to combat this gap? In our programmes to tackle malaria and other communicable diseases, we ensure women are both consulted and represented as a critical element of our targeted beneficiaries.  One particularly effective intervention that we use is integrated community case management (iCCM) for common childhood illnesses – pneumonia, diarrhoea and malaria, and nutrition.  iCCM involves working with and training people within the community to diagnose and treat these diseases, thereby addressing the challenges of access to quality healthcare. Malaria Consortium has supported ministries of health to train and equip community health workers in iCCM in Mozambique, Nigeria, South Sudan, Zambia and Uganda to diagnose and treat or refer sick newborns and severe cases to the nearest health facility.  Through iCCM, we also help to raise the social status of women by training female community health workers, a positive step recognised by WHO [3], which also increases access to health services for many more women and their children.

DSC_3452

Community health worker visits a mother, concerned that her child may have pneumonia, Buliisa District, Uganda

Women make up 69 percent of the community health workers trained through our projects in South Sudan, and around half of our community health workers in Uganda, who are known as ‘true village heroes’ in their communities. Around 30 percent of health workers in Mozambique treating and diagnosing sick children are women, as well as many of our project staff.

By including women health workers in our iCCM training, we have helped to increase significantly their confidence and status among their fellow community members. These women have set an example for their peers. Their work in treating and diagnosing diseases brings life-saving health services closer to people’s homes, freeing mothers from burdens they would otherwise face, such as going to distant health centres, missing out on work, or taking care of sick children.

In recognition of the fact that poverty is one of the primary causes of disease, Malaria Consortium works to bring change to systems that maintain or exacerbate inequality. We are eliminating various barriers to healthcare, including setting up care at community level, involving women in our projects or facilitating access to appropriate healthcare for women at higher level health centres. We bring together all stakeholders, including ministries of health, local leaders and remote communities, to strengthen health systems that are appropriate for the needs of those we aim to serve, so that communities can extract themselves from the cycle of poverty caused by poor health and, in so doing, tackle the associated elements of gender inequality.

As global health priorities falling under Goal 3 of the Global Goals, malaria, communicable diseases and neglected tropical diseases (NTDs) cross-cut with Goal 5. Most communicable diseases, NTDs and malaria, are treatable and/or preventable, yet prevail in underdeveloped regions and force economic turmoil on households affected by them. Reducing these diseases is cost-effective and relatively straightforward with sufficient and sustained investment, so Goal 3 should be an easy target to meet, particularly with the support of interventions such as iCCM. This is also highly cost-effective way of empowering women in the long-term.

Certainly, the road to women’s empowerment is more complex than simply reducing disease and providing good healthcare. But it is only with a global understanding of women’s health needs, combined with health infrastructures relevant to their cultural context, that the journey to women’s empowerment will be accelerated.

Slideshow Thumbnail Slideshow Thumbnail Slideshow Thumbnail Slideshow Thumbnail Slideshow Thumbnail Slideshow Thumbnail Slideshow Thumbnail

[1] p.16-17, The global strategy for women’s, children’s and adolescent’s health (2016-2030)

[2] p.54, The global strategy for women’s, children’s and adolescent’s health (2016-2030)

[3] p.1, WHO guidelines on health policy and system support to optimize community health worker programmes

Technology to save children’s lives

Mobile health coverage is expanding in Mozambique. Following a successful pilot in a few districts of Inhambane province, the Ministry of Health, in partnership with Malaria Consortium and UNICEF, will scale up an innovative mobile health (mHealth) app-based system to all districts of Inhambane and to the northern province of Cabo Delgado, as part of our new upSCALE project.

In recent years, mobile Health, or mHealth, has emerged as an important innovation with tremendous potential to strengthen health systems in low- and middle-income settings. It achieves this by providing better access to knowledge and information by improving service delivery and reducing response time to crises. Mobile phone coverage is growing rapidly across the world, both in terms of network coverage and the number of users.

upSCALE aims to expand an mHealth system using an interactive mobile android application.  The app provides step-by-step guidance to community health workers, or agentes polivalentes elementares (APEs), in running procedures for diagnosing and treating common diseases that are addressed at community level by trained workers. In September 2016, 258 community health workers were trained on this mHealth system.

Salvador was the oldest among the trainees, demonstrating that age is not a limitation for successfully using modern mobile technology.

“My namAPE SALVADOR PICTe is Salvador Waciquetane. I am 56 years old and I have been doing community health work for many years in Inhambane’s Vilankulo district, community of Chelene. I started to volunteer as a health activist in 2006 and, at the time, I was giving health talks in my community about good health practices. In 2010, I was the one chosen by my community to participate in the training to become an APE, as part of the Ministry of Health revitalisation programme. From the training until today, the people of my community are counting on me to provide basic health care.

Each year, I participate in various refresher trainings; in September, I received a call from my supervisor, Valério, requesting me to come to the district headquarters to participate in a CommCare training, which involves using a mobile phone in my work as an APE. After the phone call, I was curious and I began to imagine that the cell phone would be the same as the ones I saw during the general population census, when I had to map the population of my community. But when the training started, I was very impressed. I saw that the phone is equipped to help me do much more than I had imagined: family planning activities, follow-ups of pregnant women, diagnosing and treating diseases such as malaria, diarrhoea and pneumonia, as well as tracking people with tuberculosis and HIV to refer them to the health centre. I am very happy because this phone is going to help me a lot in my work, as it is easy and it guides the APE well.

“When I return I will meet with my community leader to ask him to arrange a meeting so I can present my new device to the community members. I think they will react very well and this will increase the trust they have. Any novelty is a challenge at first, but as time goes by I will find my way and I will grow to understand it.”

 

By Éder Ismael Zerefos